The Future of the Physician

Craig GarthwaiteOn Wednesday June 4, the Kellogg School of Management hosted its annual MacEachern Symposium. A packed auditorium listened to an impassioned discussion about The Future of the Physician. Presidential adviser Ezekiel Emanuel and AMA President Ardis Hoven were among the speakers. While Emanuel was optimistic about the impact of the Affordable Care Act on hospital-physician integration and the resulting potential for cost savings and quality improvements, Hoven was concerned about the impact of the business of healthcare on the medical profession. In this blog, we offer our perspective on the evolving role of the physician.

The hit television series Marcus Welby, MD last aired in 1976. Dr. Welby was the physician of every baby boomer’s dreams, whose patients always felt cared for and always got better. By the end of the century, Dr. Welby had been replaced by Dr. House, an MD cum Sherlock Holmes with Narcissistic Personality Disorder and an opiate addiction. While his bedside manner is decidedly not Welbyesque, Dr. House still embodied the basic premise of the all-knowing and dedicated provider that solves problems with little concerns for costs or standard practice.

But in the real world, physicians are evolving along a different—and we argue—better path. The 20th century physician was self-employed, championed the interests of patients, and had complete control over the medical system. But this system had at least two primary problems: (1) ever escalating costs and (2) dramatic variations in physician practice patterns with little connection to outcomes. We shudder to think how much Dr. House spent on his patients. This system is no longer sustainable.

Enter the 21st century physician, who is increasingly an employee of a large provider organization that scrutinizes every medical decision based on both cost and quality. We may all be better off for this transformation – the question is will we accept it? If past is prologue, we fear that American public is still not ready.

This transformation began with the HMO movement of the 1980s, abruptly halted in the backlash of the 1990s, but has returned with a vengeance. Despite their seeming ability to restrain cost growth, the HMOs of the 1990s were vilified. These organizations were caricatured as cruel attempts by insurance companies to deprive Americans of medical care. They’ve even served as the villain in Denzel Washington’s hostage movie John Q.

Given these facts, HMOs needed a reboot. Enter Obamacare’s Accountable Care Organizations (ACOs) – i.e. HMOs 2.0. Organized by physician groups or hospitals, ACOs contract with Medicare and private payers and attempt to hold down costs and meet performance measures in order to reap huge financial returns. To meet these objectives, ACOs are relying on the very top down control of medical decision-making that made people revolt against HMOs. This entire process is made much easier when ACOs employ physicians, many of whom are more than happy to sacrifice their autonomy in order to have a guaranteed income and a better work/life balance. Employment (by group or by hospital) is not just a viable option, it is desirable.

Employment is just the first step. Historically, we have forced many participants in the medical community, such as pharmaceutical companies, to test their products through clinical trials that rely on the scientific method. Physicians, however, develop their practice styles through personal experiences with small numbers of patients and their immediate colleagues. The result has been a patchwork of treatment patterns, broad differences in outcomes, and little consideration of costs.

Increasingly, the medical profession has accepted the idea of routinizing care delivery though protocols, and ACOs are using big data to implement diagnostic and treatment checklists. Some doctors push back against these efforts, saying these checklists effectively force them leave their judgment at the examining room door. They fear that physicians will be transformed from professionals relying on personal experience and judgment to technicians following a user’s manual. That may be, but if these technicians are making the right diagnoses and ordering the correct treatments, saving lives and money in the process, then we are all for it. Protocols are not perfect, of course, because patients are not identical. The best ACOs will use protocols as the default option and allow their physicians to occasionally use their discretion when necessary. But we have erred on the side of unlimited discretion for too long.

Much like lunch, this move to ACOs will not be free. Effective ACOs work by controlling the full scope of medical care delivery, and this will often necessitate restricting patient choice of provider. No longer can we simply shop around for the physician that will provide expensive and unnecessary treatments in order to satiate patient demand. Many fear this world, because they confuse choice with quality. In a world where people seek out physicians based on personal recommendations or Yelp-like rating system where personality matters more than skill, a little less choice might be exactly what we need.

If one of today’s ACOs recruited Dr. Welby, he might run in the opposite direction. To which we say, good riddance. The days of “physician as father figure” are long behind us. But we were looking at those days through rose colored glasses. Tomorrow’s physicians will be grounded with the information they need to make the right medical decisions and the incentives to properly balance cost and quality, even if they must rely on others to guide those decisions. Gregory House once asked, “What would you prefer – a doctor who holds your hand while you die or one who ignores you while you get better?” This may have been the dichotomy that Dr. House inherited from Dr. Welby, but it is false. It is possible for employee physicians to be compassionate and even cost conscious, while making their patients better. There is every reason to believe we are moving in that direction.

