Monday, February 4, 2019

The Last Line of Defense

Editor's Note: The following article is the fifth of six stories TMA's Healthy Vision 2025 advocacy plan, highlighting TMA's priorities for the 86th Legislative session. In this story, Dieter Martin, MD, stresses the dangers of corporations, rather than physicians, calling the shots when it comes to patient care.

Physicians are the last line of defense between a patient and a corporation’s bottom line, says Austin hospitalist Dieter Martin, MD.

Hospitalists are skilled in treating the numerous non-emergency circumstances they encounter while treating inpatients in a hospital. Emergency medicine physicians, meanwhile, are trained specifically to handle trauma and the rapid-fire assessment and treatment necessitated by emergencies. They aren’t interchangeable.

“Memorizing the rules to basketball doesn’t make me LeBron James,” Dr. Martin said. “I can play basketball, but not like he does.”

Compared to hospitalists, emergency physicians are like LeBron on the free agent market: expensive. And that cost differential, a lawsuit filed by Dr. Martin’s group alleges, is why the company that contracts for both specialties’ services mandated that hospitalists cover emergency room crises like cardiac arrest and mass casualties on overnight shifts.

These allegations have not been proven in court. But this kind of conduct is what doctors mean when they talk about the corporate practice of medicine: the usurpation by a nonphysician of a physician’s diagnostic, treatment, prescribing, and referral authority and responsibility. It’s the practice of medicine by corporations. Although illegal in Texas, it still happens frequently.

Video: Here's Why Corporations Should Not Play Doctor

Austin hospitalist Dieter Martin, MD, shares an instance where physicians - internal medicine specialists- were mandated to provide care that wasn't in their area of expertise. He says it's crucial that physicians, not corporations, have "clinical autonomy" and make patient-care decisions.

Consider the impact when administrators, rather than physicians, make critical medical decisions. Micromanagement of length-of-stay data, not a clinical assessment of a patient’s recovery, determines when a patient should be discharged from a hospital — even if he or she isn’t ready to go home yet, Dr. Martin said.

Hospitals are paid for patient stays based on diagnostic codes determined by physicians. But “it is not uncommon for hospitals to tack on additional costs based on lab results, like if labs indicate something like malnutrition,” explained Dr. Martin. “That’s not why the patient came to the hospital, and [it] will be coincidentally resolved during the regular course of treatment, but hospitals bill for it, which ultimately costs the patient more.”

Or imagine the relief you feel when your grandmother is finally ready to be discharged and her physician says she can continue to convalesce at home. Not so fast, says the hospital, insisting instead that she be referred to a rehab facility of the hospital’s choosing — and possibly ownership.

“It’s not really an arm’s length relationship,” says Dr. Martin. “It’s more like hands around a doctor’s neck.”

The more hospital-dependent medical specialists are, the more leveraged they are because the hospital essentially has a monopoly on their workplace. Emergency room physicians and anesthesiologists are most frequently caught in this cross-fire. Physicians, and their patients, have little opportunity to push back against hospital dictates.

When physicians do object, and contracts are threatened, they have few options: acquiesce or find themselves out of work. In a city like Austin, with only two hospital systems, finding other work can be challenging. Forcing physicians to another state or town, or into early retirement, only exacerbates our ongoing physician shortage.

When physicians talk about “clinical autonomy,” they mean white coats, not grey suits, should make patient-care decisions. Physicians are ethically and morally bound to put their patients first. Corporations have other responsibilities.

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