ctd With rapid advancement in medicine came an increase in relief and cure and a gradual increase in life expectancy. With education came knowledge. This resulted in the understanding of disease and the diminution of acceptance of fait. Peoples expectations increased in direct proportion to the decrease in the belief that it was the physician who healed.
Then came Health Insurance. This was a 'game changer'. This changed the perception of the cost of Medicine. Money did not come directly out of the pocket of the patient for the cost of tests or treatment, it was coming from a third party. So the real 'Value' was greatly reduced. Doctors ordered tests and treatment without much consideration of the cost involved and the patient naturally wanted the 'best'. In the 'sevetees' and 'eightees' of the last century I had patients request me to put them in the hospital for a few days for they wanted some 'rest', or asked for an extra day or two of stay for it was convenient. This, naturally, could not go on for Insurance became a right to 'medicine on demand' by patient and physicians alike. " I got insurance" . " I pay X hundred/thousand dollars a year". ergo "I deserve the best". This stood the concept of insurance on its head. It was unsustainable. Soon came deductibles audits, restrictions, denials "carving out', 'pre-existing conditions' and denials. much to the surprise of both the healer and to-be- healed. This resulted in general dissatisfaction. The doctors became unhappy due to the questioning of their previously unchallenged authority, the insurance companies, due to the unbridled cost of the technical advancements and increased demand, and the patient due to the resultant increased premiums and restriction of 'on-demand' medicine. Everyone was unhappy. This in the midst of rapid advancements in medicine.
Medicine transformed from a 'profession' to a 'trade' or business, very rapidly. With its inevitable side-effects. Business people took over the running of hospitals even though most remained' non -profit'. The old concept of a 'community' hospital became unsustainable The 'free' city hospitals closed or started asking for insurance. For -profit hospitals opened up. The people in-charge were business oriented (MBAs). Hospitals became larger in size as smaller ones were absorbed or closed, as they became non-viable. Hospitals were no longer hospitals but 'medical-centers'.
"Losing" services of a hospital were dropped as lucrative ones were added. The concept of 'charity care' of the uninsured disappeared as hospital demanded and got re-imbursement for these 'services' from the state, though never in full. 'State' hospitals, which were mainly for the physically disabled and the Mentally ill and generally run well became a 'burden' for the state as the costs increased they became a drain on the state budgets. They started shrinking in size, became mismanaged or closed. Then came the concept of placing mentally ill patients in the 'Community' where no community wanted them.
Similar things happened with physicians. Solo practice became a problem, not because of lack of patients or expertise but what was now required. Paper billing became inconvenient to insurance companies including Medicare. So they first suggested, then mandated electronic billing for their convenience. There were a few exceptions by Medicare but they penalized those by deducting some money for that privilege. Others made no exceptions. A solo practice had no power but a larger group did, With medical insurance, malpractice insurance, medical and office supply companies and others. There was 'strength' in numbers. So physicians started joining each other in small then in larger groups to be in a better position to negotiate. To start a practice all you needed was an office and a nurse/ secretary, a typewriter and a phone. Now it was secretaries specializing in billing, reception, medical records, dealing with insurance companies, medical assistants and nurses, a computer for billing and one for electronic records. And an office manager to oversee all that. These cost hundreds of thousand dollars and needed frequent tinkering and maintenance as their templates did not fit in with the needs of various specialties. Things had to be 'streamlined' and made 'efficient'. Consultants were needed for that. So what a physician and nurse did before was doled out to assistants.. The physician no longer took a history of his illness from the patient who filled out a comprehensive form- whether for ear ache or severe asthma, nor the 'vital signs', nor could he deviate from the template into which the patient had to fit. All in the name of efficiency but really to save time so the physician could see more patients per hour. 'Billing codes' were devised where the time spent by the physician with a patient was a key factor in reimbursement.
Medical specialties came out with ' guidance' for treatment for illnesses. Any deviation or ordering of an expensive test required ' preauthorization', where delay and denial were used to frustrate physicians if they did not fit a set profile.
So now when a patient came 'everything' was done, all that was needed was an exam and treatment orders by the physician and entry of these in an hand held devise, there was very little time for conversation with the patient before hurrying on to the next one. So now there were many things between the patient and healer. He or she had not taken the history of illness or vital signs- which could be in error and did not have much time for an exchange with the patient. There were also now many people in between.
Some practices were bought by hospitals and the physicians became employees. The physicians did this to get rid of the new headaches of practice not realizing that becoming an employee has its own headaches. You are told what to do how to do it and when to do it. Those who transited to all this experienced this discomfort, those who started practice in this situation did not know the difference. A profession priding itself on independence, dedication, individualized service for the welfare of the patient, now became a trade. (To be cntd)
