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John Livingston

Time for a Change

One of the great tragedies that has come out of the Covid political pandemic has been the loss of reputation and respect given to the medical profession by the public. There are many reasons for this. It has been a long time in the making. It actually began many years ago and there are many people and organizations that have failed the medical profession and the patients they have been privileged to serve. American Medicine and Surgery grew from the ground up. Doctors, nurses, and religious vocations all played a part. I think of the five Holy Cross Sisters that came across the Desert and opened St. Alphonsus Hospital in 1895. In 1902 the Episcopal Church opened St. Luke’s. Incredible doctors, nurses, technicians, and administrators many whose families continue to serve the citizens of the Treasure Valley the same way their parents and grandparents served.

Three or four generations of such service is common. Mothers and their daughters worked together in the operating room with me at St. Al’s and Luke’s. I operated with fathers and their sons at both facilities. I was recruited to St. Al’s in 1988 by two Catholic Sisters— Patricia Vandenberg and Patricia Mulvaney who were both at one time CEOs at Al’s. Ed Dahlberg and Gil Gilbertson helped me establish my practice at St. Luke’s. All four administrators were giants. Gil at one time took out a second mortgage on his own home to help complete financing on an expansion project at St. Luke’s. He never made $18 million his last two years of being CEO like what was declared on IRS Forms 990 from the last CEO at Luke’s. I doubt if he made that much his entire career!

In our country there has been a 300-year-old debate as to where the first hospital opened—Boston or Philadelphia. I have always believed that the University of Pennsylvania Hospital was the first hospital. In almost every community big and small the religious community—protestant and Catholics served their flocks by opening the first schools and hospitals. The medical and nursing communities worked hand in hand. The Johns Hopkins Mayo Clinic (originally St. Mary’s Hospital) founded by Sister Alfred Moes from the order of the Sisters of St. Francis and Dr. William Mayo—look whose name is on the building now, are examples of thousands of other hospitals across our country. The values as expressed by the Sisters, doctors, and nurses are what formed the culture of medicine for well over 100 years. The marriage of the Hippocratic Oath and Biblical virtue created an environment all over the world that saw an explosion in medicine and surgery.

Military Medicine was also part of the equation. Think of Clara Barton in the Civil War and Walter Reid in Panama finding the cause and a cure for Yellow Fever. After World War II and up until the beginning of the Great Society programs in the mid 1960’s medicine, nursing, clinical and the “bench sciences” grew exponentially. I was lucky enough to have been educated at the end of that era. With the expansion of Medicare and the advent of Medicaid government financing of first medical education and then with ever increasing Medicaid expansions, quality and access became ever more problematic. Today almost 60% of medical care is financed directly or indirectly—transfers by government programs. The relationship between doctor and patient has suffered greatly over that time frame. Doctors no longer work for their patients, but for institutions and insurance companies. Patients are attended to by doctors who do shift work—-taking care of many patients over a short period of time—hours instead of lifetimes. The relationship between doctor and patient is financial and clinical and not personal. Hospitals and insurance companies like this because they now own the “means of production” and can control the flow of patients—consultations, and priorities of care. They do this through organizational structural techniques with names like “risk management” and “utilization review”. By risk we mean financial risk, and by utilization review we mean the allocation of resources usually using “protocols” or “clinical guidelines”. I wonder what the Mayo brothers or Clara Barton would have thought about those types of clinical constraints.

Around 1980 there was a new kind of player introduced into the milieu of clinical medicine—THE DOCTOR MIDDLE MANAGER. Many graduated from their residency programs and went directly into law school or MBA programs never having to be directly responsible for taking care of patients. I know one such individual who was a Medical Director at Al’s and who was on the staff for over 30 years. He used to brag that he had never admitted a patient to the hospital! Very different values and credentials than the Mayo Brothers or Clara Barton. Taking care of patients was no longer a duty. Being the conduit between administrators and medical and nursing staffs was easier, you didn’t have to get up in the middle of the night, you never had to attend to a grieving patient and their families, and it paid more.

The current pandemic and the poor response of administrators, government bureaucrats’, and “expert middle managers” has made the job of the doctors and nurses who do see it as their duty to serve patients, much more difficult. When clinicians start using Public Health models of the herd and communal philosophies, instead of the individual patient model, and when one size fits all algorithm of care models take the place of clinical thinking and planning for each individual patient and when the decision makers are divorced from the patient by many layers of bureaucracy, patient care unravels.

Our current problems with supply chain and logistical inefficiencies and staffing for the care of sick patients instead of “wellness” programs happened before the pandemic started. Nationwide the number of hospital beds per capita has gone down by 15% since 2005. Because of advances in surgery, anesthesiology, pain control, and rehabilitation hospitals, stays for major surgery procedures have gone down by over 50%, but the cost per equivalent procedures over the past 22 years has gone up 500%—got to keep those CEOs with $10million salaries happy. And just tonight it has been reported by Hayden Dublois and Jonathan Ingram of FCA Research that in Idaho we have a 39% Medicaid error rate due mostly to fraudulent enrollment and fraudulent claims—almost the highest in the country.

The pandemic showed us how the “medical industrial complex” is spending more money on supporting itself than it is on taking care of the needs of patients and citizens. Our legislators in Washington and Boise just keep on marching along. The cronyism and corruption between government agencies and private and non-profit providers and carriers just grows. The IMA and IHA exist to serve the interests of large hospitals and their employee clinicians—not patients.

It is time for an audit. Any government agency or corporation or nonprofit organization in the private sector that is involved in the transfer of over $100million of government monies needs to undergo an independent signed partners audit to be presented annually to the people of Idaho via their legislature. Any individual receiving over $1million of transfer payments needs to present a Statement of Financial Position to the DHW.

There is lots of blame to go around. The medical professionals who have allowed the 10% of doctors who have the time to participate in medical politics determine the conditions that they now find themselves in share some of the blame. The other 85% are so busy that they don’t have time to both practice medicine and go to IMA, Staff, CME, and meeting with lobbyists. If they had had the time, the way clinical medicine is being practiced today would be very different.

But most of the blame is on us. We have tolerated politicians who have turned a blind’s eye to the needs of patients—their constituents, 60% who are paying with ever increasing insurance premiums and taxes to support government transfer programs. The lobbyists who represent the industries that they are supposed to regulate, who pay for their campaigns and the Governor’s Cup fees, are listened to more than their constituents, many who have been patients over the past two years.

Shame on us and shame on them. It’s time to get back to the principles and virtues of the Mayo brothers, Sister Moes, and Gil Gilbertson.

Cronyism + Collusion = Corruption. It may all be legal—or not. We have a real mess to fix going forward. If we don’t start now it will only get worse.

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