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    How can doctors cure America’s ‘sickness’?


    In the book, I followed around an independent cardiologist who I knew when I was a resident, just to see what it was like. It was miserable. Just the amount of time he spent getting prior authorizations, checking on insurance, etc.; He eventually shut down his practice and I think that’s sad. He’s the kind of doctor I would go to. He’s the kind of physician we say we value the most—and yet they are the most at risk. 

    I think, as patients, we need to be more vocal, too, and say we value thoughtful care, especially primary care. It is incumbent on both physicians and patients … everyone has grumbled in private on both sides, but not been active. We need patients to say this is not OK. That this is what we want from our medical care and we want these guys valued and able to access the information they need. We want to know about price, but want it easier for our physicians to have this information and not working at midnight to find it.

    It’s a bit of a David and Goliath effort. Hospitals have consolidated. Insurers have consolidated. Doctors are never going to be as consolidated, so maybe the answer is for a different kind of doctor to get involved in the AMA to recognize and drive common patient-physician interests. 


     ME: The “Age of Physicians” chapter highlights physicians gaming the system (via Medicare fraud, for example). Where do you think the majority of U.S. physicians fall? Are they trying to exploit loopholes in a troubled system or playing by the rules given to them?


    ER: Most doctors in their motivation are totally in the “good side” category and not bad apples. But there is a huge grey area to me. 

    I think many physicians have done things that are ambiguous in terms of value for cost: Are they good [for patients] or are they money-making opportunities? But the big question is: Have they resorted to these money-making opportunities because it is just so hard to get paid for what they actually do? I think the whole system has encouraged, and in some cases necessitated, doctors to look for profitable activities in order to make things sustainable. 


    Further reading: Where precision medicine is headed


    At some level, the impulse is also natural. You say, “I’m referring all these people out for physical therapy and this physical therapy center run by a business person is billing $500 an hour for a PT session. That’s nuts. Why should I send my patients out? I can do it better here, so why shouldn’t I get that money?” I understand that, particularly when you feel you are not being paid well or at all for some of the important services you do give patients.

    It is very complicated. You see in that chapter on physicians who are offering things for a lot of money that are not useful, but they are being called out by other doctors in their community for doing those things.

    I remember hearing from one cardiologist in New Jersey who somewhat reluctantly sold his practice to a hospital and said he felt like he had two choices: “[Sell to the hospital], which I’m OK with, while I liked being independent. The other was to do what the guy down the street is doing—everyone who walks in the door gets an echocardiogram and a [stress test]. I didn’t feel good about that—I knew every patient didn’t need that.”


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