Confessions of a Cultural Anthropologist: The Cause and Cure of High Health Costs

Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms. Add in such pressures as the need to pay off enormous debts, and it is not surprising that students’ choices are dictated by the desire to maximize income and minimize work time.

Pamela Hartzband, MD, and Jerome Goodman, MD
“Money and the Changing Culture of Medicine”
New England Journal of Medicine, 1/08/09

I have a confession to make.  I think the cause of high American health costs is straightforward, but it is not simple. It is American culture in general and the physician culture in particular.  There is nothing wrong with this, and I point no fingers.

The Way We Are
It is our culture.  It is the way we are, the way we’ve been for 232 years. It is our distrust of government and high taxes. It is our want to be free to choose. It is our belief in for equality of opportunity for access to the latest and best of care.

It is the notion, stemming from frontier days and conquering of the West,  that action speaks louder than words, that if you do something specifically, it is better than doing nothing generically. “Don’t do nothing, do something,” as the saying goes.

Specialty-Dominated Care
Which brings me to the nub of this essay: specialty-dominated care. We are the only nation in the Western World with more specialists than generalists. Our health costs are roughly twice those of other cultures, and our health statistics lag.

I do not reflexively attribute these results to our health system faults – we have a richer mix of immigrants, who tend to have poor health outcomes and who hail from different medical cultures; we have higher accident rates and dreadful levels of violence; and our market-driven culture lets some people fall through the cracks. But our blind belief in specialists leads to a sometimes crazy quilt system that may be good for certain problems – advanced cancers, rare diseases, heart disease, debilitating crippling arthritis, and other chronic common diseases – but bad and bewildering for the general population.

Educational Costs
And let’s not forget our educational system. It’s expensive. The rate of rise of college tuition costs exceeds health inflation. Our government does not subsidize undergraduate or post-graduate care as generously as other nations. Yes, Congress indirectly helps academic centers finance medical education and residencies. But it’s often too little and too late. Upon graduation, the average medical student carries a debt of $150,000, and many students are married to one another, which may double the debt burden.

Small Wonder
Small wonder, then, that our culture causes  medical students to favor high paying specialties over low-paying primary care. Small wonder, then, that our culture propels primary care doctors to re-enter specialty training, perform procedures in their offices in search of more revenue, become hospitalists and proceduralists in hospitals, and seek refuge in newer, more lucrative and less time demanding practice models.

Small Rewards for Cognitive Services
But alas, there is no easy way to change American culture, no way to decrease rewards for doing and performing and to enhance rewards for empathizing, commiserating, advising, and just plain discussing.  It is easier and quicker and often more appreciated to biopsy a skin lesion, prescribe a highly promoted drug or antibiotic for a viral infection, order a CT or MRI scan, order the latest diagnostic test, than to counsel watchful waiting or behavioral change, or to click onto an EMR armed with best practice information, refer to a specialist, or do something, anything, that can be defended in court.

Concierge Practices
There are options, of course, out of the primary care rat race.  Here is what our two Harvard medical school professionals, have to say about primary care.

“Some established primary crew physicians are making career choices in response to this new culture and fleeing to concierge practices, often citing their desire to escape the constant pricing of every aspect in their days.  Since concierge practices collect yearly premiums from patients, such doctors may ironically  be less “primed”  by money at each encounter and may avoid feeling “ nickeled and dimed” by insurers. This arrangement creates an environment that can foster social interaction more than market exchange. But concierge medicine is unaffordable for most Americans, and it drives much-needed primary care providers away from the larger populations.”

Medical Homes
Our two Harvard professors suggest a more reasonable answer to the specialty-dominated culture may be medical homes. “The medical home,” they say, “is envisioned as a ‘compassionate partnership’ of primary care providers and patients, with coordinated care for patients’ ongoing problems and increased attention to preventive measures.”

Perhaps the medical home is a good fit for the American culture, which yearns for the good old days of Marcus Welby, and the family doctor who knew everybody in the family, its history and its dynamics.  “Success in such a model,” assert our Harvard commentators, “will require, collegiality, cooperation and teamwork – precisely the behaviors that are predictably eroded by a marketplace environment.”

A  Pragmatic View
In my view, it will require more than “collegiality, cooperation, and teamwork.” It will require solid backing by  state and local government, major employers, and specialists; reimbursement to the tune of  $50 for each patient managed, lowering of bureaucratic red tape  for  medical home physicians,  and simpler, less expensive, more utilitarian electronic records. The obstacles and troubles and expenses of qualifying to be a medical home practitioner may winnow the number wanting to be such practitioners by 50% or more.

