So many of our doctors are becoming part of large systems. Have you ever wondered why? Many doctors are finding it harder to sell their practices because the only buyers these days are often the local hospital system(s) as indebted young doctors are avoiding taking on an existing practice, its responsibilities, and risks in today’s disjointed system The reasons doctors have difficulties in today’s medical practice often include: New doctors’ expectations for high salaries are due to the high cost of school. Many doctors in small practices have difficulty matching what hospital systems are offering in salary and perks. Selling practices are much more difficult when the only buyers are the local large hospital monopoly, a regional Wall Street-financed group, or some other entity wanting to expand their health care presence. The lack of raises from insurance carriers to small independent practices because the hospital monopolies now have the upper hand in negotiations. The individual practice that the communities rely on cannot even compete The increasing denials from insurance carriers on clean claims that should have been paid increase staff needs, while insurer reimbursements have failed to keep up with inflation for independent doctors and group practices. The cash flow crunch caused by this unnecessary burden is driving doctors out of business. Cash practice in different models depends on the wealth of the community. Doctors servicing poorer clientele, even in group practice settings, cannot compete with hospitals that dictate how much RVUs they should be paid per service, and they do not have the ability to profit from referrals like hospital systems do. If you are the type of doctor who is doing primary care the way it was designed, you would be referring less, testing less, and evaluating more. This type of practice is now wholly unprofitable due to the incentives to do more procedures vs. more preventative care. For doctors with old-time values who do not wish to be consumed by a larger system, they simply do not have the cash flow or marketing clout that larger systems offer. Some stay in practice alone and are adapting membership type models, otherwise known as concierge practice. You are basically being billed twice, the first time for a yearly membership and doctor access, and then they bill your insurance, too. When the math works, your doctor is making a high income and working less hard with a smaller practice and not dealing so much with insurance companies and their nonsense. What happens when a doctor decides to sell their practice to the local hospital system? The practice is taken over, and doctors become part of the medical system of that hospital. Sometimes they stay in their office, while other times, they may move to a hospital-based clinic. Doctors are either retiring or hoping to live out their last years in a practice they started or joined years earlier, and are usually being paid more, but based on the production of their practice. On the surface, this looks similar to private practice except the hospital corporation is paying them on the expectation of production. Unfortunately, there is a dark side to this conveyor belt approach to medicine, sometimes referred to as population health management, a one-size-fits-all approach to managing communities and their overall health. As a patient, you may now notice phone trees that require you to go from prompt to prompt, contacting your doctor now requires you to go on an app, and everything becomes impersonal. It also becomes difficult to see your primary, and people are sent to urgent care for less complex health issues, where one-size-fits-all care is given. The hospitals thrive on a model that has full schedules, by using AI mass marketing to your email and phone to have people come in constantly for different things. Americans are less healthy now with this approach, while every year, healthcare costs spike. Can we honestly say that after years of experimentation, this isn’t working? Doctors are selling more procedures as they must now produce RVUs at a certain level to justify their new salaries. True, most colds self-resolve and do not require meds, and helpful natural advice is rarely offered, although they will x-ray anything that hurts in the absence of a thorough exam and history, and you will frequently get a prescription for something that may not be helpful or can be harmful, which is why these drugs require a prescription. The Revolving door of the hospital and large clinic-based healthcare model is driving costs skyward since your doctor is less connected to you, and since their name is no longer on the door, the pride of ownership and accomplishment in private practice is mostly gone. More people are making your health diagnosis and treatment, fragmenting care and increasing costs regardless of outcomes. Nobody has developed a successful reworking of the disease model, which has left us sicker overall with packed ER waiting areas, busy walk-in clinics dispensing canned advice and X-rays to whatever aches, regardless of the history. The system is on life support, and we are paying twice what other countries do for care, as the rewards are not for keeping you well, but disguising this with drugs, which are often designed to mitigate symptoms, rather than cure problems, and the drug companies love people on renewable prescriptions. Life expectancy is down in the USA compared to other countries. If you hurt, the years of taking medication instead of seeing the right chiropractor, which, if used by the young, can help you develop better health habits when you are older. Chiropractors, most notable sports physicians, are one-stop shops for pain relief with a simple model that has proven itself repeatedly. Currently, the Veterans Administration, which has a slowly growing number of chiropractors on staff, is seeing the cost savings in the system. Most hospitals are slowly adding chiropractors since doctors who generate fewer RVU’s are less profitable for them. Medicare doesn’t allow chiropractors to order an MRI directly, although there is currently legislation that, if adopted, can change the Medicare law so chiropractors are covered as any other insurance would cover them in their state. You are then going to see hospitals bringing in chiropractors to their business models, which helps them save money, improve efficiencies, but again, the wellness model does not exist, and doctors are rewarded for how they refer and the RVUs that are produced from it. Note that this says nothing about improving your health in our unhealthy model of care, which is making some rich in the insurance industry, reducing your choice of doctors, and showing the ignorance of the current healthcare model, where there is a specialist for everything, treating people who have integrated systems as if the pieces do not add up to the whole. This is where one-size-fits-all care fails, but combined systemic care models can be made simpler with better outcomes. The system, in its current complex form, with multiple specialists all competing for the limited supply of medical dollars in systems such as ACOs, Medicare Advantage, and other models, all had the same problem: