Hospital Politics: You’re Little People
July 20, 2011 in Health Policy, Medicine
In the 1982 film Blade Runner, LAPD police captain Harry Bryant cautions special agent Rick Deckard not to stay in retirement with the line, “You know the score, pal! If you’re not a cop, 
you’re “little people.”
Little People. Yea. In the realm of hospital politics, if you’re not a highly paid specialist . . then . . you’re little people.
Recently I was privileged to have had a conversation with the head of the emergency department of the big-national-conglomerate-owned hospital where I work. One of the admissions to the medicine service overnight had turned out to be a patient with a fracture. The surgical specialist on call had requested that the ER admit the patient to the medicine service even though the patient was young and didn’t have any medical problems. The patient also had no insurance.
[Me on the phone to the ER director]: This was not an appropriate admission to the medicine service. There are no medical issues. Not even anemia. The patient’s blood pressure is better than mine right now! The only time the medicine service ever gets requested by the surgical specialists to admit a patient is when it’s an un-referred patient through the ER who doesn’t have any insurance regardless of whether they actually have any medical issues. They never ask us to admit their insured private patients! And unlike the surgical specialists, we don’t get paid to cover un-referred admissions from the ER!
[ER Director]: The surgical specialists don’t do their own admissions. They just consult.
That’s it. That’s the stark logic of reality that the ER director provided. But for those of you who missed it, I’ll provide a translation.
[TRANSLATION]: Federal law requires that we (the hospital) provide the same surgical services in the ER as we do in the OR regardless of the ability of the patient to pay. Therefore, we require the surgical specialists to be on call for the ER to provide this service. We pay them a fixed stipend (usually as much as $700 or more for each call day) because they also bring their private insured patients to this hospital for procedures that can make up to $25,000 to 30,000 for the hospital. We want to keep their business so we pay them to cover the ER. We pretty much give in to any of their demands like allowing them to consult only and not be the admitting physician on ER cases since this comes with more responsibility and paperwork than a consultant. In contrast, you medicine people make the hospital far less money. We’re lucky to usually brake even on your patients. In short . . you’re not surgical specialists. You’re little people.
Often these types of admits are far simpler and quicker to do than the average Medicare, complicated, medicine patient so is it really that big of a deal? Yes, it is.
Bedsides the principle of being discriminated against without so much as pat on the ass, there are the issues of uncompensated time and effort being taken away from insured patients and needlessly and involuntarily taking on the increased liability. In the current system, the hospitals often get some type of reimbursement from Federal and state grants and programs to help pay for care of the uninsured while the doctor is usually the last one in line to receive any compensation. We can’t write this off as a business loss since the patient was not seen in the office. Nor can be write this off as a personal tax loss. And far too many of the uninsured consider health care to be a “right”. I.e. something they are entitled to without having to pay for it.
The take home point here is that this is just another reason to avoid going into primary care if you or a loved one are thinking of becoming a doctor. Avoid it like the plague. Money (or sex) begets power and primary care physicians are at the bottom of the reimbursement totem pole. Not only do we not get paid well, we don’t even have the power to avoid becoming modern indentured servants.
I don’t know what your by-laws say, but in my hospital, that patient has to be admitted directly to the Surgical Service, and to an orthopedist on call. There is absolutely no reason for a primary care physician to take care of this kind of patient just because the orthopedist thinks his role is that of a consultant. The diagnosis – FRACTURE – is there, and to have two physicians involved in his care when he has no medical problems makes no sense at all. The fact that the patient is uninsured makes this scenario, as presented, even worse, reinforcing public suspicion that doctors are there simply for the money.
Yes, we all know the primary care physician is at the bottom of that totem pole, but that is only because whe have allowed it to happen. It ought not to be that way. Primary care remains the cornerstone of medicine, particularly at a time when we are wrestling, once again, with crucial issues like access and the continuing spiral of health care costs
The culprit is there: too many specialists.
The solution ought to be clear and simple: Establish parity by paying PCPs better even if this requires reducing reimbursements to specialists.
This is nothing new, but it’s time to make it happen by eschewing half-hearted measures that have failed us in the past. Otherwise, nothing will change, and we will be staring at this status quo for years to come.
I really don’t know what our bylaws say. Actually, I really don’t care because, as I say often, it’s THEIR hospital . . we just work there. EVEN if our bylaws stipulate that a surgical patient be admitted to the appropriate surgical service, they can pretty much ignore their own bylaws until . . and unless a lawyer or court of law forces them to do otherwise. So, I would have three choices. 1.) Hire a lawyer and spend a considerable amount of time and money to force a multibillion dollar hospital chain to follow it’s own bylaws, 2.) Refuse to admit a surgical patient and risk being “peer reviewed” for patient abandonment with loss of privileges and reported to the state board, or 3.) Quit.
It’s not that primary care physicians have allowed our status to be marginalized. Not directly. Quite simply, insurances pay for procedures, not for patient care. The money and associated political power has moved over to those specialties that bring in the most money with the most expensive procedures.