A  Practitioner's Journey from Solo Practice, to Managed Care, to Obamacare
 

A Long Day’s Journey into Night.
 

Eugene O’Neill (1888-1953),  Title of 1956 play

Up, lad, When the journey is over, there’ll be time enough to sleep.
 

Alfred Housman (1859-1936) A Shopshire Lad (1896)

In 2003 I wrote a book A Managed Care Memoir: A Physician’s Whistle-Stop Journey (Infinity Publishing.com.) The book chronicled my 27 step managed care journey from Minneapolis to Old Saybrook, Connecticut.  It speculated on what lay beyond. The metaphoric vehicle was the HMO locomotive with stops at Minneapolis, Oklahoma City, Cambridge, Massachusetts, San Francisco, Vail, Colorado, Nashville, Denver. Austin,Texas, Fort Worth, Wilton, Connecticut, Saratoga Springs, New York, Cochrane, Georgia, and Jackson ,Wyoming.

I thought of  my journey when I read about the journey of  Ed Marsh, MD,  an ex-pediatrician who now grows Christmas trees in Upswich, Massachusetts. In today’s WSJ, he writes of his journey from an idealistic medical student to a disillusioned ex-practitioner, “Reflections a Medical Ex-Practitioner. ” He chronicles his trip from  his 1962 medical school graduation, post graduate training ,  to solo practice,   to closing his practice to participate in a “prepaid group " practice, to retirement to raising Christmas trees in Upswich.

Dr. Marsh, in moving, cogent, colorful, and flowing prose, captures the essence of the evolution of medical practice over the last 50 years.

·         Of medical school and setting up a solo  practice. “.When I graduated from medical school in 1962, the profession of medicine was for many graduates an opportunity to provide care—as distinguished from, though aligned with, treatment—and to provide it to individuals, not to populations or governmentally specified groups. Young doctors hoped to establish an independent business, enjoy lifelong intellectual excitement as knowledge and therapies expanded, and have an income sufficient to live decently and support a family. There have always been some who entered medicine, as with any vocation, to maximize income. Yet most of us who came into the profession in the early 1960s had modest financial aspirations and substantial social commitment.”

·         Of solo practice - After eight years of postgraduate study, I opened a solo pediatrics practice in a community of 10,000 souls an hour from Boston. A number of lean years passed before I could build a robust practice. Yet the experience was exactly what I—and I think many of my colleagues—sought: a personal, direct and unimpeded relationship between me and those who chose to become my patients.
 

A major cause of financial stringency was that there was almost no insurance that covered pediatric care in the office setting. Many pediatricians felt denigrated because the care that they were providing was not regarded as sufficiently consequential to be covered by third parties, as was that of their brethren in internal medicine. Surveys always showed pediatricians to be the poorest-paid of all the specialties.

·         Of the entry of managed care and physician and patient reactions- Then, in the mid-1970s, things changed, and we became enlightened. Third parties, typically the insurance companies, were interpolated between the physician and the patient. Some of the consequences were unfortunate.

Patients knew that any suggestions I might make would have negligible consequences for their own budgets, so "more" became the expectation. A sense of entitlement developed. Why would the doctor hesitate to do some procedure, or hesitate to request a test? Everything was already paid for. If I was reluctant, perhaps weighing the cost to them, patients speculated there must be some hidden reason. Perhaps I was, in some obscure way, feathering my own nest. Misgivings arose.
 

This mistrust heightened—and became rational—when "prepaid" group practices became more prevalent. Physician compensation is tied to "efficiencies," which means reducing the outlays and costs to the group (translation: skimp where possible) and thus generating for internal distribution a larger share of the prepaid practice.
 

Second opinions proliferated, upping the costs. Patients could get two opinions for the same price: near zero. I could acquire additional knowledge from the feedback of the consultant and was better positioned should some legal controversy arise. One under examined aspect of defensive medicine is those excessive referrals to diminish responsibility.

·         Of why he left solo practice to join a prepaid group - Insurance relationships drove practice relationships. Patients were more likely to come to me because their insurance told them to, and more likely to leave, despite our congeniality, because their insurance required it. Thus our dealings were less personally rewarding, for my patients and for me.
 

When it became increasingly difficult to work according to my principles, I closed my practice, first joining a "prepaid" group for 15 years, and then leaving patient care altogether. As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one's patients is being extinguished.

·         Of Obamacare and the end game - When it became increasingly difficult to work according to my principles, I closed my practice, first joining a "prepaid" group for 15 years, and then leaving patient care altogether. As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one's patients is being extinguished.

The medical economist Rashi Fein observed in 1986 that there are only three ways to limit the extravagant demand for medical care: "Inconvenience," the practice used in the military, where one must wait interminably for care. "Rules," the third-party approach by which layers of rules and thousands of regulations are devised, most recently in a fool's quest to contain costs under ObamaCare. And "Price." ." This last option elicits gasps and chest-clutching from bien pensants who insist that all financial impediments to care must be removed. Yet it has one incontestably beneficial attribute: It requires the physician to study the true cost and benefits of a course of action, and then to present that data to the patient. Who is better suited than the patient to assess the value to him of the proposed treatment? Kathleen Sebelius? You gotta be kidding….

ObamaCare will, deliberately and by design, destroy what—while imperfect—has served very well. We have gotten to this point after years of good intentions making bad problems worse. To double down on the very therapy that has brought the system to its present sorry pass is a toe-ticket to the morgue.

Dr. Marsh’s eloquent rage reminds me of poet Dylan Thomas’s classic poem, “ Do Not Go Gentle into That Good Night,” which opens with this stanza:
 

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Tweet:   The journey from solo practice, to prepaid care, to Obamacare has taken the glow off of doctor patient relationships and joy of practice.