Can We Return Medicine to a Personalized Healing Art?
“The very foundation of medicine is built on compassion – the desire to relieve the suffering of others. Yet the physician’s ability to deliver care with compassion has become more and more limited by an increasingly technical and bureaucratic delivery system that leaves little time for human interaction” (Ref.1). For centuries the setting for personalized, longitudinal, and compassionate a patient–physician relationship was the physician-owned practice. In this setting, physicians could devote their full efforts addressing the patients’ health concerns which results in a more personable and satisfying relationship for both the patient and physician. However, physician-owned practices are rapidly disappearing. Since 2019 approximately 108,700 physicians have left private practice with only 26% of American physicians so employed in 2021. In 2022 hospitals and corporations owned about 135,000 physician practices (Ref.2).
The reasons for this rapid and unfortunate decline in physician private practices along with patient satisfaction have been created by the federal government initiating failed attempts to ameliorate its runaway healthcare costs. Instead of focusing on immutable factors such as fewer workers contributing funds for the care of the increasingly elderly population, the increase since 1965 in longevity with its associated surge in medical spending, and the increase in costly medical therapies prolonging life, our government focused on various managerial approaches (Ref.3). Additionally, there has also been a large increase in Americans receiving their healthcare via Medicaid adding to governmental expenses (Ref.4). Instead of addressing these demographic changes, the federal government has created a huge administrative burden that is consuming about half of the physicians’ time, along with decreased reimbursement rates made more severe by inflation. Additionally, the HIGHTECH Act of 2009 that was in essence forced on the profession without a single test run has added tremendous cost and consumes an inordinate amount of time away from patient care (Ref.5,6). Also, physicians are being prompted to become hospital employees due to the federal government’s policy of paying hospitals generous facility fees for many physician services that are NOT available to physician-owned practices (Ref.7)
There is much written on the evils of consolidation/corporatization of medical care in this nation along with its out-of-control costs. Business magazines should understand that in a non-market, price-fixed, centralized, highly lobbied system, with a huge expensive bureaucracy dominated by government and a few large health insurance companies, that fundamental change is needed. However, that is NOT the case; their comments and solutions are still mired in the impossibility of trying to fix our system around the edges while never dealing with the fundamental problems. The same is true for medical professional organizations like the ACP (Ref.8,9,10,11,12).
These underlying societal changes have taken place throughout the western democracies which along with post pandemic healthcare demands have created huge stresses on these government-based programs (Ref.13). Fundamental changes are needed: for instance, for those insured by employers allowing the pre-tax healthcare benefit to go directly to the employee’s health account; for Medicare/Medicaid permitting those who wish to receive payments minus the bureaucratic costs to go directly to the recipients’ health account. In both instances, the individual would pay cash for most care and purchase nationally available high deductible catastrophic insurance for major expenses. Changes such as these would promote physician-owned practices, re-establish the critical patient-physician therapeutic relationship and for the first time control our national healthcare spending.
- Ralph Snyderman, Medicine’s New Tools Can’t Replace Compassion, Duke Center for Personalized Health Care, July 30, 2019, available at: https://dukepersonalizedhealth.org/2019/07/medicines-new-tools-cant-replace-compassion/ (accessed January 27, 2023)
- Patsy Newitt, Private practice physicians by the numbers, Becker’s ACS REVIEW, July 14, 2022, available at: https://www.beckersasc.com/asc-news/private-practice-physicians-by-the-numbers.html#:~:text=There%20are%20now%20about%20135%2C300%20hosp (accessed February 2, 2023)
- Budget Basics: Medicare, Peter G. PETERSON Foundation, July 5, 2022, available at: https://www.pgpf.org/budget-basics/medicare(accessed February 3, 2023)
- Tara O’Neill Hayes, Medicaid: A Review of the Program After 50 Years, American Action Forum, July 13, 2015, available at: https://www.americanactionforum.org/insight/medicaid-a-review-of-the-program-after-50-years/ (accessed February 3, 2023)
