From the Board: Profit Is Not a Four Letter Word

Kenneth A. Liss, DO
Hypertension and Nephrology Associates
Eatontown, New Jersey

I try, perfunctorily, to keep up with journal reading. Some of the publications are fond of placing self-help advice for doctors. Articles about efficiency, making better use of the HER, and how to avoid unnecessary litigation are commonplace. Frankly, some of the advice is timely and helpful, but I often find myself annoyed by the fact that these articles sit side-by-side with information about how to manage anemia in CKD, latest updates on vaccinations in immunocompromised hosts, and new data about initiating RRT in AKI. It’s as if we’ve come to accept the fact that being the best physician is as much about documentation, billing codes, and staff performance evaluations as it is about patient care.

Of course this all speaks to a much larger problem. The reason that self-help has such a large audience is that physicians have been subject to an environment in which regulations trump the patient-physician relationship. As healthcare dollars become more scarce, those in charge of doling them out have decided that healthcare is a basic human right. As a result, consumers of healthcare are no longer subject to capital markets. We have created a system where consumption has no boundaries, but profit is obsolete. Better stated, profit and healthcare delivery are dichotomous. The hospitals and insurance companies have got the jump on this and have created accountable care organizations where they will control the flow of both services and costs. Unlike the previous experiment with HMOs, this will have real teeth because, by attrition, patients will give up their right to choose how their healthcare dollars are spent.

To further add insult to injury, the government is adding so many onerous regulations that I hear my colleagues tell me that they are ready for a single-payer system. The truth is that I currently fork over about $30,000 in annual healthcare premiums to the insurance company so that my family has the right to access the type of care we want. The government would have me give that same $30,000 to them so that they can then dictate the type of care we are entitled to receive. Unless we need it, they are likely to take that money and use it to pay other patients’ costs. This is known more commonly now as Obamacare except that the insurance companies are still part of the equation. With a single-payer system there will be protocols that will determine what and when we receive care. If you want to prescribe sacubitril/valsartan, check off the first eight boxes and your patient might get it. If you want to use ferric citrate as a phosphate binder, you must call 1.800.profits first. Supposedly, these protocols will be based on best practices. I am not so sure.

I am proud of the job I do for my patients and feel that I am entitled to be fairly compensated for my services, much the same way the person who built my house or sells me my water is. These are both necessities, but are subject to market forces. If we remove profit from healthcare, we likely will see a precipitous drop in innovation. We are close to self-contained dialysis systems and functional xenografts. Amgen has developed a parenteral product that has a chance to revolutionize the treatment of mineral bone disease. These treatments might never get to make a real impact in a not-for-profit system. The list is endless. If we want to see the clock set back 50 years, we just need to keep reading the articles about how to make our EMRs more efficient.