Changes in the practice of medicine.

Although the shopping list of physician complaints about the direction of the health care system is long, in my recent conversations with both practicing physicians and physician executives, four changes were discussed by everyone:

* Lowered incomes, brought about mostly by Medicare.

* Loss of control over the provision of patient care.

* The constant threat of malpractice litigation hanging over their heads, and actual lawsuits in some cases.

* Mountains of paperwork for third-party payers, requiting additional staff to manage.

Lowered Incomes

Physicians, especially those in primary care, are working longer hours for less money. They come to the office earlier, leave later, and take short lunches. Unless they are just out of residency, most physicians bought homes and offices when they were making more money. A bank is not very understanding if you try to explain that you are making less. It still demands the same monthly payment.

Dr. Tully Blalock, an internist in Winter Park, Fla., says, "The downward trend in income began when Medicare first came out. They put a cap on what you can bill a patient. You can be fined $2,000 if you over-bill. You can't do two procedures in one day. You can't do a physical exam and a sigmoidoscopic exam in one day and charge for both of them, so the patient must come back another day to have it done. You can't give the results of a report on the same day even if you know them because you can't charge for the time to talk to the patient."

Dr. Robert Thornton, a neurologist in Maitland, Fla., says, "It doesn't matter what we charge, Medicare wants to pay less every year. Botox injection is the only effective treatment for facial muscle spasms. It is an extremely sophisticated procedure--how you inject it, how you use it. We take special training to learn how to do it. We've done them for a year, and no one else in town will do them. Most places charge $500-$600 to do them. Medicare approves $110. I did one to a Medicare patient. The vial costs $200. The needle is $25. Medicare denied all payment because it was not one of their approved diagnoses. My time, the technician's time, and the cost of the vial and needle were all lost. People are becoming more and more reluctant to see Medicare patients. We battle all the time to get payment."

"Many doctors are so irritated that we have to do what Medicare says we have to do, and we have to take what they say we have to take," Dr. Blalock says. "If you leave out a dot or dash they send the form back to you to fill out again."

Other regulatory groups also have imposed restrictions that affect how physicians practice medicine. "OSHA has created regulations for medical offices," Dr. Blalock says. "It requires conferences with staff, masks, gowns, disposable bags, a written manual. It would not tell you what had to be in the manual, but said if you didn't have the right things, you could be fined up to $70,000. The manual needs to be revised every year. It cost $1,100 or $1,200 to set this up. CLIA [Clinical Laboratory Improvement Act, administered by the Health Care Financing Administration (HCFA)] requires that you register a lab and pay $2,000 a year to run it. I shut mine down. I have $60,000 worth of equipment in the other room under a sheet."

Loss of Control

Dr. Thornton says his greatest concern is the lack of continuity of care. "I used to have set referral sources. The referring physician would let me know what was going on. I could send the patient back to someone I felt comfortable with. There was stability in the practice. Now patients are sent by people I do not know from all over Florida. I never get records on them. They have many tests done both in and out of the hospital, and I don't necessarily get the results. I'm faced with complicated problems, and I do not have any knowledge of the referring physician. I hate that the most."

Continuity is also lost when patients are forced to change physicians when their employers change insurance carriers, Dr. Thornton says. "Companies change all the time from one plan to another, from one set of doctors to another. A young woman who has multiple sclerosis, with whom I had very good rapport, called to say, "I have to go to another physician because the plan changed."

Dr. Blalock says that physicians are told how they must practice. "The PRO (Professional Review Organization) has been off our backs for a few years because it ran out of money. Before it let up, if an 80-year-old lady had pus cells in her urine, its book said you need to do something about that. You get a point if you didn't do anything about it. If you get 25 points you can be turned over to the Department of Professional Regulation. It was punitive and intrusive."

Threat of Malpractice Suits

Many physicians have gone through realpractice suits, but even those who haven't expend a lot of energy worrying about them and trying to prevent them.

"Defensive medicine costs so much. We've added layers of activities that we do to protect ourselves,' Dr. Blalock says. "We hear about someone being sued, and so we develop a little habit to compensate so we don't get sued for the same thing. There is so much paperwork and documentation. JCAHO, insurance plans, PPOs, Medicare require that you demonstrate that you do certain procedures. We write and dictate reams of descriptors that aren't necessary, but we see ourselves reading them in court one day. Some people have been forced to keep better records and good medicine is good records, but it has probably been taken too far. Nurses in the hospital spend 50 percent of their time documenting everything that is done for legal reasons."