- Len Strazewski. 8 threats facing physician private practices, AMA, February 21, 2022, available at: https://www.ama-assn.org/practice-management/private-practices/8-threats-facing-physician-private-practices (accessed January 31, 2023)
- Lisa Hedges, Ten Years of Technology: How the HIGHTECH Act Influenced Physicians and EHR Adoption, Software Advice, August 23, 2018, available at: https://www.softwareadvice.com/resources/hitech-act-retrospective/ (accessed February 5, 2023)
- Keith Smith & Ashton Cohen, Why is American Healthcare So Expensive & Screwed Up, You Tube, January 2023, available at: https://www.youtube.com/watch?v=nCUQ0lQCzAI (accessed February 6, 2023)
- Robert Pearl, U.S. Healthcare: A Conglomerate of Monopolies, Forbes, January 16, 2023, available at: https://www.forbes.com/sites/robertpearl/2023/01/16/us-healthcare-a-conglomerate-of-monopolies/?sh=2f7245382e4d (accessed January 25, 2023)
- Sachin H. Jain, Practicing Medicine In The Era OF Private Equity, Venture Capital And Public Markets, Forbes, July 27, 2020, available at: https://www.forbes.com/sites/sachinjain/2020/07/27/practicing-medicine-in-the-era-of-private-equity-venture-capital-and-public-markets/?sh=2717069f51ac (accessed January 26, 2023)
- Sally Pipes, Is The End OF Private Practice Nigh? Forbes, May 9, 2022, available at: https://www.forbes.com/sites/sallypipes/2022/05/09/is-the-end-of-private-practice-nigh/?sh=96fde6d3bf53 (accessed January 25, 2023)
- Linda Carroll, More than a third of U.S. healthcare costs go to bureaucracy, Reuters, January 6, 2020, available at: https://www.reuters.com/article/us-health-costs-administration-idUSKBN1Z5261 (accessed February 2, 2023)
- Thomas G. Cooney, 3 Cs: corporatization, consolidation, commodification, ACP Internist, March 2022, available at: https://acpinternist.org/archives/2022/03/3-cs-corporatization-consolidation-commodification.htm (accessed January 24, 2023)
13. David Luhnow, Max Colchester, U.K.’s Healthcare Crisis Sounds An Alarm for Aging Countries: NHS struggles amid tight budgets, demographic changes, WSJ, February 7, 2023, available at: https://www.wsj.com/articles/nhs-uk-national-health-service-strike-costs-11675693883
In the past year I personally have reversed the above trend having resigned a position at a FQHC and starting a new practice at age 69 going on 70! Called The Healing Refuge it is a cash practice that only takes cash or credit cards( no bad checks) and uses paper records which I do while in the room with the patient. I get to see 10-15 patients a day and get to spend quality time with them and even get to pray with them which is probably the most important thing I do. I just need to cover my overhead thanks to SS and am enjoying the return of the golden age of medicine which I first experienced in the early 1980’s when I got out of residency.
What are your chances of health insurance reform? If you look at all the Western countries, the masses would rather have crap insurance and long lines to wait for elective procedures. THEY JUST GET USED TO IT.
We as physicians in the US of A, just need to set our own limits on how much we are willing to take (or make). I sympathize with the poor people who burn out or commit suicide. I understand. Today, is medical school worth the time, money, and effort? For some of us, yes. You will always be able to make a stable middle class living. There is much more of a potential in the concierge positions, but they are difficult to construct and only play in certain areas……and then there will be competition which will drive prices down.
Gary, Thanks for taking the time to respond. One of our major problems is that health insurance is NOT insurance. Home and car insurance is for major items NOT routine repairs. To me health insurance should also be for major items and patients should have a health account with the funds to pay cash for most items. Ken
I agree with you completely.
However you are proposing a 180 degree turnaround.
Personally I am almost ready to retire, as I see the same in many of my cohorts, and the new grads are just joining a system that continues to be going in the wrong direction.
Whether there is capitalism or socialism, the patient is not in charge any longer.
The only system that puts the patient in control is when it is a strict physician- patient interaction……..let the patient pay for their care and make them deal with the insurance company (and where I live, so many patients will limit their care to what the insurance company covers…….which leads them into insane Medicare advantage plans!). And frankly their is very little that I can personally control. I am forever hassled with chart audits, medication/surgery availability and costs, the insane cost of modern medical equipment combined with the annual decrease in reimbursement for using said “state of the art” devices.