by Steven S. Sharfstein, MD
[Winter 1998; Vol.25 No. 3]
I grew up in New York in a family that earned a living from and was devoted to the garment industry. The so-called “rag trade” or “shmatte” business was always rough and tumble; that is, in business terms, it was market-driven according to the socially amoral rules of supply and demand. My dad was CEO of a successful small fur coat business inherited from his father. Today, the business remains the oldest, continuous fur manufacturing business in the United States. His focus and success was based on pleasing the consumer in his store and potential consumers in the marketplace. The key question he answered well was “who are my customers and what do they want?” The customer was “always right.” The vicissitudes of business cycles and the fickleness of style, weather (warm winters) and social preferences (animal rights) led my dad to strongly encourage me to pursue a career in medicine. I became the first in my family to go to medical school.
I discovered that the abiding principles in medicine were very different from that of business. Within the medical tradition, the “doctor is always right.” We studied and paid close attention to each other’s work (beginning with the cadaver) in the context of professing standards based on our expertise and our ethics. The consumer (i.e., patient) followed and complied with the advice and recommendations of the expert physician. The combination of Aesculapian authority and the Hippocratic tradition carried the day. The successful physician answered the following question: “Who are my patients and what do they need?” This is a very different question from “Who are my customers and what do they want?”
Many of us went to medical school in order to avoid going into business. However, in the current era of market-driven medical care, we have been forced to examine many professional assumptions, to reassess our roles, and to adapt to a new marketplace where physician autonomy has been eroded by a powerful new customer: the managed care review organization.
Yet I believe more fervently than ever that the business of medicine is the doctor/patient relationship. This new marketplace (both economic and political) powerfully changes the traditional doctor/patient relationship. This marketplace, which must balance the trade-offs of cost, access and quality, forces physicians and patients to pay attention to a new customer - managed care. Today, we see through the imposition of managed care, a methodology to control costs through the control of use. The current buzz word of this managed care revolution is “medical necessity.”
What is medical necessity? Managed care uses medical necessity rules and regulations and tries to answer the question: “who are my patients and what do they need?” and forces that answer on patients and their doctors. The doctor/patient relationship, a time-honored tradition, is, therefore, threatened by these marketplace forces since financial third parties (other people’s money) have asserted their power through managed care to control costs. Third and fourth party “medical necessity” protocols intrude on the delicate doctor/patient dyad, creating the stress and hassles all physicians and their patients experience today. They do this because much, if not most, clinical care takes place in a scientific arena of clinical uncertainty. Diagnosis and treatment, by their very nature, combine the science and art of medicine. They involve balancing the individual needs of patients, the statistics on effectiveness, the risks of intervention or non-intervention, liability issues, and, of course, costs. In the old era of retrospective fee-for-service payment of indemnity insurance, “doing more” helped reduce clinical uncertainty and also led to more income for providers. In the current era of prospective payment of managed care, “doing less” is rewarded clinically and economically. Patients must reexamine their roles and become more knowledgeable consumers. The Internet is already a marketplace for health care consumers. Learning about one’s illness and treatment is a necessary consumer check on the managed care enterprise.
Today, the doctor/patient relationship is controlled by this new medical marketplace, with third and fourth parties primarily motivated to cut costs for their customers: private employers and government. Regulation of managed care by state and federal “consumer bill of rights” is one important step to improved access and quality. In order to reestablish the doctor/patient relationship, we need to find alternative ways other than managed care for physicians and patients to regain control over the market either through single payor national reform or through consumer-driven systems such as medical savings accounts.
The left and the right of the political spectrum have different solutions to our health care crisis either through single payor or medical savings accounts respectively, but a common goal of re-establishing the doctor/patient relationship. We should support either of these solutions as the salvation for the business of medicine.
Today, my dad and I argue as to which business is more troubled - the fur business or the psychiatric hospital business? A favorite joke is for my father to inquire of me “Hey, Steve, how come you haven’t asked me how’s business?” Me: “O.K., pop, how’s business?” Dad: “Don’t ask!”
Dr. Sharfstein is CEO of the Sheppard Pratt Medical System