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Till recently, it was not difficult for patients to find and reach genuine experts to take care of their healthcare needs. They could just go to a "good and reputed" hospital or ask their primary care physician for recommendations. The incentives in the system were such that patients in need of special expertise or high level of expertise were sooner or later referred to appropriately trained and expert physicians. Since the advent of Obamacare, the incentive structure in healthcare has changed dramatically and going to a good hospital or asking your trusted PCP will not get you the best physician for your needs nor are patients who require complex surgery or medical procedure referred to the most capable surgeon or proceduralist in the area.
Experienced and skilled physicians can diagnose your medical condition more accurately and use diagnostic testing wisely and sparingly. They can also help patients choose better treatment options for optimal clinical outcomes. Surgeries and medical procedures performed by technically proficient and experienced physicians have lower risk of adverse outcomes and higher likelihood of success. Little wonder then, that patients used to go to great lengths to find and reach experienced highly skilled physicians to take care of their healthcare needs. The patients have relied on certain time-tested mechanisms to be able to do this. Till a few years back, these mechanisms were reliable for doing so. However, Obamacare produced sweeping changes in healthcare that have turned the system upside down and have rendered the traditional means of finding high quality physicians ineffective. To understand why, let's first understand the changes in our healthcare system in past few years that have impacted the way healthcare is provided to patients.
The importance of the quality of individual physician(s) is systematically being discounted and downplayed
There is a concerted push to develop 'assembly-line operations' in healthcare ostensibly to "reduce" costs. By focusing entirely on 'The System' to deliver quality of care instead of recognizing the value of clinical excellence of individual physicians, this approach carries the risk of compromising the quality of healthcare both in the short and the long term. The assembly line model discounts individual worker's brilliance but relies on "average" quality workers who have been taught to perform certain repetitive task(s). It is highly unlikely that such an approach will succeed since unlike 'cars on an assembly line', no two patients are alike or have identical medical problems. The tasks performed by physicians are not 'repetitive' but solving each patient's problem requires the effort and skills of "custom" operations. As is obvious to most of us (except the healthcare executives and policy makers), this approach is bound to fail. However, this "experiment" to change healthcare is likely to inflict irrevocable harm to patients, physicians and even to the healthcare system before there is realization and acceptance of its futility and dangers. In the meantime, the highly skilled experienced physicians find themselves marginalized while the administrators favor the younger newly-graduated physician recruits and selectively direct patient referrals to them.
Quality has a new meaning in our healthcare nowadays
Good healthcare was once upon defined by timely diagnosis of medical problem and effective treatment without avoidable complications or adverse reactions. Good customer service and luxurious amenities were desirable adjuncts but not considered a substitute. In the new reality in healthcare, customer service/satisfaction have become the measure of healthcare quality since real quality of healthcare is impossible to measure.
Hospitals are trying to lure patients with fancy new buildings and advertisements about their capital investments in "cutting edge technology".
There was a time not so long ago when hospitals were considered "good" only if they had "good doctors". Lately, hospitals are trying to look good by advertising heavily about their fancy new buildings and latest hi-tech equipment. Cutting edge medical technology is only an enabler and is not a substitute for the experience and skill of the physician using it. Beautiful buildings and even 'operational efficiency' cannot substitute for high quality physicians to optimize patient outcomes and at best can only improve the customer experience but cannot optimize treatment outcomes.
New financial incentives have compromised the 'physician credentialing' process of hospitals
Credentialing process of various hospitals used to be an important quality assurance mechanism whereby only high-quality physicians were given privileges to practice in that hospital. Hospitals with high quality physicians developed good reputations which in turn attracted patients to that hospital. Now, the hospitals increasingly are employing specialist physicians directly on their payroll. This has created major conflict of interest in credentialing as hardly any physician who is employed by the hospital is ever turned down for privileges on based on their quality and for obvious reasons. Hospital administrations sometimes go to the extent of modifying the credentialing criteria so that their new recruits can meet them, usually in specialties requiring highly-skilled physicians where the supply of such physicians may be very limited (it often is).
