Since that some hospital foundation and HMO groups assign physicians to the inpatient service, where they take over the total management of patients with whom they are unfamiliar, Luis E Cebrian, MD, a GP from Chico has a word of caution. Coming from the National Health Service (NHS) in England, where “hospitalists” are called consultants, he cites one horror story after another in Medical Economics. Dr Cebrian had a patient that presented to the British hospital ER with a stroke. After the patient deteriorated, he phoned the consultant (“hospitalist”) who was annoyed that a primary-care physician and a member of the lower order of the medical world was questioning him and wasting his time. Ultimately persuaded to have a neurologist consult, the patient was transferred to a tertiary hospital where a CT scan showed obstructive hydrocephalus, a surgical correctable disease. However, the two week delay caused severe brain damage with no hope for any quality of life.

In the same issue of Medical Economics, Patricia J Roy, DO, graphically illustrates what happens to office overhead when the doctor/owner of the practice delegates payroll, accounts payable, and office management to administrative people. In eight months, her accountant noted that utilities increased 100%, injectables increased 500% and payroll, 250%. Dr Roy started coming to the office one hour earlier to re-assume these duties. When other doctors questioned Dr Roy’s playing comptroller instead of hiring a $12-an-hour clerk: “Your time is worth $200 an hour,” Dr Roy replied, “Hogwash. Paying the bills myself nets me far more than $200 per hour. It turns me into a well-informed, hands-on manager, enforces fiscal responsibility and, best of all, improves the bottom line. I get to write a bigger check to myself.” She suggests doctors “stir that idea into your morning coffee.”

In another issue of Medical Economics, the senior editor looks at why some physicians are top earners. Surprisingly, three of ten high earners are in solo practice. In solo practice, physician time and energy is not lost to politics and multilayered systems. High earners put in 3% more time, see 7% more patients and charge more per patients. Top earners participate in the most HMOs and PPOs, though they may not derive the bulk of their income from managed care. The surgical specialties still make 50% more than the rest of us. The number of physicians making less than $100, 000 has now increased to over 20%, which is about $30 an hour for the average 65 hour work week.

H Rex Greene, MD, the president of the Los Angeles County Medical Association (LACMA), has made a sharp turn to the left of center. His president’s report, “Human Rights,” advocates that universal healthcare access is socially just. He deplores that we do not recognize healthcare as a human right which may explain the puzzling unwillingness to support universal access. He feels the ethical imperative to serve patients regardless of whether they can pay is inadequate to deliver consistent health care in our communities. He proposes that we reexamine the Constitution, in which there’s ringing language about “equal protection of the laws.” Since the government is willing to be a major purchaser of care for some of its citizens–Medicare, Medicaid, the VA system, CHAMPUS, etc–he submits that it’s depriving the rest of their civil rights. He admits that this line of reasoning is a stretch. . . I would say it’s much more of a gigantic leap across an abyss. As our colleague in Chico above, and my friends in Canada and the National Health Service in England will attest, that equal access doesn’t even mean they will have care. Or as Richard Epstein develops the thesis in his book, Mortal Peril, more people will obtain access through the free market than through any governmental coercive mechanism. Or as Edmund Pellegrino, MD, states in his book, For The Patient’s Good, we will get further in helping the poor through treating this as our moral obligation rather than as a right to health care.

James Lloyd Rice, MD, a La Jolla psychiatrist, deplores that no specialty has been more deprived of managed care funds. In his articles that have appeared in the San Diego Physician and LACMA Physician, he makes excellent points about the trivialization of psychiatric disorders and treatments as well as unfairness in reimbursement, or even having access to psychiatric disorders where the psychopathology can be diagnosed from a distance. … The process he deplores, I believe, began much earlier. In the 1970s, it was quite routine to do consultations not only on the medical, surgical, OB and Gyn wards, but also on the locked psychiatric wards. Almost daily, psychiatrist were in the mainstream, and we discussed our findings with them much the same way as with the surgeons. They took lunch with us in the staff lounge. When administrators sold the psychiatric services for economic reasons, the specialty became isolated. Now we hardly ever see them. If a managed care patient needs a psychiatrist, the patient sees a psychologist or a social worker who recommends pharmacology therapy and writes the prescription for the one or two psychiatrist on the staff to sign or tells us which drug we should prescribe. It’s called divide and conquer–and deprofessionalize. Instead of back to the future, it’s time for physicians to move forward to the past and take charge of our practice.