By Antony S. Egnal, MD
As I write this article, I reflect with sadness how the medical world around us has changed. The notion of a physician who’s supposed to be the patient’s most vocal advocate and make decisions in the patient’s best interest is being constantly and progressively eroded.
Having grown up in South Africa and practiced medicine in four different regions of the world, I believe that patients are basically the same – from the Xhosa women in South Africa to the Cree teenager in Canada to the patients in Delaware and Seattle – they all want a doctor who’ll listen to them, be there in times of need and, foremost, be their advocate in the art of practicing medicine.
Sadly, it looks like my current private practice model of care is a dying breed. In 2000 (pre-Obamacare), 57 percent of physicians in the US were in private practice. The most recent numbers show a decline to 17 percent – a startling change in a relatively short period of time! I believe a lot of this is due to young graduates being misled into believing there’s no future in private practice. Also, many of my colleagues, especially those in smaller practices, have simply given up and either left medicine altogether or been absorbed by a hospital system due to the pressures they face.
Private practice physicians choose to run their own practice for many different reasons. Mostly, we highly value our personal doctor-patient relationships, many of which are long-lasting, and aim to provide our patients with the best possible care. I send my patients to the best specialist after jointly deciding on what is best for them. Unfortunately, many of my primary care colleagues (and their patients) are not as lucky.
When patients sign up with Group Health (GH), most understand they’re joining a “closed” care system (i.e. they will see a GH primary care provider who will then send them to a GH specialist when appropriate). However, when a patient signs up with a Swedish or UW primary care provider, there are often referred to a Swedish or UW specialist – even if it isn’t in the best interest of the patient. In fact, some clinics have gone as far as trying to shame their employed doctors by publishing a list (in clinic breakroom) of the doctors and their percentage of referral ‘out of the system’. Does this seem to be in the best interest of the patient?
Years ago, when most providers were independent, there were rules to prevent price fixing (known as Stark regulations).Those rules are antiquated and need to be revised. Today, hospitals are able to do what is called “global negotiating.” They negotiate rates for their inpatient services and wrap into this process their outpatient rates. Thus their outpatient charges are often higher than those in an independent office. Often, some of this cost gets passed onto the patient (especially those with a HSA account). A bill was recently brought up in Olympia to force transparency and allow actual in-office and hospital costs to be published statewide. This bill was blocked by one of our large insurance providers – wonder why?
As recently published in the Seattle Times, the insurance industry has gleaned record profits recently, even under Obamacare. They’ve done this but cutting payments to doctors (including primary care) as well as pushing a greater burden of the cost of care onto the patient.
We have to strengthen the doctor -patient relationship and put providers – not insurance companies or hospital administrators – back in the driver’s seat. All patients should have a primary care provider they can see first. They should be able to choose their primary care provider and know they’ll be referred to the best specialist/hospital care in their area if the need arises.
*A few years ago Evergreen Hospital set up the state’s first Clinically Integrated Network (CIN) called Evergreen Healthcare Partners (EHP). The CIN is a legal entity whereby physicians and progressively minded hospitals can come together to provide high quality, cost-effective, patient-centered care. Initially starting with 200 employed providers, after opening up the registration, an additional 350 independent providers joined the network. We’re in the process of trying to get Overlake to join us, thereby setting up an Eastside health care system which plans to take the best care of it residents in the most cost effective manner. Most of our patients do not want to cross the bridge for their care- unless absolutely necessary. At the end of the day, those of us who are committed to being our patients’ undying advocate will continue to weather the storm and do what we love – and that is to take the best care of our patients.
Dr. Egnal is a family physician and managing partner at Eastside Family Medicine Clinic (eastsidefamilymedicine.com). He was named among the 2015 Seattle Top Doctors list (of over 15,000 nominations) for the 9th year. When not taking care of patients or spending time with family, Dr. Egnal is out riding his bike or wakesurfing on Lake Washington.