52 replies »

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  14. It’s often said that the main method of paying health-care providers with a fee for each service results in increased spending. Such system rewards providers just for doing more procedures rather than for providing efficient and high-quality care. The implementation of accountable care organizations (ACOs), a new health care payment and delivery model designed to improve care and lower costs, is proceeding rapidly. As a part of an ACO, providers typically take on responsibility for groups of patients. The pay-for-performance program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures. The goal is to eradicate duplication of services and coordinate patients’ care, and to increase preventive efforts that may ultimately reduce the need for high-cost services.

  15. The fact that Medicare pays $10 billion for graduate medical education doesn’t mean that it is spent on training doctors.

    Certainly in the past (but maybe not so much today) an intern/resident would EARN his/her salary with the work they did.

  16. I agree that the statistics showing US healthcare to be worse than elsewhere are flawed. Life expectancy in the setting of violence and poverty isn’t really a good index of healthcare.

    Nevertheless, I would argue that the gap in the quality of healthcare delivered in the US vs that in, say, Europe is steadily declining. With rising bureaucratic and cost-cutting pressures here, and the diffusion of knowledge worldwide, I would bet that most other industrialized nations are catching up to us, at a far lower cost.

    My point is that they are catching up without handing over the provision of healthcare to restrictive managed networks.

  17. Barry, try looking at all sides of the equation. When you do you will find one common link. Government loves to spend money and people in academia love government grants which provide them with high end lifestyles, insurance and tenure. That is why we have research grants to figure out whether mice like Swiss or American cheese. That is why we have a lot of ridiculous research coming out of academia who don’t want the income stream to cease.

    Brian A was blaming all docs for their million dollar education which today can cost $100,000 or even less outside of the US in for profit institutions that expect to make a living off of educating doctors instead of serving mice the right choice of cheese.

    Now you are telling us that residents are not worth what they are being paid. Maybe you are right and if that is so we should reduce the resident’s salary, but for most of the time period from the discovery of penicillin residents were very poorly paid and probably overall provided more dollars in value than was spent on them. Brian A’s claims no matter how one looks at them are pure BS.

    I can count up the money spent on my ~decade of training and compare that to the value of my care and I can only see that I put more in then took out. Take note as well that during Vietnam when the number system existed physicians were drafted no matter what their number was. That’s another payback.

    When it comes to physician compensation maybe Professor Reinhardt said it best in 2007 and maybe that will help the envious to understand what value means. ” A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.
    Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.”

  18. ” This really isn’t rocket science. ”

    No, it’s brain surgery.
    Seriously though, Lynn, you have struck a chord. The business of medicine, because it is inundated by third party payers, has lost sight of the original party, the patient. And now, the focus is on the computer and the paperwork. Once I feel I have lost the ability to focus properly on the patient, my time as a physician is over.

  19. My vote for the 21st Century “model” doctor is Leonard McCoy of Star Trek! You do all have a tricorder don’t you?

    I recommend you all reread Paul Starr’s Social Transformation of Medicine.

    Somewhere along the evolutionary trail, medicine moved from profession to health care business. Medicine/health care are human endeavors with all that is best and worst. So what is it that patients want? Honest compassionate they can afford without fear of bankruptcy. Some may want a miracle or two or three along the way and modern American medicine does provide more than its share. This really isn’t rocket science. There is a lot to be learned by studying and understanding quality (effective care) and cost (efficient care). I want my doctor to know my name and look me, not her/his computer/IPad in the eye. Oh yes, wash your hands. Now it that too hard.

    I was struck by the tone of the discussion thread that so few mentioned patient(s) and the duty owed patients. Hippocratic or fiduciary responsibility? Which is it? As long as I know, I can deal with it.

  20. The higher the costs of care, the more money passes through the insurer. It likes to grow; the more money passes through all the agencies paying for care and research and paying for studies ironically investigating why care is so costly; the more money passes through the providers who like to add associates and staff and who like to become larger and dominant; the more money passes through the patient who likes to be attended and studied and fussed over; the more money passes through all the policy folks, economists; consultants on accounts receivable efficiency, ad infinitum into 1/7 of the entire population who love health care to be costly.

    Therefore everyone loves to see medical care become more and more costly and consume more and more of the national product. We love what is happening to health care, at least 1/7 of us do.

    Costly health care has to displease someone for this engine to stop. Someone has to care and begin shopping. Some of us feel it could be the patient who begins shopping, just a little at first, and just for services in the ambulatory safe front end of medicine. How would we be cruel to suggest that the patient shop for providers who would manage his hypertension or psoriasis?

  21. I was about to blast you for the first sentence, but realized that I agree with the rest of your comment!

    The belief that “other countries have better healthcare” is completely false. When the Sultan of Brunei gets sick, he flys in his private jet to have his surgery done in Houston, TX. When Canadians get tired of waiting to have surgery, they scamper over the border to the US to get things done. When immigrants (legal and otherwise) swarm into the US, do you think it’s because their healthcare is so fantastic in Cuba, or Ghana, or Vietnam, or Montenegro?

