The Indignity of Industrialized Medicine
A basic tenant of medicine is that every person is unique requiring tailoring of therapies to meet his or her individual needs, and that time is needed to create a therapeutic relationship. This is in contradistinction to mass produced industrial products where every individual item is exactly the same. Thus, the massive disconnect between physicians and their patients and those with financial interests such as payers, hedge fund investors and large corporate hospital systems who are advocates for mass production i.e., industrial medicine. Physicians and patients have voiced displeasure with this impersonal style of medicine but to no avail. Doctor burnout a result of this industrialization has been a problem long before the added stresses of the SARS-CoV-2 pandemic (Ref.1,2,3).
The forces driving this deterioration of care with its exorbitant cost are a combination of historical precedents and misconceptions. Health insurance was initiated in Texas as true insurance, only paying for unexpected expensive items (hospitalization) in 1929. During W.W.II, as an enticement to increase workers, mostly women, into producing war material, health insurance was added as a pre-tax benefit, which avoided wartime wage controls. The monies were NOT deposited into the individual’s health account to pay cash for most care and actual insurance for unexpected costly events. Importantly, within a short period of time this insurance quickly morphed into pre-paid total care in which the individual has NO concern for cost or efficiency. This employer-provided wrongly called “insurance” with its lack of individual oversight and with middlemen and brokers has become wildly expensive, over $20,000 for a family of 4, which is in lieu of salary (Ref.4).
The initiation of Medicare/Medicaid in1964, as with many past Congressional entitlements, has become much more costly than originally projected. Medicare was created paying for unlimited total care while ignoring future expensive medical advances, increasing longevity and a decrease in worker-to-recipient ratios. These many factors have put the program in financial peril (Ref.5).
Desperate, but always failing, to control Medicare/Medicaid costs, the federal government in 1992 introduced the Resource Based Relative value scale for physician reimbursement. This is a price fixed, heavily bureaucratic, highly politicized system that has no relationship to market value. Medicare and more so Medicaid now underpay both physicians and hospitals, but with only hospitals able to add facility fees to somewhat make up the difference.
The HITECH act of 2009 forced a politically approved, extremely costly, excessively time-consuming electronic health record (EHR) on hospitals and physicians in a failed attempt to improve care and lower costs. The law would probably have been beneficial if it had allowed the profession to use an EHR that met their individual needs on an open market. This law along with depressed Medicare/Medicaid physician payments are the major drivers for physicians to leave private practice and become subservient and discontented employees of hospital systems. Decreased payments have also driven hospital consolidation to facilitate demanding increased payments from private insurance to be able to prosper, but adding to cookie cutter, robotic care.
We are told the only way to provide access to care for ALL Americans is to expand this government dominated impersonal bureaucratic exorbitantly expensive healthcare system. There is a far better option that has proved to offer better care for ALL at far less cost by empowering individuals to direct their own care (Ref.6). Give every citizen a choice, the present 3rd party dominated inferior care OR expanded health accounts with funding available to ALL Americans by either employers, means tested government deposits or Medicare payments. This would give the individual control of his/her care, paying cash for most items and nationally available catastrophic real insurance for major expenses.
