The American healthcare system is at a crossroads. Over the past eight years there has been an acceleration in the movement towards automation, centralization and regulation in an attempt to increase efficiency, lower cost and increase access.Towards that end, there has been an exponential growth in large hospital systems which have co-opted and in some cases closed community and rural hospitals; the number of physicians in independent private practice has steadily declined now accounting for only a third of practicing physicians; the medical insurance industry has been whittled down to basically five national insurance companies and government insurance (Medicaid and Medicare); And the out of pocket costs for patients has risen while their access to doctors has decreased.
When the ends are fully examined the question remains were the means justified? Whether intentional or unintentional the consequences have had the opposite effect on the delivery of healthcare.
- Healthcare costs have gone up and access has decreased
Hospital systems which are largely corporate driven have become, in some cities, the only access to healthcare. This has fostered less competition and has set up monopolies in many instances. With no downward pressure from competition, the hospital systems have managed to keep prices artificially high and limit access to patient care by extending the time it takes to get an appointment. These actions also have had a chilling effect on private practicing physicians. The problem has also been exacerbated by the advent of the accountable care organizations (ACOs) which buy a private physician’s practice, and essentially extend the reach of the hospitals with their hospital derived fee scale.
- Healthcare costs are increasingly driven by outside interests
Health information technology has become a significant player and cost driver in the healthcare system. The cost of IT professionals, health information technology companies, and the insertion of money from Wall Street have led to a change in the practice of medicine. Clinical decision making is increasingly being driven by artificial intelligence, Evidence Based medicine and precision medicine which rely on algorithms and patient data instead of the judgment of the physician and patient about what treatment plan is best.
- The cost of centralization of healthcare policy and regulations
The need for hospitals to follow governmental regulations has led to an explosion of hospital administrators (average ratio of 16 to 1 administrators to physicians ) which drive up costs and don’t directly provide patient care.
Although this inexorable movement has been rapid there has been little attention paid to the cost to the individuals who are the actual foundation of our healthcare system – the the patient and the doctor. Over time it has become increasingly clear that the bottom line of profit on the part of hospitals and insurance companies and cost savings on the part of the government have had a devastating effect on the practice of medicine.
- Do you know what your doctor does?
Physicians have been on the frontline of the health care debate. Their role has been defined by the government, by the insurance companies, by the media, by healthcare policy experts, and by special interests taking their piece of the healthcare dollar. However, the pro physician narrative has not always been promoted to the public and the media.
The role of the doctor is to be an advocate for his or her patient. The Hippocratic Oath sworn by a physician obligates them to put their patient’s safety, privacy, and well being above everything else. Unfortunately, the changes in the healthcare system have put a strain on this oath. Those physicians who have sold their practices to hospitals or who are employees at times don’t have this ability. Their fiduciary responsibility is to the hospital or to their employer, and the freedom to treat their patient as an individual is constrained. Moreover, the ability to work within a patient’s financial constrictions is a challenge.
- Follow the money
In the guise of cost control, medical insurance, whether government or commercial, has become extremely powerful. In fact, access to medical care is increasingly being driven by these third-party payers who limit access by requiring pre-certifications and other barriers to the patient such as high deductibles and co-insurance which limit access through cost.
- Physician Shortage
There have been many articles about the shortage. One of the most recent (https://www.moneytalksnews.com/facing-massive-doctor-shortage/) estimates that there will be over 105,000 doctor shortage by 2030, but when you examine all of the causes you have to wonder if it is by design.
The loss of the physician workforce is multifactorial. As a business, it is one of the most peculiar business models. What other business has to contend with increasing costs such as malpractice, supplies, equipment and labor while facing yearly decreases in reimbursement? It is the main reason why some private practice physicians have left medicine, sold their practices and those that remain open have either adopted a model of high volume using allied healthcare professionals such as physician assistants and nurse practitioners, or they have become third party free concierge or direct pay practices.
What other profession is controlled by third party interests (who are not part of the profession) that decide the value of a service rendered and also control access to payment for the service? The physician accounts for 7 cents of the healthcare dollar spent. It is clear that the real cost driver is not the physician, but the administrative infrastructure that has been set up to monetize the physician and the patient.
Because of government control of the number of residencies available nationwide for graduating medical students, thousands of doctors are not able to find a residency; and therefore, are not able to practice medicine although they have completed the required medical school training. https://www.statnews.com/2016/03/17/medical-students-match-day/
Why not try a different approach instead of doubling down on the most expensive aspects of the healthcare system? The answer won’t come by outsourcing to health information technology that uses big data to create patient care algorithms on population based medicine. It should come from asking physicians who are on the front line.
The answer to controlling healthcare costs is to empower the patient by giving them control over their healthcare dollar
- Allowing the patient to control their health savings account (HSA) so they can put in as much money as they want (tax deductible) and be able to use it for any healthcare need without it being tied to a health insurance plan. This would free them to use direct primary care (DPC), cash pay practices (www.jointhewedge.com), and medical cost-sharing (www.libertyoncall.org).
- Mandate price transparency so that any healthcare entity – hospitals, labs, physician offices etc.. would have to list both the cash price and the price if the patient wants use their insurance plan so the patient would know the full cost before they have the service.
- Mandate that if the medical service is pre-approved by the insurance company it must be paid in a timely fashion
- Allow those who have government insurance to use funds (similar to a HSA) to access cost sharing, DPC and cash pay practices which would lead to lower costs and better access.
The fundamental question is who should have the power to make healthcare decisions – the patient partnering with their physician or the third party system which has an inherent conflict of interest because they stand to gain by controlling cost and access? The answer is that it should always be about care and not control.