As the pharmaceutical industry takes center stage in the national debate over exploding health-care costs, doctors and hospitals remain prime targets in the battle to reduce medical spending. While much has been made about the impact of managed care on patients, the impact on physicians has been no less profound. It has fundamentally altered the practice of medicine, interfering with doctors’ decision making and drastically reducing their once vaunted earning power. Despite the current focus on powerful meds, for most patients their personal physician remains their most critical link to the health-care system. As a two-generation physician family, the Miglioris provide a unique perspective on the evolution of the practice of medicine in America.
Julius, sturdy and clear-eyed at 72, is warm and open. When his sons said they wanted to be doctors, he insisted that they work awhile as hospital orderlies in their hometown of Cranston, R.I., to see his world from a different perspective. He’s proud that they followed his lead. But he has no illusions about how the profession has changed. “There was an aura about it, which is long since gone,” he says.
When Michael Migliori, now 43, got his first pair of glasses at the age of 11, he could see the leaves on the trees for the first time in his life. He decided right then to become an ophthalmologist so that he could help other people discover the hidden details of the world around them. By the time Michael finished all his training, he was an ophthalmologist and a plastic surgeon. One of his proudest moments came when he operated with his father for the first time. It was a dream come true for both of them. Michael started a solo practice in 1987 and was soon swamped with work. Unfortunately, too much of it was paperwork. “I was the office manager, I was the business manager and I had one secretary,” Michael says. As medicine evolved in the 1990s, the paperwork only became more complicated and time-consuming.
One of the worst things, Michael says, was the way insurance companies insinuated themselves into his dealings with patients. As he was taking histories, doing exams and planning treatments, he also had to think about what kind of insurance the patients carried and what he needed to include in their charts to justify his medical decisions. For modern doctors, this two-track mind has become as necessary as a beeper. After 10 years on his own, Michael became a member of a six-physician group in Providence, R.I., called Ophthalmology Consultants. He now works in a state-of-the-art office complete with foot-operated dictation machines to document all patient visits, and a 19-person support staff (not counting nurses), including a business manager, an office manager, five people to transcribe the dictation and four people to handle the billing. All of that costly overhead enables Michael to concentrate more on his patients; each week he operates 10 to 12 times and sees about 75 people in the office.
It also improves his chances of achieving what has become the holy grail of modern medicine–the clean claim. Asked to explain the term, Michael smiles. “Nobody can define a clean claim,” he says. “It’s like pornography. I don’t know what it is, but I know it when I see it.” A clean claim is one that goes through the system without a hitch. The insurance company agrees that the treatment was appropriate and that the paperwork is accurate and complete. It then pays the doctor. Says Michael, “We need to document it so that some stranger with no medical training can come in and look at the chart and come to the same conclusion.”
Halfway across the country, his brother is waging similar battles. Too often, says Mark Migliori, 37, insurance-company rules are inconsistent with good patient care. Mark, a Minneapolis-based plastic surgeon who specializes in breast reconstruction for cancer patients, also does reduction surgery to relieve back pain and other symptoms. To avoid paying for procedures that are merely cosmetic, the insurance companies have strict guidelines, including exactly how much tissue is to be removed from each breast, based on generalized height and weight charts. For a woman 5 feet 2 who weighs 158 pounds and has a documented history of symptoms, the guidelines specify that 400 grams of tissue be removed from each breast. “So it doesn’t matter what I think is safe to keep the skin or the nipple alive, or what I think will work best with the patient’s body and habits,” says Mark.
As Dr. Sidney Migliori, 39, conducts her rounds on a recent sunny Saturday morning with her three young children in tow, insurance issues are never far from her mind. An orthopedic surgeon, Sidney, Stephen’s wife, spent most of the previous day in the operating room repairing knees. The surgery went well, but other parts of her job are less rewarding–like delivering bad news, not just about patients’ medical conditions but about their insurance coverage as well. “They get mad at you” when a procedure they need isn’t covered, she says. “It’s not your fault, but you’re the bad guy.”
Growing up, the Migliori kids knew they were in the economic elite. There was a swimming pool in the backyard, a classic symbol of wealth in the Northeast, and plenty of tuition money available for the Ivy League (all five boys went to Brown University) and medical school. Doctors still make good money, of course, and the younger Miglioris all live comfortably. But unlike Julius when he was their age, they are a long way from the top of the heap. For the most part, physicians have missed out on the long economic boom that has generated so much wealth for so many Americans, most notably those in the dot-com world.
But there are other things. Stephen Migliori is repairing a hernia at Our Lady of Fatima Hospital in North Providence. Julius is the anesthesiologist on the case. “Raise the table a little, Dad,” Stephen says as he prepares to make the first of four small incisions for the procedure. Over the course of the 45-minute operation and the three gallbladder operations that he does with his father, Stephen demonstrates the energized calm of the confident surgeon, getting in and out of his patients’ bodies with speed and efficiency. His mood is light; his enthusiasm for the work as he narrates the proceedings–“Every gallbladder is different”–is infectious. Julius’s pride in Stephen, an associate professor of surgery at Brown University School of Medicine, floats in the room, another dream come true. Earlier, Stephen, who always wore a tie to the doctor’s office when he was a little boy and had a serious ear problem, explains his life. “People come to me with a problem,” he says. “As a surgeon, I take care of it.” No amount of red tape can take away that satisfaction.