    This crazy ranking of “healthcare quality” is a function of the WHO, and puts the US behind many of these places. We are punished for trying to save extreme low birth weight preemies who were born to crack moms. We are punished for having trauma systems that care for people shot up in gang wars. We are criticized for providing so much care at the end of life.

    Guess what, all this stuff is expensive, and we are NOT doing it because doctors just want to pad their paychecks. We are doing it because PATIENTS DEMAND IT. Try telling the uneducated mother of a 2 yr old who bumped his head that a CT scan is not necessary. First she will get a lawyer and then sue you and then take her kid across the street to get a CT at the other hospital. (it doesn’t matter to her that she just dropped her kid’s IQ by 20 pts.)

    Try telling the family that grannie does not need to be resuscitated simply because she is 97, demented, has a PEG and foley, contractures, and incont of stool and urine. NOPE, “do everything doc!!!!

    Try telling the 32 y/o “weekend warrior” who twisted his ankle playing softball that he just needs some ibuprofen, an ice pack, and maybe an ace bandage. He will go ballistic, demanding an MRI RIGHT NOW because “I have good insurance”!!!

    The reason things are so expensive in healthcare in the US is because the people receiving it are not paying for it. The Afford Care act will only exacerbate this problem, since it is creating millions more people who receive free or subsidized care for which they pay nothing (read: “Medicaid”).

    The reason things don’t cost this much in other countries is because THEY DON”T DO ANYTHING. Pt’s in Switzerland don’t run to the ER 37 times per year because their kid has a runny nose. Everyone in France doesn’t have an AICD. People in the UK with an aneurysm don’t get clipped. Some of the just die. Teenage girls in Belgium are not having thousands of babies at an epidemic rate. Not every patient in a Cuban nsg home has a PEG, Foley, and a trip to the ER every time she gets “confused.”

  22. Medicare pays teaching hospitals approximately $10 billion per year in graduate medical education (GME) payments. One-third of that is to cover direct costs such as residents’ salaries and the other two-thirds is for indirect costs including longer patient stays and ordering more tests which are byproducts of the education process. The Medicare Payment Advisory Commission (MedPAC) suggests that the indirect payments may exceed the hospitals’ actual indirect costs. At any rate, it’s a highly controversial subject.

    It would be interesting to see an analysis of the costs teaching hospitals would escape if they weren’t educating the next generation of doctors as well as the tuition revenue they would lose. It is a fact that teaching hospitals have much higher costs than community hospitals while the cost of research is largely covered by grants, mainly from the NIH, and philanthropy. At the same time, academic medical centers presumably have a much higher acuity case mix because they provide the most sophisticated and complex care. Also, somebody has to train the next generation of doctors. How much that actually costs I have no idea.

  23. Everyone’s environment is so completely different. Everyone’s genome is so amazingly different and complex. Everyone’s illnesses are so polygenetic., except for the very rare mono genetic problems like SS disease which are rare. Tumors usually have, on GWASs , about 30-50 differences. Epigenetic methyl and ethyl groups, attached to the histones or the DNA, are so poorly understood…. causing differences in gene expression….all this makes me wonder if there can be any logical standardization in medicine at all. Does it make any sense scientifically to have standards of care or treatment algorithms? Will our ancestors laugh at us? Shouldn’t everyone be treated as a special unique biological person? I think we shall before the blink of an aye.

  24. that my be the worst article i have ever read, No facts to support any of the opinions of the author, I will have to say that it was seeminly written by a moron that has no idea of the difference between health and healthcare and concept of the history of medicine. the escalation of cost occured when business people got into medicine not due to physicians driving up the cost. I hope the future articles have a little more thought into them.

  25. Everyone seems to forget the amount of time medical students and residents spend with unpaid volunteer faculty and even those still in training. My son did a one month rotation in my office. I don’t recall being paid.

    Maybe things depend upon the date and where one was trained. I can’t say that things haven’t changed that much except for what I glean from my son.

    I recall a large number of physicians and researchers that were responsible for our education, but my total time with them in and outside of class was slight. By the minute I was paying them a small fortune so they must have been doing something else with their time and much of their pay and facility fees for that time came out of my pocket.

    Research! I remember working with a few of them on their research and one time being trained to be anal compulsive in keeping the spectrophotometer cuvettes sparkling. This work could have been managed by a low level technician, but I wasn’t paid. I also worked in the mental hospital for one summer. I don’t remember if I was paid or not, but if I was it didn’t even cover my rent for my slum apartment. I did physical exams, occupational therapy. prescribed medications and dealt with the patients while the paid psychiatrist did almost nothing. It didn’t matter for he went on vacation and I was in charge of about 60 males, many of whom had been hospitalized for decades. When the female psychiatrist went on her vacation I was in charge of her 60 patients as well, or at least on paper.

