American College of Physicians: Internal Medicine — Doctors for Adults ®

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President's Column

How some internists are surviving the corporatization of medicine

From the November 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

The last decade has been a difficult one for internists. While many of us started our careers working in smaller practices that built their reputation on performance and patient relationships, many of us have moved to an entirely different practice environment: the corporate delivery of medicine.

The business model of small, autonomous solo practices or partnerships has given way to the mega-clinic, controlled by a corporation and often directed by nonphysician "managers." As hospitals and corporations gobbled up practices in an effort to expand patient bases and profits, many internists sold their solo or small practices to be part of the "clinic" environment. Many internists—including me—were lured by promises of reduced management responsibilities, a better working environment and more time for patient care.

Disillusionment

Many of us quickly realized, however, that the corporate delivery of health care presents more problems than the small practices we left. The autonomy that we had cherished was gone, and in its place were orders from nonphysicians who knew less about running a practice than we did and virtually nothing about patient care.

Demands to increase patient encounters soon took precedence over patient satisfaction, making it impossible for internists to use the skill that we have developed so well: listening. Simultaneously, more and more expenses were shifted from these organizations to physicians. The result was that at least in terms of compensation, the set-up resembled a solo practice—but without the autonomy.

That wasn't all. The new "owners" and their affiliated organizations often instituted compensation strategies that rewarded increased patient volume and encouraged fewer referrals, all to augment the bottom line. It was bad enough when insurers and health plans tried to impose limits on internists' referrals. It's even worse when those same demands, under the guise of "utilization review," come from the organization where the physician works.

As capitation expands to specialists, things are getting even worse. With internists receiving incentives not to refer and specialists being encouraged not to consult, patients find themselves between Scylla and Charybdis. They have a hard time getting appointments, and access to the care they need is delayed (or denied). We internists frequently find ourselves having to fight these restrictions and incentives to do what is best for our patients.

Even hospitals, which physicians turned to as allies to address some of the inequities in managed care, are having serious problems. Stories abound of hospitals operating at full capacity yet losing money. When hospitals bleed, they turn to doctors to make up the deficit—in rent, expense reimbursement or anything else they can find.

But corporate medicine has caused perhaps the greatest damage by chipping away at the sacred foundation of internal medicine: the doctor-patient relationship. How can patients trust their doctors to do what's in their best interest when HMOs, insurance companies and corporate managers have created a system designed to elevate a business's well being above a patient's?

In search of an antidote

Is there an antidote? I am not sure. To start, however, we and our patients need a meaningful patients' bill of rights. Internists should appreciate the work of Rep. Charles Norwood (R-Ga.), who is leading the fight. If anyone other than a patient's physician is going to influence the kind of medical care patients receive, he or she must be held accountable.

We must also each decide how to deal with the unfair pressures placed on internists. Unfortunately, some internists have simply given up, taking early retirement or starting ancillary businesses. Some, however, have decided to pursue an alternate course.

In my travels on behalf of the College, I have met many internists who have become disillusioned with corporate ownership and management of physicians, the dictates of insurance companies and HMOs, and the degrading effect these influences have had on the practice of internal medicine and on the internist-patient relationship.

Some of these colleagues have returned to their roots. They have decided to leave managed care and corporate controlled medicine to put the joy back into what they do. The good news is that their efforts are working. These internists say they are more happy and fulfilled than before.

Earlier this year, I reached a similar decision. I am leaving a large hospital-controlled medical practice and hanging out my own shingle, free of the dictates of corporate "managers" and managed care. I am looking forward to re-entering solo practice, to taking care of patients without artificial incentives, and to managing my internal medicine practice without corporate interference.

Surprisingly, many of my patients were as relieved as I. They too were fed up with managed care hassles and welcomed a smaller practice. I cannot begin to express the unspeakable joy I feel because of that decision: "Free at last."

—Sandra Adamson Fryhofer, FACP

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