Coming to Grips with Reality
American health authorities will have to come to grips with the reality that broad based primary care systems are less costly and have better outcomes than specialty-dominated systems. We also need to pay primary care doctors more and to reward them for the right reasons – more time spent with patients,  quick respond to one day appointments, prompt answering of e-mails and phone calls, proper guidance through the medical maze, and more efficient, effective, personal, and practical care.

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15 replies »

  1. This thing is obvious. When the cost of Medical education is so high, in our country $70,000 to $100,000 and in India it is $100,000+, students are likely to be money minded as they have in mind that its like an investment.

  2. There is an inherent ticking time bomb in the health care industry’s business model. Health insurance is based on “young and healthies” buying coverage, but not needing care. Their premiums are supposed to subsidize the expense of care for seniors, which amount to about 80 percent of care provided. But insurers are selling – and employers are buying – lower cost plans with higher deductibles. So “young and healthies” are contributing less revenue to the health insurance pool. This is preparing us for 2011 – 2030, when 79 million American baby boomers will turn into senior boomers. We’ll have a population of millions of older people needing care, and fewer younger people buying classic insurance plans to pay for the care. It reminds me of the business of derivatives and sub-prime mortgages. Why didn’t investors realize that at some point people without sufficient funds would be unable to pay their mortgages? Similarly, why don’t health insurance executives know that someday soon there won’t be enough money to cover health care for people who have been paying premiums for 45 years? Are they counting on a federal bailout? To me this is a serious issue, and blaming physicians for the high cost of care seems superfluous.

  3. President-elect Obama will offer some form of universal health care coverage. However, we need to fix the health care system as well.
    As a patient and a former employee (I used to work at a famous hospital on
    Long Island) of the health care system – I have first-hand knowledge on how
    the care system works in America. Close to 100,000 people die each year in hospitals due to medical errors. The hospital I worked at had too much administrative waste. There was endless paperwork in processing patient information. Many of the positions, especially in the non-medical areas, were filled through nepotism. Many of the supervisors and mid-level managers at this hospital were concerned about how they looked to top administrators, rather then perform their jobs effectively. (CYA was the major activity).
    A question I would like to ask the general public, particularly doctors – How come doctors never challenge other doctors?
    Right after I graduated college I was “confused,” doing drugs, and getting into trouble; so my parents sent me to psychiatrist. The psychiatrist said I was “mentally ill” and he sent me to neurologist for my tests. (Our family doctor stated at first I did not need any tests, and then he changed his mind.) The neurologist examined my brain and said I was fine. I just needed to “grow up.”

  4. Gravitation towards specialization may also be the result of physicians wanting to be masters of a discipline rather than a “jack of all trades”.

  5. But are high salaries really the cause of high health care costs? Only 10% of health care spending goes into physician compensation. Over the last couple of decades physician compensation in real dollars has actually been trending downward while health care spending goes up.
    I still say that part of the solution is to stop training so many specialists. Just don’t make the training available. Since the money to support post-graduate training mostly comes from the federal government, that shouldn’t be a difficult goal to accomplish. At the same time, begin to ratchet down the differential between primary care and specialty care so that only people who are really attracted to a field are motivated to spend the extra years in training.
    I saw FFS patient today. She had a problem. She went to the dermatologist. He sent her to the endocrinologist. She brought me the results of the second specialist’s tests to discuss. If she had started with me, I would have ordered the same tests and discussed the final results with her by phone a few days later, saving two specialist fees.

  6. If you think physicians are money grubbers, you should see the untalented, pathetically unethical, community college attending, cult-religion following, hired because they are in their respective cult, hospital administrators.
    Want costs to go down? Eliminate hospital admins and require everyone to pay 500$ into a national payor system. Let docs select their own to run hospitals. Etc.
    Think about it carefully..

  7. Looks like high compensation didn’t give us better financial managers – why would you think this would be any different for medicine? Money attracts bottom feeders and perverts motives.

