The Rise Of The Middlemen

“The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized,” the great Boston physician and Harvard professor of medicine Francis Weld Peabody wrote in “The Care of the Patient” back in 1927. To Dr. Peabody, the clinical and the personal were deeply intertwined; a deep sense of intimacy between the physician and patient was essential to healing.

What would Peabody think of today’s Frankenstein healthcare system—pieced together inelegantly with no obvious logic. It is populated—no, overrun—with middlemen, actors and sub-actors who promise to fill perceived gaps in the healthcare system. Mostly of these middlemen insert themselves between the physician and the patient—in a space Dr. Peabody insisted should never exist. The doctor-patient relationship is inadequate, they tell us, refuting the remarkable simplicity of Dr. Peabody’s notion that the doctor-patient relationship, so long as it is maintained, is definitionally adequate.

Each day, people knock on our doors (and invade our email boxes and social media feeds) and tell us that there’s something that’s not happening in patient care that should be happening. They ask us to let them fix the problem. More often than not, they (and their investors—often venture capitalists and private equity executives) ask us to pay them to fix the problem.

If your patient isn’t taking her medication, we’re told, employees of a call center in some distant country will make them adherent for a low cost. We spend time building trust with our patients, but somehow, they hope to convince us, a set of well-intentioned, but ill-informed, and ill-equipped strangers is key to ensuring that the patient we know and recognize will put faith in our diagnoses and prescriptions.

Focusing intensely on specific conditions seems to be key to many of these companies’ business plans. There’s a startup that promises to help guide women through menopause, a job that the gynecologists I know are capable of performing. One company promises to use physicians and the latest technology to provide care in patients’ homes. Sounds good enough—until you realize the physician is a moonlighter or locums physican whose primary job description involves coding and documentation to increase the payments their insurance company receives from the federal government.

Some middlemen seem more determined to create alarm than to provide care in the name of “consumerism” and “consumer empowerment.” One company provides ultrasounds to women, insinuating that the procedure—for which only accept cash payments are accepted—can detect cancers that mammograms and physical exams do not. Even Kim Kardashian has joined the crowd marketing full-body, cash-pay MRIs delivered by the company PreNuvo. I shudder at the thought of alarmed women frantically trying to get care for a false-positive findings on scans for conditions that likely don’t exist. If only they’d stuck with their doctor.

And some middlemen are determined to participate in complex financial engineering shrouded by the term “value-based care.” They help practices “take risk” and “succeed in new payment models” by adding countless layers into patient care and patient care administration—most of whom don’t ever engage meaningful with a patient’s primary care physician and specialists—and help patients how exactly?

As the leader of a diversified healthcare company with an health insurance arm, I would not only be remiss and hypocritical, but also completely clueless, if I didn’t mention how often physicians see organizations like mine as the ultimate middlemen of healthcare. Who are we to deny claims? So many have asked in earnest, often with great justification (along with similar questions about pharmacy benefit managers [PBMs] and other great utilization management ‘middlemen’).

Of course, health insurers exist because they promise the same thing as all of these companies—lower costs. We all want lower costs. Patients want lower costs. The government wants lower costs. Insurers want lower costs. So we hire middlemen to perform an array of functions that, we’re promised at least, will lower costs.

And yet, the costs keep rising.

And we keep hiring more people to “fill gaps” and execute “cost of care” solutions with no real end in sight. What would happen if we instead paid doctors and their teams—the people closest to the patient—to do the same tasks and got out of the way? Just a thought.

“The secret of the care of the patient is in caring for the patient,” Dr. Peabody wrote. When I first encountered his words as a medical student, his meaning seemed clear: treat your patients. That’s your job. Not somebody else’s. That concept stuck with me because, like most medical students, I’d not yet encountered a middleman. I’d also never been told by a healthcare administrator how long I could spend with a patient or by an insurer that a drug I’d prescribed wasn’t on the formulary.

The system Peabody advocated was pristine in its simplicity. The key to healing was the relationship between patient and doctor. Has medicine become so complicated that we need the middlemen? Perhaps—but do we have the right ones with the right underlying intent and motivation? Can we ever recover the true essence of Dr. Peabody’s vision?

I think we can, but it starts by challenging all of healthcare’s sundry middlemen to demonstrate real, tangible, and meaningful clinical benefit to patients.

Otherwise they should simply get out off the way and go home.


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