    Third and fourth year were rotations mostly with unpaid physicians, but tuition was still paid for those years. Part of the time was running the clinics along with many others treating patients with supervision of one M.D.(?paid)

    Residency was much of the same with the most time spent with unpaid staff and even more time spent with others in training. We stayed up all night admitting and treating patients as well as all day. In some hospital rotations the hospital didn’t pay technicians to work in the evening so we would run the necessary equipment doing blood counts, blood gasses and microscopic work.

    Working in the ER was a hoot. Non stop work 16 on and 16 off without holidays. When someone got sick the work hours went to 24 hours. I don’t remember ever seeing a paid physician though I think they now have one at least during the daytime. This was a very active emergency room with people that were insured and paid for the care. Those in charge were in training themselves.

    Then we have to listen to the ignorant like Brian A

    that thinks it cost the public $1,000,000 for my education. Steve is being more reasonable, but I think he overestimates the actual money spent on medical school and residency. One can get a partial answer to the question by looking at schools outside of this country that make huge profits graduating medical students that then return to the USA. I haven’t done a recent search, but from what I remember (check it out yourself) in the western hemisphere one can finish the first 4 years with a tuition expenditure of less than $100,000 to profit making institutions. That tells a lot about the costs of educating a medical student in the first 4 years.

    Brian A, if my medical school tuition was zero you could say that I worked my way through school and advanced training since during that time period I treated thousands of patients that either relied upon the state or actually paid the hospital for my services.

  26. Steve,

    It would be interesting to take a careful look at the numbers from an unbiased perspective (if that is possible). It would also be interesting to look at educating a Medical Student with a “fresh eye”.

    For example:
    – Do medical students need to learn anatomy on cadavers?
    – Does a PhD in Physiology need to lecture on the physiology of the kidney for every class of Med Students – or could one lecture be put up on the Internet like Khan Academy?
    – etc.

    I don’t think that the traditional method of educating Medical Students is necessarily as much for their benefit as it is for the Benefit of the Institution and Faculty.

    As for the reference to the Productivity of Academic Radiologists vs. Private Practice, it was several years ago and I can’t recall what Journal it was in. I believe one of the authors was Jonathan Sunshine. I do remember the conclusion though since it affirmed what I had long believed.

  27. I dont know the data in every field. You could be correct for yours. I have looked at costs for my area (Anesthesia) and i know what they generally are for the surgical specialties. We looked into having a residency and we cannot afford it. Having surgery residencies at my place has cost me money. We just opened a medical school a couple of years ago. It is expensive. I suspect that when/if you ever have to make out budgets you will start to understand.

    ““That 30 minute appy with an experienced surgeon takes 2 hours with the residents.” True. What about seeing the patients in the ER at 2 am with the attending tucked all snug in his bed.”

    OR time is incredibly expensive. It doesnt come close to offsetting the OR costs. Also, you could use an experienced PA and get the same info for the most part.

    ““The labs are not cheap” Anatomy lab, Micro, neuro etc.

    “You mean the ones that some of the top students in my class skipped?”

    What were they worth to students not smart enough to skip classes? What about clinical rotations where someone has to take time to discuss cases with students and residents?

    Hispitals get money from Medicare to help offset training costs. So in your case, it may be even worse than what you think. However, that is not necessarily how we budget. We know that the costs of training some residents is higher than others. At our center we average those costs out.

    I am a bit skeptical about your productivity claims since measuring it in your field is a relatively recent phenomenon. However, if you have the study would love to show it to our Chief.



  28. Until the tort system is modified for medical malpractice, no one will be practicing “Evidence Based Medicine”.

  29. I’m somewhat more optimistic on the cost issue, at least over the longer term.

    Medicare costs are coming in below projections for the fifth straight year. For the first seven months of fiscal 2014, total Medicare spending net of beneficiary premiums is up only 0.3% despite roughly 3% growth in enrollment. The standard Medicare Part B premium of $104.90 per month is roundly 11% below what it was estimated to be by now back in 2006.

    Different segments of healthcare are behaving differently when it comes to cost. Dental care, for example, is not growing as fast as other segments. I think it’s interesting to note that we have good price transparency in dental care. Diagnosing the patient’s issue(s) is/are relatively straightforward most of the time. It’s hard to rack up a huge bill, in part, because very little of it takes place in a hospital setting.

    Nursing home care is costly in aggregate because of the aging of the population. However, again, we have decent price transparency. Much of the cost of nursing home care consists of relatively low cost labor plus real estate neither of which is increasing faster than general inflation for the most part. On the positive side, the percentage of the elderly population in nursing homes is considerably lower than it was 30 years ago.

