Under My Skin

Demotion (With Apologies to Franz Kafka)


As Dr. Gregory Samplingerror awoke one morning, he found that he had been demoted overnight to a ridiculous second-tier physician.

"I cannot go to the office," he thought. "All the patients will see the change in me at once. And even if they don't, they will realize it when they find their copayment is $10 more."

Gregory called his new secretary, Ms. W, and told her to close his schedule indefinitely, as something had come up. He could tell that Ms. W knew the reason.

Gregory unfolded the official notice. "You have been assigned to Tier Two," it read. "You have been tiered at the customer service unit [CSU] group level, according to your LCU/CSU."

"This must be some mistake," thought Gregory as he showered and dressed. He chose a charcoal gray suit, dark blue tie, black trench coat, and bowler—attire befitting a Tier One physician. "I will straighten things out at once by contacting my LCU Medical Director, as instructed," he said. "But first I must learn what an LCU is."

Pulling up his collar and drawing his bowler down over his eyes, Gregory set out for an unfamiliar district. Rows of gray apartment blocks lined both sides of the street. Unemployed men in shirtsleeves idled on balconies, toasting marshmallows. A young woman took Gregory's arm. "I see you are lost," she said, handing him a marshmallow. "The local care unit is there," she said, "third floor." Then she was gone.

On the third landing, a uniformed guard leafed through a dog-eared ICD-9 manual. He eyed Gregory with a sardonic smile.

"I must see the director," said Gregory. "By some mistake, I have been …"

"Designated Tier Two," said the guard, with a show of indifference. "The director is out," he added.

"When will he return?" asked Gregory.

"Afterward, possibly," said the guard, offering Gregory a chair.

Three months later, Gregory asked, "Is there someone else I can see about this?"

"The deputy director is in," said the guard, "but I warn you that he can do nothing. However, you may suit yourself. Third office on the right."

Eager to be heard at last, Gregory hurried to the office near the end of the corridor, where he found the deputy director at his desk, wearing a green eyeshade, smoking a fine Havana cigar. "Please come in," he said, "but I cannot help you."

"Why have I been designated Tier Two?" asked Gregory.

"Our clinical performance improvement initiative," said the deputy director, "incorporates principles agreed upon by local or national stakeholder groups. ETG methodology was used as the basis for efficiency analysis. Please take off your hat."

"What is an ETG?" asked Gregory.

"Episode Treatment Group," said the deputy director. "It measures your quality and efficiency compared to those of your peers in treating episodes. These measures have been validated by RHI, HEDIS, and AHRQ. Cigar?"

Gregory declined. "Can you tell me what I've done wrong?" he asked.

"No," said the deputy director. "The director might be able to, but he is out. In any case, he takes directives from the Group Insurance Commission, which has mandated quality measures. Our job is merely to implement their mandate."

"Where is their office?" asked Gregory.

"They don't have one," the deputy director said. "And now, if you'll please excuse me …"

"But wait," said Gregory, who was beginning to grow alarmed. "Why has the GIC done this?"

The deputy director aimed a contemplative puff across his desk. "To address rising health care costs and reduced employer coverage, the GIC has demanded incentives for consumers to make more informed choices about health care options and for providers to examine their practices relative to their use of resources compared to their peers."

"Is it clear that consumers will change doctors to save $10 on a copayment?" asked Gregory.

"Not yet," said the deputy director. "However, we have identified a problem and taken a proactive step."

"But how can I rise to Tier One," said Gregory, "when I don't know what I did to sink into Tier Two?"

"For one thing," snapped the deputy director, "you could improve your relative score! Look at this!" he demanded, brandishing a sheet of white paper. "A q-score of 1.3! A resource utilization score of 1.16! Outlying performance on ETG 675, 'Fungal skin infection w/o major surgery'! Disgraceful! If we labeled you Tier One, how could we justify our fiduciary stance to our stakeholders?"

"Do the stakeholders have an office?" asked Gregory, who was trembling now. "I can explain …"


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