Corporate Healthcare

Yesterday, I was reading the Greenville Hospital System (GHS) medical staff newsletter.  One of the articles was excitedly explaining how GHS had struck an EXCLUSIVE contract with Blue Choice Medicaid.  This means that the 14,000 members of Blue Choice Medicaid in the Upstate area will only be able to receive their medical care from GHS physicians.  The article was presented as very exciting, positive news, but I saw it as an illustration of what is happening to health care in the United States as it moves away from individual centered health care to corporation based health care.

The deal between Blue Choice Medicaid and GHS, despite all of the claims about improving quality is really about money.  It has been done for the purpose of both GHS and Blue Choice making more money. Of course, contractual deals between businesses have been done as long as business has been around.  This makes sense, if you are talking about Walmart buying  a large volume of shirts from a manufacturer so that they can sell them cheaper to entice the consumer to come into Walmart and buy the shirts.  I think it is a different matter both morally and functionally to do this in healthcare.   In order for the deal between GHS and Blue Choice to work, a population of patients has to be bought and then their behavior as well as the behavior of their doctors controlled in order to produce “savings.”  This would maybe be okay if the patients were free to move in and out of the Blue Choice Medicaid plan, but whether you are talking about Blue Choice Medicaid plan or any other insurance plan, the patients do not have the freedom to move and out of their insurance plan.  As a consumer, I have the choice to buy a shirt at Walmart or Belks or wherever.  However, as a patient I am locked into the insurance plan that my employer chooses or in the case of Medicaid, the plan the state chooses for me.  I have no control over the deals that have been struck by these insurance plans.  If I am insured by Blue Choice Medicaid and my doctor is not part of the GHS network, I will be forced to either change doctors to one of the GHS doctors or go without insurance coverage, which few can afford.

This process has been going on for quite some time and it has been accelerated by the Affordable Care Act (Obamacare).  Once insurance began paying a majority of the health care costs, patients and doctors were no longer viewed as individuals, but now lives to be purchased and members/providers whose behavior was negotiated and controlled.  Obamacare brought Accountable Care Organizations into existance and this is driving much of what is happening now.  Under Obamacare, much of the money will be distributed to hospitals, who will then determine how the money will be spent for the healthcare of the populations under their control.  This is why hospitals have been very aggressive at buying physician practices and coalescing numerous hospitals into their networks.  The more healthcare a GHS can provide, the more of the money they can keep for themselves.

On the surface, GHS trying to provide a wide range of services themselves is not a problem.  However, it becomes a problem, when they establish themselves as a monopoly that drives out of business any doctors unwilling to be owned by a system and thus controlled by the system.  It becomes a problem when patient’s choices are limited because their doctor is not part of the system or their doctor is limited on who he/she can refer to based on whether they are part of the system.  It is a problem if the patient’s choices are challenged because the choice does not fit the patient behavior guidelines of the system.  It is problematic, when vastly different individuals with unique needs, preferences and biologies are all treated as one monolithic patient population.

As a doctor, I will never be owned by the system.  As a patient, I fear the kind of health care system being created is not in MY best interest.

It’s The Attitude!

In 1992, in order to encapsulate the central issue in the Presidential election that year, James Carville popularized the statement:  “It’s the economy, stupid.”  I am reminded of this during some of my patient encounters.  I think of a couple  I delivered a few months ago.    This couple had transferred to me, from a local obstetrical group, part way through her pregnancy.  A major reason for transferring, was that they wanted a nonmedicated  vaginal delivery and believed they would be more likely to achieve that under my care than that of the obstetrical group.  Unfortunately, her delivery process turned out nothing like they had planned.  There was an induction, an epidural, vacuum and ultimately a cesarean section of a healthy baby boy.  At the conclusion of this birth, I felt terrible.  This couple had come to me for a specific style of delivery, but I believed I had failed to meet their expectations.  The day after the delivery I went to visit this mom and talked with her about her birth experience.  To my surprise, she was extremely happy with her birth experience.  Obviously, she was thrilled with her new baby,  she was also very happy with the whole experience and happy they had changed doctors, even though the details of the birth had not turned out the way they had planned. 


I have been reflecting on the reason for the positive satisfaction, despite the specific unpleasant details and I believe it can be encapsulated in the statement, “it’s the attitude.”  What was the attitude that this couple found appealing?


1.      This couple was treated like family.  Since I am the only delivering doctor in this practice,  I get to know them very well and they get to know me.  We not only talk about their pregnancy, but also about both their and my personal lives. They know that, except in a very rare situation, I will be the one shepherding them through their labor and delivering their baby.   I will not be turning them over to another doctor, who might have different ideas, because my shift is now over.  They have my personal cellphone number and can reach me when I am needed.  At the end of all this, the couple has no question as to whether or not my priority is their well being.


2.    Throughout the pregnancy all interventions are discussed and a seeking of approval is obtained.  This is even more important during the labor process.  Nurses did not suddenly start doing things because the doctor ordered it.  Rather, the reasons for any intervention are thoroughly reviewed prior to the intervention happening.  The attitude part of this is that they are treated as equals in this process.  While I may have more education and experience, their input is just as important as mine.  This is a collegial process with sincere give and take.   This means they remain in control of what happens, rather than being taken over by a big unresponsive medical system.


3.    All options were attempted.  During the labor, she was encouraged to move around and change positions.  Other methods of achieving a vaginal delivery were pursued.  There was no timer running, so she did not feel pressured by the doctor’s fatigue, schedule or arbitrary time line. By the time the decision to do a cesarean section was made, the couple knew there was no other option and were in full agreement with doing the section.


Every case is different and rarely there is a true emergency or situation, where the doctor has  to take a more paternalistic approach.  Nevertheless, that should be very uncommon.  


Too often, the doctor has the attitude that they are the educated professional and the patient’s views and concerns are irrelevant.  Too many times, doctors will make up rationalizations to justify what they want to do to the patient, rather than admitting it is a doctor preference or the way they do things.   


My view is that physicians need to be transparent with their patients.  Agree or disagree with the patient’s viewpoint, a physician needs to be collegial in their approach.  If the doctor disagrees with the patient’s viewpoint, than try to persuade them in a respectful manner.   A doctor should never approach the patient with a condescending attitude.  A doctor should not make things up, to get a patient to agree to a given treatment.  Physicians should treat patients the way they themselves would want to be treated.  It is the attitude!