Viewpoint: Exam room involves more parties than the doctor and patient

February 5, 2010

The once private consultation between doctor and patient no longer exists.

How did all of these people get in this little room? How did a disconnect develop between the ideals of medicine as a science to help humanity and a profit-motivated business with its own agenda? In the 1984 book, The Social Transformation of American Medicine, Paul Starr recounts how organized medicine has turned from an altruistic "obligation of kinship and mutual assistance" to a vast business driven by corporations. An underlying premise is that medical technology and delivery is an expensive enterprise, and those who can supply the capital control the profession.

Insurance companies are a major player in the room, ensuring that their expenditures are tightly controlled. An order for a CT scan, for example, often generates a complicated "pre-authorization" process, in which the caregiver must prove that the indications were justified. Frequently, a third-party company does the actual review, thereby shifting blame from the insurer if the request is denied. Negative decisions can be appealed, of course, requiring more time and effort - with no guarantee of success. By placing enough roadblocks in the way, insurers hope that a percentage of the requests for these expensive services will be abandoned, lowering cost.

Pharmaceutical and advertising companies are in the exam room as well. If a prescription is written, many factors have shaped the final decision of drug choice. Direct-to-consumer advertising gives patients the idea that a new, branded drug may the best solution for their problem. In fact, many therapeutically equivalent and usually less expensive choices may be available.

The legal profession also participates in the exam. Although it is true that patient's rights as consumers must be protected, this seemingly wholesome motive is all too often easily corrupted. In a litigious society, a negative therapeutic outcome from the natural course of disease sometimes is confused with malpractice. This raises the cost of practicing medicine through higher insurance premiums, and, in turn, reduces the dollars that might otherwise be available to compensate patients who were truly disadvantaged through medical malfeasance. Cases of true malpractice certainly exist, but the current adversarial system of medicine and law often leaves the patient on the sideline. As caregivers, we find ourselves forced to practice a more expensive, "defensive" brand of test-intensive medicine, spending ever more of the insurance company's money.

This cycle of cost shifting and decision manipulation eventually serves only to increase the costs to practice medicine for the practitioner and to decrease care for the patient. We as practitioners are forced to perform a balancing act between the demands of the payers and the needs of our patients. This forces us to ask a painful question: Are we above manipulation by industry, or are we skillfully maneuvered into doing the bidding of the for-profit players that control medical care?

So as I sit in this crowded examination room with my patients, I worry about how to reconcile the essential problem of delivering the finest possible care to all in a society where corporate profits control access. This adversarial, complicated, competition-driven system is not in anyone's best interest. I look forward to the day when healthcare decisions may be made solely on the basis of a patient's needs and not determined by third parties whose interests often are less noble.

Robert A. Edelstein, MD, is a urologist in Lexington, Massachusetts. Send your feedback to meletters@advanstar.com
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