To save money, Dr. Blalock says, "People say--do less, but tort requires that you do more. If you do one thing wrong, you are going to get sued. One lawsuit will wipe out two years of your time, and it destroys you emotionally. Until that pressure is off, we will have a hard time getting physicians to do less. If patients say they want to see a cardiologist, you may know they don't need it, but if they happen to die the next week, you are finished."

Dr. Thornton says, "Liability hangs over your head with every patient. Mine is one of three groups of doctors being sued now. It's been going on for three years, and I'm sure the legal fees are a quarter of a million at this point. If the insurance company decides to settle, we are implicated. I do not want a settlement, but I have no control. For every patient I see, covering every potential base to prevent a suit is important. I see complicated problems that require complicated decisions. Sometimes I'm going to be wrong. We'll never solve the problem of rising costs of health care if we do not have tort reform. Brain scans are done for headaches even if you know there is a slim chance anything is wrong. An MRI is done because the primary care physician is afraid not to order one."

Filling out Forms

Physicians get patients from many different contract groups, each of which has its own paperwork and rules about preadmission requirements and utilization. "The concept of managed care is now a major force in shaping how health care is delivered," Dr. Blalock says. "Lots of people are looking over your shoulder. The advent of managed care has affected me more than anything else. I have to sign contracts with the various ones. It has the greatest influence on how I practice. We will have to do capitation, and you need a big group for that. Some solo physicians who have participated in capitation have owed the insurance company at the end of the year rather than making money. The risk of providing health care to a group will have to be shared by the physician, the hospital, and the insurance company. No one group will shoulder all the risks."

Solo practitioners are thinking of ways to get associated with groups so they can continue to get patients as the rules of practicing medicine continue to change. "As of July 1, the law in Florida formed an organization called CHPA (Community Health Purchasing Alliance), which will provide information to members on comparative prices, usage, outcomes, quality, and enrollee's satisfaction with Accountable Health Partnerships,"(1) Dr. Blalock says. "For example, the region of Orange, Osceola, Seminole, and Volusia counties might form one unit for the region. Small employers will go to it and say they want insurance for their companies. CHPA will go to a physician, hospital, and insurance group to get health care for the requesting company. The physician will have to be in some sort of organization or he or she will be left out of plan. At Winter Park Hospital, we will have the Physician Health Care Network. Participating physicians can join for $1,200-$2,500. We will have to offer a managed care product."

In an article late last year, Dr. A. O. Singleton III described how his older partner, who had just died, reminisced about the days when a physician was supported by one employee. "When we talked about the financial crunch, my old partner had a hard time understanding why it now took 10 physicians and 21 employees to support an army of health care regulators, claims re-pricers, pre-certitiers, concurrent reviewers, retrospective reviewers, quality assurance people, managed care sales reps, administrators, assistant administrators, peer reviewers, practice consultants, CPAs, corporate attorneys, headhunters, forms devisers, forms revisers, and computer programmers--all of whom now lay claim to a piece of the pie.(2)

Physician executives are caught in the middle--needing to enforce costsaving measures and trying to soothe angry physicians who are losing income. Physicians are grieving over significant losses whether they admit it or not. One of the essential elements of moving through the grief process is talking about the loss and accompanying anger and sadness. When grieving, you need to say what is bothering you more than once. People get tired of hearing you complain, so you have to find several different people to talk to. The physician executives I talked to are trying to find ways to provide an arena for this necessary discussion.

Hospitals

Dr. Gordon Wolfram, an internist and cardiologist who has been chief of staff at Orlando (Fla.) Regional Health Care System, helped initiate a program that gave physicians feedback on their clinical treatment of patients. "Orlando Regional Health Care System was a high-cost hospital. The doctors said it was because they treated sicker patients. We bought three software programs to help us become more efficient. The software allowed a doctor on the staff to compare costs for common admitting diagnostic groups with those of peers in Florida, adjusted for severity of illness. It confirmed that we were an expensive place. We were losing $12 million a year on Medicare. Now we are making $3 million a year on Medicare patients."