Hospitals now control the referrals to specialist physicians and use this for financial gains
Hospitals now own most primary care practices, internal medicine hospitalists groups and emergency rooms, which have traditionally served to coordinate multidisciplinary patient care and generate direct referrals to appropriate specialist physicians. Hospital administrators now directly monitor (via the Electronic Health Records) the referral patterns to ensure that patients are preferentially referred to physicians who are directly on their payroll or the 'compliant' physicians favored by the administrators
Hospitals also discourage referrals outside the system even when the most appropriate or the best medical/surgical expertise is not available in-house. This is obviously done to maximize revenue per patient and prevent "leakage" of patients from the system. Patients are referred for alternate test/procedure/surgery within the same hospital that is poor substitute (with either more complications or less effective or accurate and usually more expensive) for what the patient actually needs. To keep patients within their system hospitals have started providing all services in-house, usually by hiring physicians who are inadequately trained, just out of training or are not adequately skilled.
In the newly changed healthcare system, patients cannot count on traditional methods of reaching good specialist physicians
- 'Going to the ER of a good hospital' – Patients looking for good healthcare usually go to a "good" hospital assuming that they will then be treated by highly skilled and experienced physicians. This used to be the case till the hospitals started employing physicians directly on their payroll. Now patients are likely to be referred to a specialist physician directly employed by hospital or a 'compliant' physician favored by hospital administrator who as expected are not as good as the high quality physicians who are less likely to 'give in' and 'sell out' to the administration. Even now, most high quality physicians prefer not to be employed by the hospitals.
- 'Asking your primary care physician': Most patients have known their primary care physician for a long time and have developed trust and confidence in their doctors recommendations including about the choice of a specialist. Unfortunately, in the new reality, your trusted 'primary care physician' will now be 'forced' to recommend hospital employed/favored specialists and not the best one they know, as used to happen earlier. The hospital administrators keep a close watch on who the patients are being referred to and errant ones promptly get called by administrators to 'correct' their referral patterns.
- "Good physicians are in demand and busy. So, I will go to a specialist who is booked for 4 months"- Now that the administrators control which specialist physicians get the referrals from ER, PCPs and hospitalists, physicians who are busy now are those who have strategic business alliances with hospital administration. The age-old criteria of a doctor who has a lot of patients waiting to see must be good does not apply anymore.
"That is why I research my physicians on the internet"
Increasingly, patients look for information about the quality of physicians on the internet. Even though there is a 'lot" of information about physicians available on the internet- there are >80 physician rating sites. However, there is paucity of credible information about physicians on the web. Most information about physicians available on the internet is flawed and often misleading
- Physician rating sites: They have become forums for a few disgruntled individuals (including disgruntled patients, employees, competitors) to settle scores with individual physician(s) by writing bad reviews. Furthermore, physicians can and often do game the system by having their family, friends and employees provide stellar reviews
- CMS' Physician Compare site: It is misleading to compare physicians based solely on their success and complication rates since the good physicians who treat sicker patients and more challenging problems appear worse than their average or below average counterparts who just accept the easy less sick patients.
Using Surrogate criteria to select high quality physicians:
Patients often use surrogate markers such as affiliation to prestigious academic institutions, academic and or administrative titles, media spotlight etc. to find good physicians. However, in the new healthcare reality, these surrogate markers are usually misleading, easily manipulated and a poor substitute for learning about the clinical skills of a physician based on their reputation amongst their peers for their clinical skills. Good clinicians who are not into performing research are undervalued and underpaid in university hospitals and therefore prefer to go into private practice. The university programs pay clinicians poorly and are therefore increasingly finding it difficult to hire good clinicians. They try to market their clinicians by giving them impressive sounding administrative or academic titles which impress patients who are not aware of the reality of the present day healthcare. Increasingly university hospitals are trying to entice referrals from still unaffiliated private practitioners by giving them phony academic titles such as 'Clinical Professor'. These titles are liberally conferred based on the 'amount of business' that private practitioner can provide and not based on any existing quality evaluation or future 'real commitment' to quality of the practitioner.
In summary, the changes in the healthcare in past decade have rendered previously effective and time-tested ways of finding and reaching highly skilled experienced physicians completely ineffective. Patients are now virtually at the 'mercy' of the healthcare system and have no option but to "trust" the system about the quality of physicians taking care of them. when the 'players' in the system have perverse incentives including financial ones that are out of sync with the patient's wishes and often in conflict with the patient's best interests. If this is how "improvement" in healthcare is defined, we have come a long way in "improving" our healthcare in past decade.