Friday, May 8, 2020

Retrospective #447: What’s happening to medicine today?

Note: This post was originally written in 2018…before the global pandemic that medicine is also experiencing today.
Lots of things are happening to medical practices today, and at an accelerating pace. I remember 40 years ago when my GP quit medicine, giving up a nice practice in an upscale community because of Medicare’s onerous reporting burdens. He was independently wealthy, and had a nice social life, so he could, but he was only in his early 40s!
Today, independent private medical practices are disappearing at an even more alarming rate, being sucked up by hospital conglomerates. In my area Health Quest and CareMount are cutthroat competitors. A search on CareMount redirects to “Medical Outsourcing.” Wikipedia explains: “Some small practices have outsourced business functions to management services organizations” (MSOs). “Business functions” includes all office personnel. My urologist told me that the benefit to him was that he can now “just practice medicine.” He has since retired.
Two specialists I have seen in the last year now work for one of these MSOs. So does my wife’s GP. My internist in NYC is a noteworthy exception. He resists the trend and recently, while maintaining a very busy private practice, joined a “boutique” medical group where he offers his patients, for a fee, more personalized attention. I declined. I told him I see him 3 times a year just for blood work. He originally suggested a few years ago that I come just once a year.
On a recent final visit to an orthopedic for a damaged Achilles tendon, his receptionist asked me if I wanted to receive an updated printout of his clinical notes. I told her “no.” After unexpectedly receiving and reading an earlier version, they upset me. I thought that they did not fairly reflect what I had told him or his nurse; instead, they read to me like they were written to be read by the MSO or some clinical practice insurance reviewer at HHS (Medicare).
I had a similarly eerie experience in Florida several years ago. I had to fire one physician, who was peddling statins and claimed to be a lipidologist.  Another, an endocrinologist, had justly fired me when I told him he needed to go back to school. They both worked for a large group that dominated that part of Florida where I spend the winter. Their MSO is part of HCA Healthcare based in Nashville, Tennessee. The network includes “178 hospitals and 119 independent surgical centers in 20 states and the UK.” The UK!
The orthopedic – remember, his specialty is skeletal issues, in my case a torn tendon – asked me if I was eating a “mostly plant-based diet.” Earlier, his nurse, recapitulating notes from the previous visit, asked me if I was still walking for exercise. I told her I had NEVER told her or anyone that I walked for exercise. I have NEVER walked for exercise. The only exercise I do is garden work. Where, or more to the point, why was it in their clinical notes that I walked for exercise? And why would an orthopedic counsel me to eat a “mostly plant-based diet”? I think you know the answer.
I protested the counsel to eat a mostly plant-based diet. I replied that I eat a Very Low Carb diet and would be a CARNIVORE if my wife would not go apoplectic. I told the nurse that the body had a zero requirement for plant-based foods and can make all the glucose it needs via gluconeogenesis from protein and fat. I also told them that I drink a pint of collagen-filled bone broth from pasture-raised beef every day to help repair my torn Achilles tendon (as my brilliant editor had suggested). Tendons are made of collagen. My ortho appeared to listen attentively and replied simply that he admired a person “who held such passionate beliefs.”
My conclusion, I’m afraid, is that to practice medicine today your MSO MD needs to follow the MSO’s and the government’s “formulary,” not just with respect to medications, but for lifestyle (“diet and exercise” and “plant-based diet”) as well. And if those recommendations and that guidance are not in your clinical notes, the MD is penalized by lower reimbursement rates from Medicare and thus with a lower rating by the bean counters at the MSO….because the MD is not pushing the government’s recommended “lifestyle.” To not push it risks lower profits for the MSO and even job security for the MD, based in part on “job performance.” That’s the price a doctor has to pay today to “just practice medicine.” And if you follow them, you’re just going to get sicker and sicker. And that’s what happening to medicine today.


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