  8. Richard,
    the cost of healthcare is, as you menioned, straight forward and if one were to look at the healthcare as a whole, will find the solution also straightforward. The trouble is that there has been so much of misinformatin sowed to keep the discussion going.
    Here are some of the opportnities:
    1) integrate the clinincal and business processes first within the facility then across and then may be more
    2) Develop standardadized platform for medical informatics
    3) Universal healthcare
    4) Wellness focussed care not cure focussed
    5) Tart reform to punish the doctors criminally if mistake is criminal. Move from rewarding the victim to punishing the culprit. Victims do not need multimillion dollars, they just need able to maintain the lifestyle they had as much as possible.
    6)Insurance should be based on life choices as much as possible without violating the privacy laws. If a person smokes, their heart disease should not be subsidized, etc.
    7) EPA reform – we need to tighten the rules on medicines, water quality, emissions, etc.
    8)…..I would invite others to add more
    We are in the business of healthcare transformation and believe if the providers are a bit open, there are huge opportunities at their facilities.

  9. Interesting comment from bev MD, although I think that the process is reversible. If one adjusts the conditions (both tuitions and compensation), salary expectations and motivation will change.
    However, it seems important to me to find a reasonable middle when you adjust things. I grew up and went to medical school (early 90s) in Germany, and the numbers of (centrally sponsored and planned) medical students were very high, probably exceeding future needs by far. Some of the older physicians commented: “The government wants to create a flood of doctors in order to destroy the medical profession and make them submissive”. And I think they were at least somewhat right – I remember the anxieties of being a German medical student in the early 90s, about not getting into a reasonable residency program etc. and worry about the career in general.
    This worry and the – at many institutions – terrible working conditions (if you have enough applicants, you can abuse your residents) is that very many left and still do leave medicine, and the current situation seems to be that Germany produces state sponsored many MDs for Switzerland and GB (and other countries incl. the US to a lesser extent), while local positions are unfilled or often filled with immigrant MDs (usually from eastern countries) who are often fighting with a language and cultural barrier.
    Improve primary care working conditions and reimbursement, create some scholarships for aspiring PCPs, and the situation for PC in the US will be better in a few years. Provided that patients accept the concept of a medical home and don’t insist on seeing a specialist for every ailment. I think some education and steeting is needed there as well.

  10. I do not think the medical home is the be-all and end-all for U.S. health care. After all, it applies only to qualifying primary care physicians, and those numbers may be small. Also I don’t think putting all physicians on salary to avoid FFS incentives is the answer. The answer may be a blend of FFS, a management fee, and bonuses for prompt responses to patients via same day appointment and responses to email and phone calls. I am not a fan of strict capitation, which I regard as a failure for the most part. Physician are smart people, and they will adapt. Physicians are also compassionate, and I don’t think lack of compassion is the root of our problems.

  11. Why is there a primary care shortage? I have been a family doctor for 19 years. Finally, the NEJM has touched the nub of the matter–I’ve been telling people this for years now. It’s the new medical students who are increasingly bottom-line focused. They were raised in a culture that is bottom-line oriented, and they’re not going to change. More money, less work (this is also a crucial factor that the editorial doesn’t discuss). Cultural, cultural to the core.I mentor freshman med students. They’ve never been on the wards, never heard primary-care bad-mouthed by doctors, but still they’re heading towards specialties(not all of them, of course–there are a few neo-hippies among them).
    Of course I am not without sin here. I earn way less money than most of my old medical school classmates. If I think about it, I feel like I’ve been screwed. I try not to think about it.

  12. The physician culture of money is an enforced adaptive response to the American choice of a free market healthcare system, not a driver of it. I watched it evolve during my career. Yes, now it has become an entrenched attitude among today’s physicians and medical students (and therefore now attracts those kinds of people to medical school), but that is a side effect, not the primary disease. As one of my evolutionist friends says, “adapt, or die.”

  13. Medical students in Europe, where national health programs are virtually universal do not pay to attend medical school, the government who in a very real sense limits the ability of these future doctors to earn a living, has made a implicit bargain with the students; education is free but the government reserves the right to determine your level of compensation throughout your professional career. At the moment, the American medical student is asked to go into hock for $200,000 or more while their ability to control their level of compensation once they graduate may be determined by government bureaucrats. Americans are likely to perceive such a system a inherently unfair, and may insist that the either the government pay for medical education or refrain from limiting the free market in medical reimbursement.
    William J. Bologna (cincinnatusblog.com)

  14. I read this article and was perplexed by the transition from an ‘all docs should be salaried money is evil’ theme to a largely unreferenced last paragraph endorsement of the medical home. And not just an endorsement: in addition to fixing All That Ails Money Grubbing Physicians, the article implies that the medical home will save money, promote social compacts and increase compassion. Puh-lese! Do the authors realize that the payment mechanism will be a version of old fashioned risk-adjusted capitation? That’s not necessarily bad, but there’s a lot of work to be done between here and there.

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