Why is it so hard to practice good medicine?


The first time I heard a hospital CFO tell me that improved access in the hospital’s primary care practices was a problem for him I was shocked.

“I’m not sure I get the problem here…” said the naive me.

“Well, our system gets about $450 every time one of these patients visit the emergency department and only $50 when they visit our primary care practice.  You do the math.”

“But….” [picture me turning a bit red and breaking a sweat here]  “but…. when people see their primary care doc they get better care.  I mean of course the emergency department is great, but there are really good studies….”  He’s glazing over – he doesn’t want to hear about studies.

I try the high road: “When people see their PCP the care they get is more personal,  more nuanced.  Recommendations are tailored to the individual.  Clinical outcomes are better, satisfaction is better and we get more affordable health care because the costs are lower…”

“But that’s just my point,” says the CFO, “costs are lower because you’re taking money out of my pocket.  This is a business.  It is my job to make it work.  What you’re doing is unacceptable and it needs to stop.”

This is not the only such conversation I’ve had over the years.  It is the norm, not the exception.  Of course there are exceptions and there are great health systems that figure out how to make ends meet while practicing ethically.  The problem is that so much of insurance payment policy is lined up against the ethical practice of medicine.

I don’t mean to say that ‘it is all the fault of those darned insurance companies,’ we all have played roles in this mess, but we need to start calling these policies what they are – shameful and harmful to the health of Americans, self-serving policies that may currently improve the bottom line of a corporation but hurt the bottom line of our society.