1. Abigail Zuger, Dissatisfaction with Medical Practice, Jan. 1, 2004, N Engl J Med, 2004; 350, 69-75, available at: https://www.nejm.org/doi/full/10.1056/NEJMsr031703 (Accessed April 15, 2021
2. Lee AV, Moriarty JP, Borgstrom C, Horwitz LI, Patient Dissatisfaction. J. Hosp. Med 2010;9;514-520. Available at: https://www.journalofhospitalmedicine.com/jhospmed/article/127444/patient-dissatisfaction (Accessed April 15, 2021)
3. Pamela Hartzband, Jerome Groopman, Physician Burnout, Interrupted, June 25, 2020, N Engl J Med, 2020 382;26, 2485-2487, available at: https://www.nejm.org/doi/pdf/10.1056/NEJMp2003149?listPDF=true (Accessed April 12, 2021)
4. Christopher S. Girod, Susan K. Hart, Scott A. Weltz, Cost of health care for a typical family of four now over $28,000, May 21, 2008, Milliman Research Report, available at: https://pnhp.org/news/cost-of-health-care-for-a-typical-family-of-four-now-over-28000/#:~:text=In%202018%2C%20the%20cost%20of%20healthcare%20for%20a,31%25%20%28%248%2C631%29%20%E2%80%93%20Inpatient%2019%25%20%28%245%2C395%29%20%E2%80%93%20Outpatient (Accessed April 15, 2021)
5. Committee for a Responsible Federal Budget, Pre-Covid, Social Security and Medicare Faced Insolvency, April 22,2020, available at: https://www.crfb.org/blogs/pre-covid-social-security-and-medicare-faced-insolvency (Accessed April 15, 2021)
6. Avik Roy, Obama Administration Denies Waiver for Indiana’s Popular Medicaid Program, Forbes, Nov. 11, 2011, available at: https://www.forbes.com/sites/aroy/2011/11/11/obama-administration-denies-waiver-for-indianas-popular-medicaid-reform/?sh=610f74b93ff0 (Accessed Jan. 18, 2012)
Good post, except:
“The HITECH act of 2009 forced a politically approved, extremely costly, excessively time-consuming electronic health record (EHR) on hospitals and physicians”
Let’s stop the victim routine with EMRs (I don’t know what a Electronic Health Record is – I do medicine, not health). Every physician who is complaining about how EMRs have made their job miserable either volunteered to use them or volunteered to work for an organization that uses them.
In our small practice, we saw thirty years ago that EMRs are completely incompatible with what we wanted to do as physicians.
We’re still on paper, prospering financially, leave the office at 5 PM with all our work done, and look forward to practicing into our 70s..
If physicians want to have some credibility in attacking those who have done so much harm to our profession, we first need to accept responsibility for the truly terrible decisions we ourselves have made.
Stuart, agree, wish thousands more doctors had your stregth of will. At least allow physiians to choose a record on the open market that meets their individual needs, what ever that may be. Ken Fisher,,
That’s nice you were able to stay on paper. In a larger rural multi-specialty practice of 16 docs that was always financially strapped, the administration moved towards EHR due to the fact the “gubbermint” would compensate us slightly better if we did. Made my last 8 years of practice absolutely miserable and I bailed out and retired at age 64. I’m so glad to be done and out. Anyone has to be nuts to go into primary care these days. Used to be fun but the powers that be “e’ffffffed” it up.
Kurt
Dr. Savoretti, excellent supplement to Dr. Fisher’s narrative. I enjoyed your take.
It is absolutely criminal how the profession is being dumped on.
The only good thing is that the young physicians being trained now know nothing else. They will have nothing to look back on fondly. Such a shame.
The situation passed the threshold of hopeless years ago. The past year has demonstrated beyond any doubt that this society is too cowardly, and too stupid to ever accept true reform. No one with any imagination or integrity should consider starting a career in medicine.
Thank you for the excellent historical summary and suggestions but it is going nowhere in current political environment. Readers of Authentic Medicine and fans of Douglas Farrago will agree with you and most articles published here but we are a tiny minority of Physicians and the general population. “Free” is all the voters want. Quality is not understood. “Free is for me!” The current administration caters to their voters handing out more and more dollars for zero work, more and more “freebies” to purchase re-election with our tax contributions. As Margaret Thatcher famously said to the voters of the Socialist ruled devastated United Kingdom: “The problem with socialism is that you eventually run out of other people’s money.” Meanwhile we can only hunker down while tending to our tiny individual fiefdoms as best we can hoping to avoid the Lord of the Manor’s wrath. When it all comes crashing down as it did in Great Britain then maybe things will improve…but their National Health Service lives on. We’re a dying breed in private practice but I shall never surrender. They can pry my Primary Care Private Practice Providing Concierge Level of Care at Popular Prices out of my cold, dead hands.