The business of medicine

A Colorado cardiologist speaks out about Medicare, membership and more

When Nelson Trujillo Jr., MD (below), says he’s been involved with organized medicine for as long as he can remember, he’s not kidding. In fact, the Colorado-based interventional cardiologist attended the Medical Society of the District of Columbia meeting at the young age of 10, tagging along with his gastroenterologist father, Nelson Trujillo Sr., MD.

It was there that the younger Dr. Trujillo, currently serving as Boulder Medical Society president and a member of the Colorado Medical Society’s legislative council, got his first taste of life as a physician.

But times have changed, and medicine isn’t the same business it used to be. So now, this long-time AMA member is on a mission to educate other physicians about the changing face of the business of medicine, and its potential fallout on patients – particularly the elderly.

The U.S. Senate must act in January to halt the cuts and prevent a Medicare meltdown. Both patients and physicians are encouraged to join in the effort. Call the AMA toll-free hotline at (800) 833-6354 and push “1” on your keypad to be connected to your senators’ offices. Tell your senators that you want them to pass legislation in January to stop the Medicare physician cuts.

“I hear everyday how medicine is changing,” Dr. Trujillo said. “Physicians who are generations ahead of me are ‘getting out of it’ because they’re finding the ability to do what they did is being hampered. But medicine hasn’t changed. People are still sick, they still have the same anxieties and fears, and it’s still our obligation as physicians to take care of them. It’s the business of medicine that has changed tremendously.”

The culprit? A kind of “generational switch,” which Dr. Trujillo believes has ushered out the golden epoch of medicine – characterized by professional autonomy and high reimbursement. “Now, we are in an era where increasing financial control is exerted upon us.

Medicare or HMOs have decreased the amount of money they are willing to pay. We are surrounded by providers in Colorado who are being forced to stop seeing Medicare patients. That just starts to hurt people. The population is aging, and nobody’s going to be willing to take care of them, because they can’t take care of them and stay in business.”

Cognizant of the dearth of public sympathy for physicians’ financial concerns, Dr. Trujillo emphasized that such talk isn’t self-serving. Rather, it is indicative of a societal need to reconsider the value placed on the healing profession – and the many costs associated with providing such a service.

Dr. Trujillo used his office to describe the situation. “I have 42 full-time employees. Every year, they need a raise, health care benefits, disability benefits, gas for travelling between offices. The costs of business are going up every year, and reimbursements are going down.”

According to the preliminary results of a new AMA online survey, almost half of physicians will limit the number of Medicare patients they treat in 2003.

“In the business model, you either increase your charges or your cut back. But we cannot, by law, correct [for decreasing reimbursements] by increasing our charges – even if, for a $500 Medicare operation, we get paid 30 cents on the dollar.” Add the rising burden of medical student and resident debt – Dr. Trujillo’s oncologist wife left medical school saddled with nearly $200,000 in loans – and suddenly even the youngest of physicians are battling serious concerns for the future of the profession.

“I have to spend more and more time not taking care of people but saying ‘OK I have to negotiate with so-and-so today,’” said the 40-year-old cardiologist. “It seems that in health care, we don’t even know who the consumer is anymore. Is it the patient? Is it the physician? Is it the insurance company?”

Dr. Trujillo does point out that, technically speaking, “at their basic level, insurance companies are just doing their job. Insurance companies and HMOs are not in business to take care of patients. They are in the business of returning profits to their shareholders. So if a drug is not on formulary for your plan, you can be frustrated at the plan you brought but you can’t be angry at them, per se. We, as physicians, have bought into the system.”

In fact, the question may not so much be Who should we be angry at, but Who should be angry?

“Patients should be angry,” he said. “They have lost their freedom of choice. Because of the nature of the workforce, because employers can’t afford to offer them choices, because health care costs are so high.”

So how does someone effectively communicate these issues to physicians, and then take that message to the individuals and families they serve?

In an effort to help raise awareness about hot button issues in organized medicine such as Medicare reform and prompt pay, Dr. Trujillo joined AMA Trustee Herman Abromowitz, MD, at a Medicare media roundtable in early October of 2002. Soon after, he began filming “Medicare Mondays,” a PBS television show featuring panel discussions of doctors and legislators, and is designed to educate patients about the risk of losing access to physicians.

Dr. Trujillo believes the key to impacting public health policy is understanding the laws and knowing how to change them. He feels lobbying groups like the AMA, are faced with the challenge of representing all physicians who often experience a high degree of intra-specialty and inter-specialty disagreement. Nonetheless, “I think the AMA is our strongest lobby,” Dr. Trujillo said. “We need to teach physicians how to do this well. Trial lawyers each spend $1,000 to $2,000 per election trial. Do all physicians even belong to the AMA? The apathy needs to change.”

“One of the signs of a cultured society is taking care of its young and its elderly,” Dr. Trujillo emphasized. “If we stop taking Medicare, the consequences will be tragic.”