American College of Physicians: Internal Medicine — Doctors for Adults ®

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Commentary

Why we must take responsibility for health care’s woes

From the April 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Harold Frolich, ACP–ASIM Member

I read with some disbelief and much bewilderment the President’s Column by Sandra Adamson Fryhofer, FACP, in which she described her frustrations and disillusion resulting from her own choice to affiliate with a large practice that had a “corporate” affiliation. (“How some internists are surviving the corporatization of medicine,” November ACP–ASIM Observer,.)

What is so disturbing about Dr. Fryhofer’s article is that her thesis seems to be rooted in the same sentiments of blame and inaction that have characterized the physician community for the past two decades. These attitudes have caused much of the frustration physicians feel today.

Dr. Fryhofer paints a picture in which physician responsibility and accountability for the health care system are nowhere to be found. Apparently, all the changes in the health care delivery system have been caused by others. Physicians and patients have been the victims of this undesirable change and are devoid of any responsibility.

She absolves physicians of any responsibility for their choice to affiliate with hospitals or corporations. As she states, internists were “lured” into their decisions, as if they were put into a trance and forced to become part of the corporate medicine machine. Did someone hold a gun to physicians’ heads and force them to affiliate with large, corporate-based practices, or did they make that choice on their own? Did anybody actually compel physicians to sell their practices to the highest bidder?

Rather, weren’t physicians motivated by their own greed and attraction to the illusion of long-term security? Didn’t they choose to “sell out” rather than “tough it out” and fight for the principles of medical practice that they allege to hold so dear?

Our health care delivery system has some significant flaws. One of the most important flaws, however, is the physician community’s failure to take responsibility for any of those problems. Physicians seem more inclined to complain and shift blame to the government, the insurance industry or corporate managers.

Many physicians fail to realize that the systemic changes they dislike came about for very specific reasons. Managed care was created because of shifts in the national economy. The business community, which pays for a good share of the health care delivered by doctors and hospitals, became frustrated when costs escalated and neither doctors nor hospitals seemed willing to eliminate unnecessary costs in the system.

In order to compete economically, the business community concluded it had to control medical costs, and it turned to managed care. The government had come to the same conclusion years earlier when it instituted diagnosis-related groups (DRGs) in the early 1980s.

If physicians and hospitals had managed the health care industry properly, those who pay for services would have exerted little pressure to alter the relatively laissez-faire nature of medical delivery that prevailed before 1983. The medical community, however, had become complacent and was not prepared to counter marketplace changes. Rather than get in the game and manage the business of health care, physicians sat on the sidelines while others began creating the rules of the new era in healthcare economics.

What would have happened if physicians had left the sidelines two decades ago? We would have recognized that medical practice variation among physicians is too broad, narrowed the field and reduced outliers. We would have loosened the reins of physician autonomy to organize and work together to improve quality and cost-effectiveness. We would have recognized the divisiveness of great disparities in compensation and status among our ranks and would have made sure all physicians are compensated fairly.

But as a profession, we did little in the areas mentioned above. Instead, we chose to protect our turf. When it became apparent that we weren’t willing to make productive contributions to the changes ahead, business, government and insurers stepped in and created mechanisms to reduce practice variation, ensure quality (according to their definitions), lower costs and chip away at the high reimbursements traditionally given to subspecialists. As a result, physicians do not like the way others are managing health care. Perhaps if we had taken care of matters ourselves, things would be different today.

Dr. Fryhofer extols the virtues of physician autonomy, claiming that the villains in the system have eroded the “sacred foundation of internal medicine: the doctor-patient relationship.” But what is her antidote? A government mandated patients’ bill of rights! How would more legislation preserve physician autonomy? Her response seems inconsistent with her thesis that physicians suffer too much interference and regulation.

I applaud Dr. Fryhofer’s decision to return to solo practice. I congratulate her for taking responsibility for her own destiny and hopefully accepting accountability for her decisions.

As physicians, we are at great risk of becoming quite peripheral to the system. But there is still time to make a difference and take control of our destiny.

Our future will hold some hope only if all physicians accept their share of responsibility for the system, stop sitting on the sidelines complaining, and play a constructive role in shaping the future of health care delivery. Are we up to the task?

Dr. Frolich is president of HF Medical Management, a physician organization and care management company in Fairlawn, Ohio.


Dr. Fryhofer responds

Editor’s note: Immediate Past President Sandra Adamson Fryhofer, MACP, responds to the above comments from Harold Frolich, ACP–ASIM Member:

The response to my November ACP–ASIM Observer column by Dr. Frolich provides a novel view of the causes of a managed care system run amok: Physicians are the problem, not the managed care organizations and insurance companies that control the system, the patients and the physicians.

Dr. Frolich maintains that because physicians were allegedly irresponsible in not implementing cost containment, big business and the insurance industry stepped in to save the American health care system and the national economy. And, by the way, the last thing any physician or patient needs is “a government mandated patients’ bill of rights!” (exclamation in original).

Although the foregoing may reflect the managed care party line, I believe it is disconnected from reality. Internists are not, as Dr. Frolich claims, on the “sidelines” in attempting to address the problems of managed care. Within their individual practices and as part of larger organizations like ACP–ASIM, many have fought to protect their patients and return patient care to the judgment of physicians. Many internists have also discovered, to their dismay, that they are often powerless to control much of the worst that is imposed on them and their patients by those in management positions who do have the decision-making authority within that system.

I also strongly disagree with his labeling practicing internists with such loaded terms as being on the “sidelines” of this problem or having “sold out.” To the contrary, it is the practicing internists who are “in the trenches” and delivering patient care. We, more than anyone, understand the magnitude of the problem and the solutions.

ACP–ASIM is dedicated to our members and our patients in addressing the worst abuses of managed care. A patients’ bill of rights is but a small step in the right direction. With a change in the political winds, it now looks like a bill may become reality. It remains to be seen whether the managed care and insurance industries will continue to blame and fight physicians and the public, or whether they will join with us to effect a change for the better.

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