    The big ticket expenses in U.S. healthcare include care provided in a hospital setting plus brand name and specialty prescription drugs and medical devices. It’s here where prices exceed what is paid in most other developed countries, often significantly. Moreover, a relatively small percentage of patients account for a disproportionate share of costs in any given year. Specifically, the sickest 5% of the patient population accounts for about 50% of costs though, of course, they are not the same people from one year to the next.

    I think there are huge opportunities to contain costs in the area of end of life care. Oncologists are just now starting to look at cost-effectiveness more systematically. Palliative care specialists working with oncologists and patients can do a better job than oncologists alone in teasing out the patient’s goals, hopes and fears and expectations. Too often in the past, treatments would be prescribed that the doctor knew would not help the patient because he didn’t want to be seen as abandoning the patient.

    Finally, as we get more robust and user friendly price and quality transparency tools in the hands of doctors, it will be easier for them to direct patients to the most cost-effective high quality providers and tort reform that gives doctors safe harbor protection from lawsuits if they follow evidence based guidelines and protocols where they exist could reduce defensive medicine.. I’m not sure how all this shakes out in terms of physician job satisfaction but the long term cost outlook is hopeful, I think. As the late economist, Herbert Stein told us, “If a trend can’t continue, it will stop.”

  30. If we don’t get health care costs under control nothing else really matters. In the last 50 years wages adjusted for inflation have gone up 16%, GDP 168% and health care costs 818%. It doesn’t take a degree in economics to understand this is not sustainable. I read an article int the Annals of Family Medicine that was a game changing wake up call to me. It has inspired me to try to do something about it. The article is: Who Will Have Health Insurance in the Future? An updated Projection. I consider it a must read article for every American.

    “If health insurance premiums and national wages continue to grow at recent rates and the US health system makes no major structural changes, the average cost of a family health insurance premium will equal 50% of the household income by the year 2021, and surpass the average household income by the year 2033. If out-of-pocket costs are added to the premium costs, the 50% threshold is crossed by 2018 and exceeds household income by 2030.”

    I personally know a woman whom works 30 hours a week in a retail store. She has health insurance and is the prime reason she even work. Her adjusted gross income last year was a little over $10,000. Her companies share of her health insurance was $12000 and she paid an additional $3750. Her health insurance cost 1 1/2 times what her AGI is.

    We are going to pay $29,000 more that Canada is for the new Hepatitis C drug that costs $1000 a pill in this country. If we cut health care spending to what the Swiss pay, which is primarily a privately funded health care system we fund the eliminate the budget deficit with enough left over to pay the tuition of every public college student in the country. It’s the lobbyist’s, it the lobbyist’s and its not going to get any better until the American Public something about it.

    They say it can’t be done. They have to much money. Well the NRA, whether you agree with them or not has demonstrated a model that work’s, I imagine that the NRA is they decided to could turn our a million man march on Washington. I would also say the those opposed to the NRA could also turn our a million and maybe two people if they tried really hard. How many people do you think the health care lobby could turn out for a march to demand higher drug, medical device, and hospital bills.

    Sorry for my rant but I am passionate about this subject.

  31. The author of this post is mistaken if he thinks that state and federal regulations are going to force doctors to practice based on evidence based “protocols.”

    Exhibit A: Washington state just passed a law requiring that Medicaid pay for all services that are provided by NATUROPATHS AND ACUPUNCTURISTS.

    Does that sound like evidence based “protocol” medicine to you? I didnt think so.

  32. “The labs are not cheap” – Ordered for the patient, we were used to get results instead of the hospital having an efficient infrastructure.

    “Someone has to pay lecturers” – You mean the ones that some of the top students in my class skipped? And what were they worth if they could be skipped?

    “That 30 minute appy with an experienced surgeon takes 2 hours with the residents.” True. What about seeing the patients in the ER at 2 am with the attending tucked all snug in his bed.

    I would like to see an HONEST cost accounting for what teaching a medical student or resident costs. I don’t think that what has passed for an analysis of the situation in the past will pass the “smell test”.

    In my field (Radiology) the issue has actually been looked at (sort of). It turns out that the productivity of Academic Radiologists is as high as that of Private Practice Radiologist. This is because Residents DO increase the productivity of faculty. And if you look at Academic Salary + Resident Salary it is less than Private Practice Salary. So in other words, training residents is profitable – at least in my field.

    I am not drinking the Kool Aid you are serving

  33. Actually, it did cost a lot. The labs are not cheap. Someone has to pay lecturers. When you do clinical work someone has to spend time with you. They could have been working, or working faster if they did not have to spend time teaching you. That 30 minute appy with an experienced surgeon takes 2 hours with the residents. Longer if you are not lucky, The simple breast biopsy with an attending takes 3 hours and a 3 unit transfusion when the residents do it. Real case BTW. So yes, training does cost a lot. We try to make some of it up with grunt work, but it is called grunt work for a reason. It would not cost much to have others do it. It costs tons to train you and let you do stuff.


