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I have been doing general and trauma surgery since 1979. I have seen many changes. Most surgeons and medical specialists I work with are fine people. Problems really started in 1981 when the DRG (Diagnosis Related Groups) were begun to be implemented in Medicare cases. As that became applicable across the board, essentially fees were set by Medicare, Medicaid, Insurance companies, HMOs,PPO, and others. The idea that doctors essentially play golf and make millions simply is not true. I don't even own a set of golf clubs. It might be interesting to consider, though, whether you want to keep someone lean and hungry who is going to recommend for or against an invasive proceedure. Most physicians make a reasonably decent living.

What has been perhaps the most destructive element in health care today is the selective panel of insurers. That means an insurance company or group of insurance companies come into an area, hire a select panel of physicians, exclude others, and then once the group is "hooked" then beging to amend "rules" as to how the doctors practice medicine. Some physicians will leave the company, some will comply. There will always be plenty who will comply. Let me give you and example. If the drug of choice for a certain affliction cost $1800.00 and the second and third drug of choice cost $180.00 and the insurance company or PPO or HMO excludes the drug of choice; from its panel, then the patient will not get the best drug, he will get the second best drug. If, for example, that is an antibiotic, and the 2nd choice is a cheaper antibiotic which does not do the job, then at deposition the physician will be forced to say he chose the 2nd best choice and the resultant complication of inadequat therapy and subsequent drainage of abcess is because of falling below the standaard of care. The HMO does not take the fall, the physician does. To make the scenario much more odious, the physician who "spends"less of the HMOs money will often be rewarded with a bonus for "rationing" care or medication. The same is true for surgery recommendation. Often surgeons will have to call a high school trained secretary in Munsing, Michigan to get "approval" to perform a proceedure. Prior approval is the insurance companies way of keeping premiums in the pipeline for a longer period of time. If I recommend a Laparoscopic Cholecystectomy in a patient who is myserable and a secretary tells me and the patient we have to wait for prior approval, it might be 12 hours or a few weeks to obtain prior approval. It creats a hardship for all of the principals.

What has become very dangerous is when a group of physicians put on the "insurance companies hat" and tries to exclude insurance money managers so the doctors "cut" will be greater. It happens all of the time. I will give you an example. A group of physicians got together and decided to form a PPO. They laid out the guidelines, requirements. I was on the board and told them it could not possibly work because of conflict of interest. Well the board started parring down certain expensive drugs, proceedures, etc. which were considered the gold standard of care. When some of us refused to comply, it became very contentious. Finally, when they were 1 million dollarsdebt due to fiscal mismanagement the organsization went bellyup.

I believe in the final analysis, and it pains me to say it, but health care delivery will come down to 2 disparate systems. The first will be a Hillary-like system...much like that of Great BRitian. It will dissappoint all of its members and all of its providers. The second system will be for the extremely wealthy who subsidize through grants and being able to pay these exorbidant costs. The days of cost-shifting are numbered. Just as we have been conditioned to expect perfection in outcome (or you sue the physician) we will be conditioned to expect less. These will be generational changes, but the changes are already being implemented. Think about it. YOur freedom to choose which physician, which facility you want is already curtailed. We have come to accept that as the norm.

Take heart in this...that most physicians are decent and want to do the right thing. But just like teachers and the NEA, the AMA has been coopted by social engineers who are governed by moral relativism and expediency, and in the final analysis, the marketplace. Lives will soon have an actual price placed on them...For example, it will be said to be "immoral" to spend tax dollars on a person with certain chronic illnesses beyond age 68. Euphemism will be used to indoctrinate people to begin to think like this. We have already seen it happen. (Right to Choose=Abortion=Killing).(The Shiavo case-The judge "did her a favor" by dehydrating her unto death") Many, even on FR, are fervent advocates of this world view.

It seem evident to me after being in medicine some 30 years, that we, as a nation, have lost our moral moorings and are adrift. The anchor,that it is wrong to kill,has been detatched from 3 generations of young people. And now, the organization used to codify these notions in the minds of patients and doctors alike, has served up a dose of the "physicians right to choose or advocate death". Don't misunderstand me, I am a big believer in Physician Directive. I and my wife have such document regarding our lives. But as a treating physician, I know I cannot devine the mind of others or what their wishes would be, and therefore must err on the side of life. I have never stopped fluids or a ventilator. I have allowed myself to participate in the care of patients whose family assigned a DNR.

These are difficult concepts to wrangle with. Every responsible adult should procure a Directive to Physician.

Finally, all of my bitching will not supercede the defined will of HCFA or insurance companies. Their claws are sunk deep into the medical profession and those medical professional have families to feed just like you. Like all men, they want to keep their jobs. These changes seem glacial at pace, but we have moved a staggering distance from the salad days of 1980. That included much pro bonum, insurance, medicare, medicade, and being paid with a half gallon of blackberries. Those days are gone, and not for the betterment of any of us.

Thank you for your post. I wish we could get many physicians on here for an anonymous discussion of the problems in our medical care.

I worked in a corporation medical dept. and remember well the warnings when the HMO's and PPO's were implemented and the TRUTH of what a "gatekeeper" does - allows some to enter for care, some turned away.

I also saw our Medical Director see an employee who had very little blood in his system due to the care from an HMO for his medical condition. Don't remember the details but this employee had been fighting with the HMO's to get his condition treated and just got weaker and weaker. This medical director got on the phone and demanded that this employee get the medical treatment that the medical director demanded. So, he saved the life of that employee.

He immediately came out and told each of us "this is exactly why you should never use an HMO". So, although the medical doctors in the corporation were totally against the HMO's in the Medical Plan, it was done anyway.

I will not use an HMO but instead use the PPO portion of our medical plan. You pay a little more but you always have the choice of either using physicians in the plan or paying a little more to go to unlisted doctors.

HMO's do not allow that option. They also draw physicians that cannot make it in private practice, that do not mind skimping on the care of patients or who just want a easier practice.