I had the pleasure of performing surgery on a nurse a few days ago. She has been nursing for 20+ years and is a “top gun”, working the ICU of a well known hospital. During her procedure we had a conversation (the procedure was done under local anesthesia) about why my practice is the way it is.
I shared with her the reasons.
I trained at an excellent residency, like every other doctor in this country. I signed up with insurance companies and became and “in-network” doctor like most other doctors in the country. I got on staff at hospitals and surgery centers to perform surgery for my patients like the majority of foot surgeons in the country.
It didn’t take long for this mix to reveal it’s flaws.
None of the above mentioned systems really took steps to improve the experience of the patient, or the environmental effect of their facilities, or the health and well being of their staff in a manner that was outside of our “standard reactionary western medicine ways”.
As my RN patient pointed out during our conversation, “the bean counters decide on what products or medicines are carried in the facility, and how health care is rendered. Take this example for instance, the nurses on the floors would place bed pads beneath every patient. This would help a lot when the patient had to be moved or repositioned. It made it simpler and less difficult for both patient and nurse. But these bed mats are thick and heavy. This matters because the laundry service the hospital uses is billed by weight. So to save on expenses, the hospital cut the bed mats from the linen services.
I then told her a story about the first time I decided to begin my own “state-of-the-art” facility. It wasn’t for extra revenue. In fact, every year, I reduce my volume to ensure that we can continue to provide the caliber of care our patients deserve. Rather it was because of this interesting story.
I was performing surgery at a well known hospital in the Los Angeles area, and during surgery I asked for a specific suture. When I began to suture my patient, the needle “popped off”. This is normal for some kind of sutures, but I didn’t ask for a “pop off needle”. So the nurse opened another suture. Again, after 2 throws, the needle pops off. I then asked the nurse to show me the packaging of the suture, and much to my surprise it was a lesser quality “off brand”.
I asked the nurse why this is the suture I was given and not the quality Ethicon brand suture that we all respect.
The reply was this “oh, sorry doctor, the hospital switched contracts and we carry this brand now”.
I replied “well who decided on this switch?”
"The purchasing department", replied the nurse.
"Purchasing is deciding what I suture my patient with?" I stated, slightly infuriated now. "That doesn’t make any sense… I don’t see anyone scrubbed in and working on this patient from purchasing right now?"
The conversation stopped here of course, because neither the nurse or anyone else could do anything about this. Except for me. I could. And I did. I decided to compete.
I spent all my savings and opened my own surgical facility… but we had a different business model. Rather than the passive attitude that has become the norm for leaders of society today, I decided to do things a little differently.
I find it fascinating that companies like Google that are so large and influential are okay with corporate mottos like “Don’t be evil.” I see this as a sad statement indeed. Wouldn’t the world be a better place if the Googles of the world had mottos like “Do some good”? So when we opened our concept practice, I micromanaged every corner of design.
The patient experience: the smell, the sounds, the colors. All tailored to give the patient a calm, clean, cutting edge surgical experience.
The technology: by investing money in technologically advancing my practice beyond the “standard office” I am able to spend more time with my patients because I spent less time documenting and doing redundant paperwork.
The environmental footprint: I created and entirely new category of practice. As part of our core DNA, our practice implements every policy and procedure with patient safety as a first priority, and the environmental impact as the second. The reason behind this was simple, the environment out patient lives in is just as important to their health and well being as the as the care I provide them in the office. What good is the care I provide in the office, if our office and my own lifestyle is harming our patients outside the office. So we made the shift.
The financial model: we don’t participate with contracted insurance companies, because we want the freedom to work directly for our patients, and not under the thumb of the bean counters of billion dollar profit driven companies.
I’ve written numerous articles about how a for profit insurance model is the core of the problem with American health care. Most of the issue stem from this root. We have the best doctors in the world, with the most abundant resources, yet we are among the highest in obesity, heart disease, cancer and diabetes. The percentage of uninsured people in our country sparked historic legislation that extended the role of the government to unprecedented areas.
All because what procedures are paid for, what materials are used, and how medicine is rendered is decided on an economic model that puts profit before patient. I acknowledge that this is a broad statement and there are many models in the country that don’t play this game. But the “average” insurance company is a for profit machine. It doesn’t have a product. The product is something the doctor has… health care. Rather the insurance company triages the money and decides how much, to who, and when to pay it. This starts the vicious cycle of my favorite equation… Q=1/v.
Quality is always inversely proportional to volume. There is no escaping this equation.
To make more profits, insurance companies either have to increase their premiums, or reduce their reimbursements. When reimbursements are cut, doctors have to balance this new loss in revenue, and they do so by increasing their volume. Seeing more patients means less time with each person, so the patient suffers.
Doctors don’t increase volume to be millionaires. There are the outliers, but I’d like to still believe that the doctors of our society are kind, compassionate people who dedicated their youth to education rather than financial gain. We could have entered into business 15 years before we started our first practices, and made a lot of money during those years. But rather, we went to school, incurred debt, and stayed up long nights taking grueling exams and enduring stressful coursework to do what we love… fix people.
The fix is simple. We need to put the patient back at the top of the pyramid, then the doctor, then the ancillary staff, then everyone else. That everyone else includes all the insurance company executives and employees. And let’s not forget to mention the shareholders. If you own stock in an insurance company, you’re just as guilty for the broken healthcare system we have in this country.
Until we as colleagues gather the courage to cancel all their contracts, and patients stand up to their insurance providers and demand they respect the actual providers of health care, there will more discount medicine being practiced in America.
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