  34. Brian A,

    “So after US taxpayers invested close to a million in your training”


    For the first 2 years of Med School, I sat in a class with 250 others listening to mostly forgettable canned lectures. Some of the top students never went to class but studied at home. What was that worth?

    Second 2 years we worked around the hospital, starting IVs, getting lab results onto the chart, and mostly being supervised by busy interns and residents who were being paid far less than the attendings. What was actually spent on me – versus given to the hospital and used for other purposes?

    Meanwhile, I paid tuition, bought my own books, stayed up late at night studying, etc. etc.

    Residency was similar, doing a lot of the “grunt work” for the attendings for a low salary. What was actually spent on me?

    Just because the money went to a Medical School or a “teaching hospital” doesn’t mean it was spent on my education. And as far as I am concerned I don’t owe the US taxpayers a damn thing.

    Now, I am not saying that Physicians don’t have an obligation to take care of the poor. I believe we do. Just don’t try to make me feel guilty or pretend that taxpayers were giving me some kind of free ride.

  35. The physicians who responded are bringing the type of passion that is needed when advocating for a patient but which often causes their knowledge to be discounted by the health policy people who have never sat with a patient and a family to talk to them about the options available for an illness that will surely lead to death or fought the system for a patient in need. The health policy people can bring a certain smugness in assuming that the doctors are greedy, old fashioned, and lobbying for their own income when they are often just trying to achieve the type of flexibility needed to approach each patient in a unique way . While flexibility is often built into the design of the systems, the administrators of that design often do not get that message so that despite the best thinking and intentions of the health policy community, we end up with rigid metrics to judge dynamic care problems. Until we can get metrics that are embraced by the medical community as truly reflecting the profession of medicine, we will have trouble communicating.

  36. Ah the real issue greed. The average salary in the US is about 50k, the average primary care doc makes 150K, most specialists make 200 to 400K but you want more.. So after US taxpayers invested close to a million in your training (did you complete your residency and internship) I am curious what job did you get instead?

    thank goodness you got out since you clearly don’t know how to handle money and lack the compassion we need in doctors.. Being a healer is hardly washing windows. We should have screened you out prior to medical school.

    That being said there is no question that it is stressful to be a doctor. Over 400 a year commit suicide (out of 40,000 total) and it isn’t the pay that is the problem but that we treat healthcare like a profit center. Although we don’t need single payer we clearly need to eliminate much of the administrative overhead in healthcare and pay the others less not doctors more

  37. Wow it sounds like you are really upset that your customers might be going away not that you want a better health care system? Are you a lobbyist?

    Center for Responsive Politics reports that the health-care industry spent over $243 million lobbying on health care issues through the first six months of 2013. No other industry sector spent more lobbying Congress and the federal government. The industry is on-pace to match its 2012 lobbying of around $500 million.

    The bottom line is that we spend too much and get to little under the current failing system. Just as an FYI – there is no evidence that patient demand drives this – people don’t shop for care (other than a few elective procedures) and doctors, hospitals, drug companies and robotic equipment manufacturers drive demand.

    You are right that the lobbyists in DC are setting policy but they aren’t employed by patients but again by drug companies, doctors who want to block NPs from practiicng (evidence shows with the same outcomes, at lower cost with happier patients).

  38. Every other developed country provides its citizens with good health care at a fraction of the cost in the US. Yet not a single one of these countries has anything that even remotely resembles the intrusive and choice limiting managed care solution that is taking over here.

    I realize that we’re smarter and better than everyone else, but shouldn’t this at least make us pause on the way to creating the wonderful world of corporate medicine?

  39. I went to medical school and trained as a dedicated slave so that now, I can wash windows at a pittance for the MBA hospital CEO making $$$ millions, and the health insurance company CEO making tens of $$$ millions.

    I quit, as will many others.

  40. Hmmm. Doctors don’t go to medical school? They don’t read The New England Journal of Medicine? They don’t go to conferences and continuing education courses? They just wing it and learn as they go along, like the ACO’s? Medicine has evolved over centuries. Obama didn’t. Yes, the payment system has encouraged doing more procedures, and even doctors respond to financial incentives, but probably not as much as the corporate types running healthcare today. Stop insinuating that all doctors are incompetent scoundrels. Look at all the corporate abuses, even Obama’s VA.

  41. Barry, I don’t think the AMA ever had that much power, but that doesn’t make a difference. The AMA doesn’t represent physicians practicing medicine outside of academia. They seemed to have power when they were on the side of a big player where the combined powers were magnified. If the AMA were that powerful Medicare would never have been passed and the alternative program would have been.

