Lee, I will just take on one of your points, since I could write about this stuff all week long. Being a physicians is not like a lot of positions. Healthcare over large geographic areas are usually controlled by 1 or 2 major players. Taking a new job for a hospital based physician (read anybody that takes care of really sick people) requires getting staff privileges at the hospital. That process involves a mound of paperwork, background checking and usually takes 3-6 months. Once you have privileges, then you have to get credentialed for every insurance company that you may encounter treating patients. Can’t credential insurance at the same time as privileges, since most insurers won’t accept applications until you are credentialed at a hospital. So another few months trying to get insurance contracts for the major players. So if you were to just quit your job, you are going to be out of work for a while, probably close to a year. Now look at the non-compete clauses in your contract, you may have to leave the area, since you can’t set up shop within 50 miles of your health care entity. But that entity has hospitals or clinics in all populated counties. So time to sell the house that you are upside down in, relocate the kids. Not easy for many to do.
So you decide to move to a different state. Same process as above, except no hospital will start applications for privilege, until you have a license in that state. That may be another 2-4 months, thousands of dollars, and another few days of paperwork.
Imagine that you are an established physician in the hospital and the community. Maybe 55, your practice was just bought by the hospital. You continue to treat your patients, except that the contract you signed say they are no longer your patients. They now belong to the hospital. If you were ever to leave, you can’t advertise to those patients your location, or even call them.
A friend of mine just “relocated”. His hospital that bought the practice sent out a letter stating that He had left the area, but they had other excellent physicians that would assume their care. When patients ask where he went, the answer is “we don’t know” . Yet he relocated 3 miles away.
Back to our 55 year old physician. As in many industries, that more experienced person is not as desirable to a health system as a new grad. Too set in their ways, too knowledgeable, and less controllable. All around a liability for the goals of big medicine. So She is stuck. But she is a good physician, always does right for her patients. Now the big medicine bean counters start profiling her along with all the other Doctors. At first, they tout efficiency; read ordering fewer tests, prescribing fewer expensive medications, and fewer referrals to specialist. They count the number of CT scans, stress tests, blood tests, referrals and pharmacy costs that each physician orders per patient. The efficient physicians that spend less, are extolled and profiled as an example to all. The high cost physicians, are put on notice. When they fail to bring their costs down, their contracts are not renewed. So they tow the line, or leave. So she is conflicted. She either practices medicine that she don’t believe in, or she could get a new job. See what that entails above. In all of this, at no point are true outcome measures, such as mortality, missed diagnoses or correct diagnoses tracked.
This is not coming from a disgruntled physician. I am a very successful Pulmonary Critical Care Doc, and I have been able to do extremely well in this current environment. It does not mean that I am blind to what is happening, or blind to where this is going. My older colleagues right now are getting screwed because in spite of their incredible experience and track record they are not mobile for many reasons, so are very vulnerable to the pressure of big medicine. The new grads coming out, they don’t have any experience in contracts, have never seen medicine that is not controlled, coming from a supervised training environment, so they don’t know any difference. Best I can tell though, they do not seem to be any happier in the managed care environment. They left residency under the impression that they could see and examine a patient. Come up with the appropriate diagnosis and effect an appropriate treatment plan, and make it happen. The reality is eye opening for them.