Long, long ago, medicine was a true art, a calling, always enticing “the best and the brightest”. Doctors and hospitals worked cordially together and there was little medical inter-specialty competition. There used to be cohesiveness in medicine, but things change. Now there seems to be an underlying friction between doctors and hospitals, and divisions within doctor groups. This animosity has been evolving for quite a while. As with many breakdowns it comes down to differing politics, an inability to exercise any flexibility, and in almost all cases, outside threats to the bottom line. At the root of this issue is likely the loss of the captain. A cruise liner which has no one at the helm is not going to track a very steady course to its destination if it gets anywhere at all. Doctors used to manage medicine. More and more though, many decisions are being made by insurance companies, the government and hospital corporations, all groups with interests more diverse than just caring for the patient. With the current evolution in medicine, your doctor has had to share the helm to these groups. And with too many groups vying for the position of captain discord was bound to evolve.#placement_573654_0_i{width:100%;max-width:550px;margin:0 auto;}var rnd = window.rnd || Math.floor(Math.random()*10e6);var pid573654 = window.pid573654 || rnd;var plc573654 = window.plc573654 || 0;var abkw = window.abkw || '';var absrc = 'https://ads.empowerlocal.co/adserve/;ID=181918;size=0x0;setID=573654;type=js;sw='+screen.width+';sh='+screen.height+';spr='+window.devicePixelRatio+';kw='+abkw+';pid='+pid573654+';place='+(plc573654++)+';rnd='+rnd+';click=CLICK_MACRO_PLACEHOLDER';var _absrc = absrc.split("type=js"); absrc = _absrc[0] + 'type=js;referrer=' + encodeURIComponent(document.location.href) + _absrc[1];document.write('');Additionally, it seems our society is losing its respect for authority, and this is not just an issue with medicine. Growing up, I don’t ever recall referring to a teacher or a friend’s parents by their first names. But that is where society has gone, it’s the new standard. Everyone is now considered equal and deserves an equal voice. But, should the playing field of life be level? Probably not. Respect is something that needs to be earned, either through aging with valuable real-world experience or because of life achievement. Seniority divisions in society are not only necessary, they are healthy. The same is true in medicine, we no longer have doctors, nurse practitioners, physician’s assistants or nurses……..they have all been grouped as “providers”. There isn’t a word that bothers me more than this designation. After years of extensive training it seems your health care professional gets the same designation used by only one other profession on the planet, one that has nothing to do with healthcare. How did this happen? The medical cruise ship is well off course and badly needs its captain back, unfortunately the mutiny is still raging.Another area which has changed medicine is the legal profession bringing litigation risk. In medicine, as in all parts of life, errors can be made. In the perfect world the legal system would be able to separate out mishaps which may reasonably occur while delivering appropriate care from those which are unacceptable and therefore compensable. My father used to say, a good legal system is society’s watchdog, allowing for checks and balances in all aspects of life. Problems occur when the system is abused for profit, and with the potential for substantial malpractice settlements, abuse was inevitable. A few decades back, when malpractice mania was in full swing, doctor’s insurance rates skyrocketed because of the huge surge in frivolous lawsuits. That era came with a large financial and emotional toll for your doctors and hospitals. Doctors worked in constant fear of being sued. Subsequently came a time of malpractice reform which restricted malpractice suits and changed how your doctor conducted his practice. To guard against frivolous lawsuits protective medical documentation quickly became excessive. Currently, your doctor probably spends as much time generating an office note as he does seeing you. Additionally, physicians are now more likely to order unneeded tests to protect themselves against a potential suit. Even though malpractice reform eliminated much of the lawsuit risk this aftermath persists, adding greatly to healthcare costs and taking time away from your doctor he could have spent with you.Let’s further examine rising medical costs reviewing commercial health insurance. First and foremost, no medical insurance plan should ever be “for profit”. All dollars collected from the patient in premiums should be applied to the care of those insured under the plan. Certainly, as with any business, plan administrators and employees should make an appropriate salary, but profit for the company from premiums shouldn’t even be a thing. If there is a profit it infers that either dollars taken in premiums were excessive or needed care was denied (something commercial insurance plans are good at). At year end there shouldn’t be exorbitant bonuses for company executives or large residual profits intended to boost the company’s stock price. Any patient who was denied a surgery or a required drug is now subsidizing executive bonuses. In all fairness, some specialized treatments have become almost humorously expensive. Your insurance company is needed to help police those prices and negotiate better rates. Also, some plans are better and more fairly administered than others. Still, in the ideal plan, after reasonable expenses are paid, the insurer shouldn’t have a large bank balance at the end of the year. Any excesses should be rebated to the patients, used to lower future premiums or allow for additional future care. Regardless of the warm, wonderful ads these companies broadcast on your TV, your care is not their primary concern. Running a successful business needs to be, thus your