Sunday, May 24, 2015

Pandora's Iceberg

It was disturbing to read on the news the suspicious P2 Billion claim filed by Philhealth affiliated hospitals and clinics for fraud.

It drew another blow to the medical health profession that was reeling from allegations of tax evasion by the Bureau of Internal Revenue, bidding and research irregularities in the public health service, and unethical relationships with the pharmaceutical industry. It saw health care receiving the brunt of criticism from a public that was dissatisfied with the care that we, as physicians swore to uphold with the highest ethical standards.

There is a clamor to restore the image of the physician to align with more appropriate ethical practice. The question is, why has this happened?

Greek mythology has it that Pandora, the first woman on Earth, was endowed by the gods with several attributes of goddess qualities. Pandora was gifted a box full of evil by Zeus. As the story would have it, Pandora's curiosity (much like Eve's curiosity of the apple tempted by the serpent in the Garden of Eden), would release all the evil (including death) in this world. By the time Pandora realized what she had done, she had released all the contents except for one thing that laid in the bottom.

To open Pandora's box figuratively emanates from that story. A small act or seemingly innocent one at first can have a domino effect and result in far-reaching consequences by the time we become aware.

Undoubtedly, the root cause of all the inappropriate behavior of the physician is financial remuneration. Not that financial remuneration is bad. It's how we earn our keep that matters.

To understand why this happens is not within the realm of this blog. There is no excuse for such behavior in any profession. Why the medical profession is highlighted is a different story altogether. I guess it's because people consider the health profession a noble one. What once was a simple doctor-patient relationship became complicated with third party business providers and as the future evolved, so did health care. The HMOs were the business boomers. They turned health care into a business far beyond what the naked eye could see. The HMOs took advantage of both the doctors and the patients. It's rubbish for any one to claim that their HMO business is to benefit the patient, and make it worthwhile or profitable for doctors to get reimbursed. For god's sake, an HMO is an insurance company. Why do you think they even came up with business models like these if it's not profit oriented?

HMOs sell health insurances to companies in guise of a "perk" being provided to employees. Employees believe that this perk is a right to badger the hospitals or doctors whenever they feel there is a need to utilize their insurance. You see patients in the emergency rooms with health cards demanding to get seen for a health problem that should have been seen on an out-patient clinic. But since they're too lazy to go and make an appointment with their doctor, they will use limited resources from their health card since to them, the ER visit is "free" anyway. They're also the same ones that abuse the hospitalization privileges. Even mild viral infections are admissible cases to them. They will DEMAND that they or their children get confined and worked-up, simply because they can claim leaves of absence from work or won't have to pay for medicines, or simply take advantage of the whole insurance health care system scheme. They will connive and coerce doctors to utilize their health cards even if the first admission was not admissible and the next admission is a true emergency but is the same illness as the first. Their reason - it's paid for anyway! And when their credit limits are breached during the hospital stay, they're also the same people that will DEMAND that they get discharged at once because they're not willing to dish out additional expenses for patient care. Those belonging to the lower rung of the totem pole in the corporate ladder has the highest utilization for HMO privileges.

Patient care.

Where does the physician fit in this complicated business maze?

The HMO-affiliated doctor simply gets a drop in the bucket. The biggest share goes to the hospital or clinic and the HMO. That's the reason why some HMOs do not like hospitals that are too expensive because their bottom line costs will bloat and patients will not benefit from exuberant costs in hospitals. Which goes to the point of having to "standardize" the hospital payment cost of every HMO to any and all hospitals that want HMO affiliation so that patients will benefit from the insurance cost. Regardless of whether the patient would want to get admitted to Hospital A in Pasig or Hospital B in Taguig, the HMO pays the standard cost to the hospital for the procedure, hospital stay, professional fee and medicines in the hospital. At the current scenario, only the professional fee to the poor doctor is standardized. If the professional fees can be standardized, why not the other costs of board and lodging and procedures in the hospital? They are, after all, more static and negotiable by hospital administrators with their suppliers. As a matter of fact, it is obscene that the physician does not enjoy the same perks and benefits as the nurse or the occupational therapist or the pharmacist or the CEO of the hospital because the doctor is NOT an employee and has no privileges at all. When doctors get sick, sadly the hospitals they work for don't and won't take care of their medical expenses. There are very minimal, if any, medical privileges provided by hospitals to their doctors. The rationale of hospital administrators is that while doctors bring him patients to the hospitals (and are therefore its major source of income), the doctors also financially benefit from hospital admissions for patient care. A seriously absurd corporate mentality!

Which leaves us with the question - do these aforementioned scenarios justify the unethical practices of physicians in the profession? The answer is NO. But the last two decades has seen the boom of the HMO - as a business. It has transformed the paradigm of health care from one of personalized care, to one of big commerce. I am not saying that a HMO is totally bad. It just needs to be totally redefined to both educate the beneficiaries as well as appropriate the scarce resources to more admissible medical conditions and just compensation for services rendered. It should design packages that absorb costs of preventive health care such as immunization in children and not for adult health lifestyle check ups alone.

This applies also to Philhealth. There's so much money in reimbursement to physicians involved when it came to cataract surgery (which according to the ophthalmologist of my mother, is a relatively quick procedure like pulling out a tooth) compared to how much we are reimbursed for moderate to severe pneumonia, which is life-threatening and has higher mortality than cataract surgery. I recall my mom's cataract surgery went for one hour and the doctor had gotten P16,000 from Philhealth. I had a patient who had very severe pneumonia (TB Pneumonia) and got P3,600.00 from Philhealth for a 16 days hospital confinement which included a closed thoracostomy tube insertion! As to what the basis for the professional reimbursement costs for various medical cases by Philhealth were - your guess is as good as mine.

The paradigm shift in the practice of medicine has gone from healthcare practice to healthcare business.

Because we don't have a lot of benefits unlike full time employed workers, some often ask the question "what's in it for me"?

The answer - none. And there should be no expectations set to to our younger colleagues.

You see, I never wanted to be a doctor. So I guess that's why my outlook is quite different. I eventually found out after graduation and my years of practice, that one cannot expect to get paid for everything one does in the profession. That the anatomy of disappointment are expectations. And that I learned to love what I do and I have passed up many opportunities that came my way for better and more stable pay in place of my private practice. At the end of the day, it's liking and loving what you do - not for the hefty cash you bring home (which is the icing on the cake) - because you know you're really good at it! Making kids better, making your profession more meaningful, adding extra years to lives that would have been zapped up had you not cared for them.

Medical practice is an art. It's not a business. Some big business changed the way health care has evolved. I guess all the commercialism and hullabaloo of who makes more and what car he or she drives or how many foreign travels one has in a year is the mark of success for some of us in the medical profession. If these are the drivers and parameters of one's success in our profession, I don't think we will be happy in what we do. There is nothing wrong with earning. But we cannot build a reputation where business speaks louder than the care we provide to patients. We need to shift the tides back to the question - why did we become doctors in the first place?

As many of these challenges collide with one another, like an iceberg waiting for a major disaster to occur, I hope that many of our leaders in the health community see the situation as an opportunity to change the tide.

Everything came out of Pandora's Box that day. From greed to envy. From despair to loathe. She allowed all the contents of the box out.

All except HOPE.

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