incentives for production but not for reducing healthcare needs. Unhealthy lifestyles, ignoring mechanical problems, and then treating the pain rather than the problem, have resulted in a public dependent on drugs for everything and unhealthy trends everywhere. Perhaps this is why chiropractic holistic thinking helps people avoid chronic problems years later. Welcome to the for-profit RVU model. What is an RVU or Relative Value Unit? According to the AMA (American Medical Assn.), What are RVUs? RVUs are used to represent the value of resources needed to perform procedures and services described in the Current Procedural Terminology (CPT®) code set. Each RVU accounts for the time, skill, and intensity involved in delivering care, and together they create a relative ranking system known as the Resource-Based Relative Value Scale (RBRVS). Each service a doctor orders or performs themselves, including examinations, has an RVU. In our chiropractic practice, we also have a value assigned based on these standards. Doctors who sell to the hospitals become employees and are offered larger salaries when compared to what is offered by private practices. Who wouldn’t want to be paid more and just practice medicine? There is no shortage of referrals from other doctors in the system because doctors are incentivized to refer there. Tests are ordered in the system. Specialist visits, which can take weeks or months to get, make them a hard-to-get commodity. The more visits, the more specialists, the more drugs, the more treatments, the more notes in the electronic records system owned by the hospital. The hospital profits from everything, and as they grow, they have been able to make negotiations on prices more difficult. This is the largest cost driver in our healthcare system as we drive out competition, incentivise doctors with money that is earned with production, there is nothing in this RVU system incentivising more things, more referrals, more stuff, and ignoring outcomes, which have no incentives. Making matters worse, Governor Christie, in a closed-door meeting, allowed Horizon Blue Cross Blue Shield in NJ to use tiering, which moved even more work to certain practitioners and hospitals by giving them tier 1 status. Large hospitals self-insure and even have their own higher tier, making it too expensive with $100 copayments for their employees who finally visit us as their costs for their complaints rose, and their chiropractor often resolved the problem for a low cost in just a few visits. The patient is the victim of a system that should be accountable for getting results. When doctors do not know, they test. When they do not find answers often found in a comprehensive exam, which is rarely done, the patient is passed on, and the doctor increases RVUs, and as long as the doctor produces the required minimum RVUs for the month, everybody gets paid. If not, the doctor may be told that their salary, which is actually a draw against commission, is in jeopardy. You can now understand why patients may have doctors who care in an uncaring system designed to mint money. What are the incentives for healthier patients? I don’t see any either. This is the smoking gun, and any attempt to reduce costs using it fails because everyone is incentivised to produce more, refer more, test more, and the patient is sent from doctor to doctor often without someone caring enough to get the diagnosis right. While the doctors all add to this document in the computer with our health history. Unfortunately, when my mom was in the hospital in pain, the hospitalist looked at the screen, my mom complained of leg pain, and the doctor was treating the electronic health record, yet the patient was the one in the bed. I worked on her for 10 minutes, and her pain was gone, and she was now sitting in a chair. Based on this experience, in my opinion, every hospital needs chiropractors on each floor. My mom passed a month ago. Everyone was treating something, promising they could do something, and accomplishing nothing. Hospice did a better job at managing her last few months and was on top of everything. Are there other reasons for the high costs? The cost of drugs – Drug companies are notorious for having some products priced so high in the USA compared to other countries. Patients are convinced they need a particular product to improve their immunity after it was destroyed by chemo. One patient recently found out the cost was not being covered all of a sudden by the insurer, which is wonderful at causing issues for patients and providers alike. The cost was $29,000 per dose. Has anyone wondered why it was so expensive? Did anyone question the cost before approving to pay for it in the first place? What does it cost in other countries with universal healthcare that do a better job of negotiating prices? Insurers are merely middlemen, profiting from our health issues, worsened by predatory practices, tiering, and other nonsense. They are like poor governance; Take our cut and move on. Be aware that if your premium does not arrive on time, they will cancel you immediately. Too many specialties making too much while doing so little. Poor eating habits. Remember those sugar boxes our children drank while in elementary school, or the Cheerios they would eat to quiet them down. These older, sometimes obese children grow into obese adults. GLP-1 Drugs have interesting effects hormonally that cause weight loss and reduce hormone-induced desires for food. Solving these now systemic problems medically fails, and we are less healthy. Healthier Americans begin with a health-based system and better food in the food chain. Not broadening the number of physicians. Only 75% of physicians get an internship where they are mentored into the practice of medicine or osteopathy. Where do the rest go? They are likely medical consultants denying your claim, or they wait around a year to try again. I personally know physicians who tell their children, looking into becoming doctors, to become Nurse practitioners due to better pay, less schooling, and good salaries. This may improve the number of providers in the pool, but Chiropractors who can do primary care for the musculoskeletal system often do better than their medical counterparts, who are badly needed to help reduce costs, deliver musculoskeletal primary care, and reduce unnecessary testing. The poor incentives will cause chiropractors to overtest as well. By simply paying them for evaluations, the improved histories and examinations will reduce the use of tests that do nothing to improve the patient’s health. Medical doctors need to get musculoskeletal instruction as part of their continuing education requirements. Teaching them to refer properly, avoid unnecessary testing, and be more health-oriented requires a cultural shift. End of part 1. In part 2 over the next week, I will offer solutions as the experts who sit on the committees are also stakeholders in the problem. Asking the doctor on the front lines may be far more helpful. More doctors are complaining that this model leads to burnout and that this is not what they signed up for when they became doctors. I will also be posting these blogs with regular frequency on Substack.