Dr. Wolfram says that "three past chiefs of the medical staff were chosen to be education physicians. Each talked to 60-100 physicians in one-onone interviews. We emphasized that we were not trying to find bad apples or punish physicians. We discussed their practices. Many were a little paranoid and thought that how they practiced was no one else's business. I invited them to volunteer to come for the face-to-face interviews. I explained that the state has been collecting this data for almost two years. It is the law that each hospital has to send the information in. Nobody knows what they are going to do with it, but right now they will sell it to anyone for $75. It's conceivable that the information could be published in a newspaper. It seems reasonable that each physician would want to know what the state knows about him or her. I explained that there was no punitive process involved; we just wanted them to stay competitive in a cost-effective environment. I had only two refusals and one changed his mind. He wanted to see the information but would not talk to anyone about it."

Dr. Wolfram says that he and one of the hospital administrators would go over each physician's practice profile prior to the interview. "If we saw variances, we began the interview by listening to him. I asked, "How can we improve your life in the hospital? Each doctor had suggestions. One ordered lab results to be on the chart at 8:00 am and frequently they weren't. We discovered that some of the people who draw the blood were actually carrying the blood around for 1 1/2 hours before they went to the lab. We made a .rule that they had to take it to the lab in 30 minutes. So, if possible, we made changes that would help the physician. Physicians are pleased to have a peer listening to them who is able to get something done. I've been chief of staff, have administration backing me, and can get it done." Dr. Wolfram says that, if the physician executive listens to complaints from physicians and tries to alleviate them, the physician is more receptive to hearing about changes the administrator wants.

Part of the process, Dr. Wolfram says, was showing physicians computer printouts that told what tests were ordered and what drugs were used, along with the hospital's cost on each drug and procedure. "Some cardiologists used only TPA--an expensive clot buster. Streptokinase, a similar drug, saves almost $2,000 per patient. I found one physician used the most expensive antibiotic, cephalosporin, on all his pneumonia patients. When I pointed that out, his initial reaction was, 'My patients deserve, the best. They might have pseudomonas. I pointed out that the most cost-effective drug costs $200 a day less to use and that he never uses that drug. He looked at the data and said, "Wow! I use cultures anyhow, so if pseudomonas showed up, I'd have time to switch.' A light came on. Each physician thinks what he or she is doing is logical and that everyone is doing it. Then they realize that they're not. Physicians are competitive they will want to do better."

Managed Care

The number of health maintenance organizations has increased greatly in the past 10 years. When I asked Dr. Edward Lowenstein, Medical Director of the Orlando (Fla.) Medical Group, how the practice of medicine has changed, he said, "Asking an HMO medical director about changes is like asking a monk what it is like to live outside the monastery." He says that HMOs essentially ushered in the changes that fee-for-service doctors are upset about. Most group-and staff-model HMO physicians realize they have joined a certain kind of society, and they follow the rules much as they did when they entered their residencies.

However, Dr. Lowenstein, like others, has to deal with a fair amount of disciplinary matters--physicians yelling at patients, giving bad service, taking a lot of sick days. "I approach these problems from their point of view," he says. "How can we serve his or her values so we can change behavior. The assistant medical directors and I spend a fair amount of time role playing so we can turn the behavior around.

Dr. Lowenstein relates the case of a family practitioner who, because of his ego, really feels that he needs to do lots of procedures in the office-- vasectomies, minor surgery, prenatal counseling. "It was not a good use of his time, and it put us at risk for malpractice suits. I looked at his productivity and realized it was just at certain times of the day that he scheduled these procedures. I found out he enjoys relaxing and doing them rather than doing so much head stuff (an 80-year-old lady who comes in with a bag of medicine and low back pain, and you have to figure out what to do.) He also thinks that if he doesn't do these procedures, he'll lose his touch. He said, 'Only sissies don't do these things."'

Because he understood that it was important for the doctor to perform at least some procedures, Dr. Lowenstein made that part of his solution, allowing four of them for the doctor each day. He says that coworkers see the doctor as cooperative, a team player. "We also schedule a few runny noses and skin biopsies for relaxation. It would be easier to call him and tell him not to do the procedures, but I wouldn't get as good a result."