    With regard to costs I am not sure if you are or aren’t trying to correct your prior opinion which was wrong. (“In the past, doctors never saw it as part of their job to know or to care about healthcare costs”) In today’s world there is no great incentive for physicians to be concerned about costs and that concern is reduced if coverage is increased. Obamacare might actually create concerns about cost because instead of reducing costs by $2,500 we are seeing deductibles exceeding that amount and significant cost sharing beyond the deductible up to 60%. That is going to hurt the poor, but it will make them and their physicians cost conscious. This could have been done with a lot less pain, but for the experts that have difficulty seeing the forest through the trees.

    I know NYC healthcare costs very well, but Metropolitan NYC especially Manhattan is anomalous to the rest of the country and NY state like NJ is a community rated state. People might be reluctant to bring up costs, but once a market exists that reluctance fades. I ask my dentist how much each item he does will cost, but not a word to my doctor. He doesn’t set his prices, someone else does.

  42. allan,

    I know the AMA represents a comparatively low percentage of doctors but their political influence and access to the highest levels of government in DC is still very significant just as farmers still have disproportionate political influence even though only 2% of the U.S. population works in farming these days as compared to 40% or more 100 years ago.

    Regarding healthcare costs, the vast majority of healthcare costs paid for by insurers consists of hospital inpatient and outpatient services, physician services performed in a hospital setting, post-acute care following a hospital stay, and prescription drugs. Aside from the drugs where at least costs can be fairly easily ascertained in advance, primary care docs are not responsible for most of these costs though they do make specialist referrals.

    Cost differences are attributable to everything from whether or not to try conservative physical therapy before plunging into surgery for back pain to sending a patient to an inexpensive independently owned imaging center instead of an expensive teaching hospital to deciding which drug to prescribe if there are several that will get the job done without serious side effects within a therapeutic class.

    Even if patients directly controlled the money to pay for care instead of third party payers, many are reluctant to bring up the cost issue because they were taught to generally not question doctors’ decisions or recommendations. This is due to a combination of knowledge asymmetry to fear of being labeled a difficult patient. For hospital based care especially, patients often encounter an attitude of “this is the way we do it here” and questions to the contrary are not welcome. I don’t know where you live but here in the NYC metropolitan area where costs are very high, the attitudes I express are widely shared.

    On the other hand, I met a primary care doc on my vacation last year who has long practiced in rural Arkansas. He told me he was never sued in 30 years even though he made his share of mistakes. He would apologize to patients, explain what happened and they would understand that he did his best and they wouldn’t sue. He also noted that end of life discussions in his area are comparatively easy and straightforward. People around there are more accepting of death when the time comes. The bottom line is that it’s a big, diverse country and generalizations are dangerous. Different regions probably need different strategies to figure out what works best locally. Kaiser, for example, may work very well in CA but would likely bomb in NY and NJ.

  43. “In the past, doctors never saw it as part of their job to know or to care about healthcare costs”

    Simply not true. Doctors always had to think of healthcare costs. The less coverage the patient had the more concerned the doctor had to be. 1)They wanted to be paid 2)They didn’t want to incur costs that would not be paid 3)They had to compete with their neighbor down the street.

    Barry understand the vast majority of physicians dislike the AMA. The AMA’s membership is only around 15-18% mostly academics, politically minded and medical students. The AMA makes a lot of their money from a deal with the federal government (which may not even be legal). People had to sue in order to find out the heinous deal made that negatively impacted almost every practicing physician in America and patients as well.There is a big difference between the AMA of the past and the AMA of the last several decades.

    You really should check some of these things out because there is a lot printed about healthcare (by so called experts) that is totally wrong.

  44. Life is full of tradeoffs and very few people get to do everything their way. Giving up some autonomy for a steady, predictable paycheck and more reasonable work-life balance is perfectly understandable, in my opinion.

    I don’t think anyone is seriously suggesting that we can replace primary care doctors with NP’s and PA’s though I think both should be able to practice at the top of their license. While NP’s can handle a large percentage of typical primary care encounters, they can’t handle all of them and I think they are quite capable of identifying the encounters they can’t handle and refer those to an MD. A couple of times over the years, I called my insurer’s nurse hotline including once when I was on vacation over 2,000 miles from home. Both times, after asking a series of questions, she was able to address my issue and saved me a trip to the ER while I was on vacation. Another time, a colleague called our nurse hotline for a problem he was having. After another series of questions, she told him that he needed to see an MD for his issue.

    In the past, doctors never saw it as part of their job to know or to care about healthcare costs unless the patient specifically brought it up as an issue for him or her. Quite recently, the American Society for Clinical Oncology (ASCO) is finally starting an effort to systematically identify which cancer drugs are most cost-effective in which situations even as the long term trend in oncology is toward more customized treatments based on genomics.