concerns, even as their client, will always have to be secondary.Another layer of increased medical costs is the growing market for managed Medicare or the Medicare Advantage plans. Now about 50% of all Medicare recipients are members of these plans. Medicare is fine as it is. It does not need to be managed. It is already managed by the federal government, which in and of itself is bad enough. Adding a middle group to manage your Medicare just means that you will find it harder to get what Medicare freely allows, needing to pass a second line of scrutiny before your care gets approved. There will be required pre-authorizations and potential for denial. Managed Medicare adds an insurance company’s scrutiny and restrictions to your Medicare. As with conventional insurance, these plans can only make money by bringing in more revenue than they pay out in care. Medicare Advantage plans are expected to cost the Medicare program 600 Billion dollars over the next eight years. This is over and above what Medicare already cost, likely while providing less care. The only place these plans may help is in negotiating better medication costs and perhaps reducing secondary payments (the percentage of costs not covered by Medicare). Still, you are probably far better off with an independent secondary plan, one that plays by Medicare’s rules rather than enforcing their own to generate profits. A major contributor of excessive costs would be advanced technology. Much new technology is good, still there’s is always a tendency towards overuse. Other advances are just expensive changes and do not offer an improvement over what was already available more economically. Developing better treatments is desirable. Unreasonable costs and potential overuse of newer technology is not. There are so many examples of this within medicine, I’ll pick on two. Lately it seems everyone with skin cancer needs to have it removed with MOHS surgery. Micrographically Oriented Histologic Sectioning, or MOHS, is a complex, time consuming and costly process developed for consistent removal of certain types of skin cancers. MOHS was introduced decades ago, developed to treat particularly complex tumors where conventional techniques would likely fail. These included tumors which were harder to define because of a complex location, showing more aggressive growth characteristics, or had already recurred once following a prior excision. In practice, these complex cases represent perhaps only 5-10% of all skin cancers. These days though MOHS is being used for everything. Conventional surgical techniques for skin cancer removal are simpler, less time consuming, far cheaper and less stressful for the patient. They should also be successful 90% of the time. An experienced surgeon should know when to refer for MOHS. In the proper setting, MOHS is a game changing option, allowing for control of tumors previously difficult to treat successfully. The problem here is we’ve all been convinced MOHS is now the “standard of care” (the catch phrase to justify everything new and expensive) for any skin cancer, so it’s unnecessarily being used to treat even the simplest of tumors further escalating healthcare costs.Another highly promoted technology is the field of robotic surgery. The da Vinci company spearheaded this brilliant technology a number of years ago. In many areas this device has been a game changer, allowing da Vinci and its shareholders to be duly rewarded. It has important applications allowing certain complex surgeries to be done more safely, with less complications and reducing hospital stays. The robot also allowed the pioneering of new treatment options which weren’t previously possible with conventional techniques due to limited surgical access. Off-site surgery is also theoretically possible with this device. The problem here is, as was the case with MOHS, soon the robot becomes overly applied. Surgeries which could have been done as effectively and safely with conventional endoscopic or open techniques now are done robotically. When it comes to bringing patients to an institution, the robot has huge marketing appeal. Therefore, to stay competitive even smaller hospitals will have to purchase the device, spend money promoting it and then use it to cover its expenses. Each surgery requires not just the multimillion-dollar robot, a six-figure annual service contract and a specialized team, but also many costly disposable surgical instruments adding an additional layer of costs to already escalating healthcare expenditures. Whether or not a hospital actually makes money on robotic surgery seems to be a mixed bag depending on the hospital’s surgical volume and how many other hospitals in the area offer robotic surgery. Market dilution has taken away the marketing advantage. And as with any technology, the robot you have will become obsolete requiring replacement or updating. It’s the classic technology trap where the only real winner is the company. New technology in medicine is desirable but will always create evolving costs. The more an expensive technology is used the more the market seems to demand it. Hospitals, to compete, get caught up in this medical arms race, thus their costs continue to spiral as well. Is your doctor or hospital to blame? Absolutely not. They must use what’s new and current to remain competitive and valid. They have no choice but to adopt the latest technologies or get left behind. Tech companies are good at creating a snowballing effect. Highly priced goods support large advertising budgets which finance comprehensive ad campaigns leading to a surge in public demand leading to overutilization. The companies achieve this by convincing the public their technology should now be considered the “standard of care”, thus demanding it even in situations where it may not be. It’s unlikely any of this will change, so don’t expect to see your medical bills dropping any time soon.Doc H googletag.cmd.push(function() { googletag.display('ad-1515727'); });