The Practice of Financial Medicine

What’s that you say? You didn’t know about the specialty of financial medicine? Well neither did I until recently. No, this is not about President Obama’s plan for public health insurance. Although I do side with the American Medical Association in being skeptical of it I’m annoyed that their main bone of contention seems to be with what will happen to physician reimbursement under the plan. Way to get society on your side AMA. I actually don’t oppose a public health insurance plan, I’m just skeptical of how efficiently it would run in a country like America where everybody has a ME!, ME!, ME! attitude and a FREE=MORE=BETTER philosophy. On the other hand, if there was a single health insurance plan, I wouldn’t have to fill out all these damn forms, but I digress.

I’m talking about the practice of financial medicine as introduced to me by a physician friend over dinner just the other day. I was introduced to Atul Gawande’s recent article in the New Yorker titled “The Cost Conundrum”. Essentially, it’s about what happens when physicians act primarily as money-generators rather than people in a field that’s supposed to help people. All this time, I have whined about how the public does not appreciate how being a doctor is not like winning the lottery, apparently I’ve deceived myself. Sobering.

When I was looking for my first job out of fellowship just a few months ago, I did come across an advertisement for infectious disease specialists in McAllen, TX . It had a ridiculously high potential salary and a busy consult service but it was Texas thus it would take a very long process to get licensed and credentialed. Also, it being a border town I figured they would be better served by a Spanish-speaking physician so I passed it up. Now, I’m not surprised why the salary offer was such an outlier.

In his article, Dr. Gawande tells us that Medicare spent $15,000 per enrollee in McAllen; almost twice the national average, and $3000 more than the annual income per capita in the city. Wow! No wonder the American health care system is in crisis. The explanation in a nutshell is that “…doctors were racking up charges with extra tests, services, and procedures”. Probably as a result of CYA medicine. That’s another field of medicine I didn’t know about until sometime after third year medical school. Cover-Your-Ass medicine, the other kind of preventive medicine, to keep the malpractice lawyers and litigation and increased costs and increased malpractice insurance away.

Compared with patients nationwide, patients in McAllen got more diagnostic testing, more hospital treatment, more surgery, more home care, all of which was billed to and reimbursed by Medicare. See why I’m skeptical about the plan for public health insurance. You just know that the stingy private health insurance companies would have scrutinized and contested each bill. The doctors would then have had to think about which tests and procedures were actually medically necessary. Of course, it goes to the other extreme with private health insurance companies. They love to not reimburse even for very medically necessary tests, treatments, and procedures. Go figure!

Yes, the American healthcare system is broken. We are all to blame. We the physicians, we the consumers, we the government, and we the public and private health insurance systems are all to blame. But how is it to be fixed? That’s the question. It’s certainly not going to happen overnight. And accountability, as Dr. Gawande suggests, should be forefront. Right now, “no one is in charge”.

President Obama seems to have his finger on public rhetoric. I would like to hear his opinion on this article and what it means to his health care reform plans.