Group Practice

Dr. Raymond Fernandez, Medical Director, the Nalle Clinic, a 100member group practice in Charlotte, N.C., says his board is planning to spend its fall retreat focusing on the problem of how to deal with unhappy physicians. "We are doing a survey to find out how discontented they are, but my guess is we are on the poor side of average. Finances are part of how good we feel about ourselves. Doctors' compensation is being threatened by HMOs and 'Clintonomics.' Paperwork is an increasing hassle factor. You can't just talk to patients to make them feel better. You now need authorization."

Dr. Fernandez feels that physicians will have to refocus on why they are doctors--to help another human being feel better. "It's the reason we went into medicine in the first place. Younger doctors are tolerating the changes better than older ones, who have seen the golden age and are losing it. Those who have lost their way of practicing medicine need to say what's bothering them out loud more than once and to a group. It will take enormous energy and coordination to make that happen, but they will have to heal themselves before they can heal anyone else."

Dr. William Rock, Medical Director, Dean Medical Center, a 320member group in Madison, Wis., says, "Incomes are going down. That's a major problem. We are planning to change our compensation manner. Our incomes are based on productivity, and everything is coming up capitation. We have physicians that act out when that happens. When they do, I keep a cool head and listen. Their practices are much busier, so there is not a lot of camaraderie. They do not have time to sit around and unload. They tell friends and family, but that's not enough. Physicians no longer meet in a lounge for coffee or lunch. They used to get together and this interchange could happen, but it's not happening now.

Dr. Rock says that physicians need to talk and get some of their feelings out. "We try to facilitate that. We are scheduling more meetings so they can complain. Also we give them lots of information. I can't wait for news of what is happening in medicine to filter down. We have to keep getting information out. I let the department chairs know as soon as the board decides something. We have newsletters. I talk to everyone individually at least once a year to find out how they and their family, their practice, and their health are doing."

It's important for the medical director to try to influence the physicians who influence other physicians. "Sometimes the movers are not in office," Dr. Rock says. "You have to get to the opinion makers in unofficial ways. You have to be in a group long enough to know who the opinion makers are. You may have a nonleader in a department chair position if the positions simply rotate. You can't act as if you are showing favoritism, but you have to talk to the people who have influence."

Although Dr. Rock believes that doctors have lost something and are grieving, he says that you have to be careful how you talk to them. "I learned not to use the term 'group support.' The physician's attitude is, 'I'm perfectly capable of taking care of my own affairs. I don't need support.' You have to word things carefully. You might have to say, 'We're going to have a meeting to help old Joe over here, not you."

The physicians I talked to were clearly disgruntled. Some spoke with great animation and others had a quieter but more troubled demeanor. Only one seemed to visualize a way through the major changes.

"We have a dreadful period to go through," Dr. Blalock says. "There is so much more stress. We work longer hours and harder and make less money for the same amount of work. Change is so deep and rapid that everyone is pretty fed up with whole thing. There are not many happy people practicing medicine, but I think it will work out. We will learn to be more efficient, spend less, standardize protocols for care. Outcomes assessment is causing us trouble because we don't know how to do it, but eventually it will help. We don't need to bash people when they are wrong, but teach them how to do better."

Dr. Blalock believes that much has already been accomplished by physicians in adjusting to changing times. "We have already learned to keep people out of the hospital, about home nursing care. We can do I.V. fluids, hyperalimentation, oxygen, once-aday oral antibiotics in the home. A nurse goes by every day. We can do a laparoscopic gallbladder operation and have the patient back at work in two days instead of a week. Technology has helped us keep people out of hospitals. The need to be more cost-effective has driven these changes. We can learn the rest of what we need to adjust to rapid changes."

Almost anyone you talk to wants the cost of health care to go down, and yet patients want the absolute best of everything when it comes to their treatment. Physicians are caught in the middle of two contradictory desires, and most don't like the feel of it.

References

1. "Florida Health Care Reform." Foley & Lardner, Attorneys at Law (111 N. Orange Ave., Orlando, Fla. 32802-2193), April 22, 1993, pp. 1-5.

2. Singleton, A. "When Our Partner Died, So Did a Way of Medicine." Medical Economics 69(22):133-5, Nov. 16, 1992.

Barbara J. Linney, MA, is Director of Career Development, American College of Physician Executive, Tampa, Fla.