Rewarding Poor-Quality and Punishing High-Quality Medicine

To the Editor: As a physician practicing for 40 years in southern California, I feel it is important that I reply to your comment regarding Dr John G. Black’s excellent letter (July 2007).

When I graduated from medical school, the president of our medical college, W. Ballentine Henley, stated, “Not everyone can practice in Beverly Hills, and if you just try to do a good job and take care of the patient, you will make a good living.” I took those words to heart and tried to practice only high-quality medicine, without regard for anything but my patients’ best interests. Unfortunately, those words are no longer true. Medicine is a business, as well as a profession, and if reimbursement falls below the cost of running it, it fails. If you ever tried to run a small business, you would be aware that one needs business licenses, supplies, malpractice insurance, money to pay salaries and taxes, and so on to continue providing services.

Poor-quality medicine is being rewarded; high-quality medicine is being punished. Example: When we spoke to the then-director of the Insurance Company for Medicare and explained that we were able to take care of people aged 70 to 102 on an outpatient basis and avoid costly hospitalization, we were told, “We will be happy to pay you if you simply put your patients in the hospital and start a line in them.” When we pointed out that we were under the impression that keeping our patients as healthy as possible and away from the hospital was a better route to take, we were told that they did not reimburse for that.

In contrast, the insurance carrier pays off like a slot machine if a resident in a teaching hospital does a procedure in a demented, terminally ill patient with virtually no hope for reasonable quality of life. Imagine the costs to the carrier.

Yes, you are naïve if you think that it is possible to practice high-quality care without thinking about your income. After all, the gardener, the house painter, and workers everywhere need to be paid for their services—why not physicians? Would you still do your job if you lost money each month?

—Charles G. Willson King, MD
Sherman Oaks, Calif

The Fate of Internal Medicine

To the Editor: As Dr John G. Black said in his letter (July 2007), with only 11% of physicians going into internal medicine, and 90% of those taking hospitalist positions, the fate of general internal medicine/primary care is not very hard to figure out.

It will eventually be run by nurse practitioners and physician assistants.

—Kashif Memon, MD
Vernal, Utah