    The AMA complaints strike me as just another continuation of their long history of trying to protect doctors’ turf and to stifle competition at every turn. I don’t recall ever hearing anything constructive coming from the AMA that even attempts to deal with the issue of unsustainable cost growth in medical costs. In my own encounters with doctors, I make it clear that I care about costs even when taxpayers or insurers are paying most of the bill. I wish more of us patients would do the same.

  45. Lawyerdoctor when doctors are wrong causing harm to one patient they get sued big time, but when the ‘intellectual elite’ provide unproven and faulty programs hurting many people they can not be sued at all. In fact frequently they are given tenure at universities despite unproven and erroneous ideas.

  46. “The 20th century physician … and had complete control over the medical system.”

    Really? In the early almost half of the century Penicillin didn’t even exist and after WW2 the government became involved through our tax system creating a third party payer system. Such an out of touch recognition of how control was divided has to extend to any conclusions being brought to the table in this article.

    Did the HMO’s reduce costs as you say? Maybe a little in the earlier stages and maybe they pushed up cost saving a bit earlier than would have occurred, but long term it was just a drop in the bucket. Around that time we were learning that cardiac patients could go home sooner and we were developing procedures that could lessen hospital stays. The HMO’s may have nudged these things to move a bit quicker, but long term they were here to stay. HMO’s could also reduce costs by denying care. Don’t forget Ware’s 4-Year Health Outcome study that concludes: “During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems” and states: “The elderly treated in HMOs were nearly twice as likely to decline in physical health over time” Denial of care can save a lot of money despite the positive image the authors would like to provide as a lead in to the ACA’s, ACO.

    Of course ACO’s have the same incentive to deny care as the HMO does now and in the past except the ACO is more powerful and controls more aspects of healthcare delivery. Thus ACO’s can become even more dangerous than the HMO. Hopefully they will fall flat on their face so that medical ethics and appropriate bedside management of care can continue to exist.

    I find the one’s looking through rose colored glasses to be the ones writing this piece of near fiction where the enemy of good health care is contrived to serve the elites for whatever purpose they might have in mind.

  47. lawyerdoctor,

    Many very good points!

    However, I think you are being too optimisitc 😉

  48. I for one, do not confuse choice with quality. However I do fear the arrogance of knowing what is best for everyone rather than understanding the individual patient’s values, beliefs and desires and customizing care based on their voice, as well as the “best practice protocol.” I must admit that I worry that the authors assertion that we have “erred on the side of unlimited discretion for too long”and their belief that a “little less choice is just what we need” will doom us to health care that replaces one set of excesses for another set more deadly than that being replaced.

  49. Neither Dr. House nor Welby would survive in the future, or even be employable in the “real world” today. The kindly, compassionate Welby would not be able to even sign up with most insurance plans, since he is not “board certified” in family medicine, thus “not eligible for credentialing” in their wrong-headed logic of “quality.” Thus, he would be out of work. Perhaps he could start his own “cash only” outpatient clinic until persecuted by the state insurance commissioner, or run out of town by the state medical board.

    Dr. House has no chance either, since he is clearly a “disruptive physician” and would be summarily terminated by any hospital who was foolish enough to employ him. Everyone knows that if a doctor says something remotely construed as “rude” to a patient (or worse, to a NURSE or a unionized hospital employee!!!) then lawsuits, HR investigations, “sensitivity training,” and other similar types of foolishness are immediately mandated.

    No, the “doctor of the future” is simply a technician. There is no use for primary care physicians (i.e., internists, GP’s, family docs, pediatricians, or Ob/gyns) since Nurse Practitioners and PA’s can do all of their jobs “better” and “for less money.”

    Surgeons are easily replaced by robots, which are smarter, make fewer mistakes, and are less cranky. Radiologists are replaced by computers, armed with analytical software, which state on every report, “consider MRI if clinically indicated.” Anesthesiologists, ER physicians, and Critical Care physicians are likewise of no longer necessary since NP’s can perform their functions (at least, in the eyes of Obama and the insurance companies).

    There is no need for pain management specialists, since receiving all the narcotics ever desired by any patient has been deemed a constitutional right, thereby rendering physician supervision of controlled substances an anachronism.

    Oncologists are useless, since every patient has a right to receive any and all treatments that Oprah Winfrey or Dr. Phil (who, BTW is NOT a doctor and doesn’t even play one on TV) advised them to have.

    Most allopathic medicine is useless anyway, right? I mean, naturopathic, or ayeurvedic, or native American chant therapy has been shown to be much more effective at treating things like staph infections, appendicitis, acute coronary syndromes, and multi-system trauma. All practitioners of these ilks are of couse fully certified to receive payments by medicare.

    No, the only doctors needed are the ones who are the paid shills of the politicians, who set health policy for the rest of the country in accordance to the political ideology of those in power. (no reference to any particular surgeon general nominee is intended)

    Isn’t the future going to be GREAT?? I’m glad I went to law school.