The New York Times today ran a piece under the headline: "A Hospital War Reflects a Bind for US Doctors," about doctors who had sold their practices and are now employees of two big hospital centered corporations in Boise, Idaho.
Accompanying the article was a graph showing the number of doctors still in "private practice," not unemployed by hospitals or other forms of corporations had fallen to 36%. Of course, this number is a little slippery: Doctors may be employees of a group practice of doctors, which may number from three to several hundred, and that group may be controlled by those doctors, to a lesser or greater extent. But it is likely this is a number which is meaningful and may truly reflect the number of doctors who are employed by corporations, hospitals who control the doctors and their patients, and the doctors do not control decisions related to medical care like to whom they can refer their patients, whether or not a patient gets admitted to a hospital or to which hospital they get admitted or what happens to that patient once the patient is admitted. The phantom believes at least 75% of Americas practicing physicians no longer control any of this. They are simply employees and their ability to control what happens to their patients is minimal.
Republicans are constantly saying we have the best medical care system in the world because it is ruled by private enterprise. They imagine doctors are still out there practicing independently, running their practices like small businesses, the last bastion of the independent man, but this is no longer true and likely has not been for a decade.
Decisions may not be controlled by the dreaded federal government "bureaucrats" or death panels, but they are driven by insurance companies and CEO's with MBA degrees who speak of markets and regard patients as consumers to be wooed, hoodwinked, charmed, misled, controlled, and bilked as thoroughly as any other type of consumer.
I once argued for legalization of drugs, for setting up neighborhood "package stores" for heroin, cocaine and marijuana, much like the government run liquor stores in New Hampshire and my friend replied: "You can't do that. It would kill the economy of the inner cities. All those eight year old hoppers and touts would be put out of business. All those teenagers who sell on the corner. All those mid level lieutenants in the drug organizations, not to mention the kingpins. All gone. The entire economy which is based on heroin would collapse."
Of course, many Americans would reply, "Good riddance. Those jobs should be lost. That is a sector which ought to be closed down."
But most Americans would not say that about all the hospital administrators, all the insurance company executives and adjusters and file clerks and computer personnel at insurance companies. If the entire health insurance industry were outlawed tomorrow and replaced with a national health bureaucracy, patients would be cared for just as surely, just as well, if not better, likely better, than the day before. These people in the insurance industry who sell, staff, "manage" health care policies and pay outs are not just not essential--they actually get in the way of good care, of economical care because they are unnecessary middlemen who add no value to the process.
But there are a lot of them and if they all lost their jobs, it would cause quite a kerfuffle in the nation's economy. Likely as many as 15 million people work in health insurance or related or dependent industries, and if the federal government hired only the bureaucrats they needed to track claims and make payments, all that could be done with as few as 5 million--that's 10 million people thrown out of work if we replaced our commercial, profit driven system with an efficient, medically driven system.
And that's just the health insurance employees who would be out of work. Throw in the staff at doctors' offices, hospitals, clinics, who would no longer be necessary to process unnecessary paper work, to send out and receive bills, to do marketing, drive deals with insurance companies, we could be talking another 5 million.
So our current bloated, inefficient system is a lot like our defense industry. We don't need all those air craft carrier groups or all those nuclear submarines or all those destroyers or those pricey new bombers and fighters, but think of all those towns across the country where jobs depend on building all those systems and bombers and ships we do not need.
I wonder, if we actually did place efficiency and real need above all other considerations how many people in this country would be thrown out of work. Twenty-five percent of our employed work force? Thirty? Hard to say.
But, one thing is clear: If you removed the profit motive from providing medical care, the cost of the overall system would by cut by two thirds and the quality of the care would improve by almost the same.
Don't you think that there are doctors who are just trying to practice good medicine. Perhaps if patients payed directly for their care and billed their insurance company to recover their expense we could reduce the overall system expense. It would also tie the insurer to the patient more directly. If the patient were unhappy with the response, he/she could and would shift insurers.
ReplyDeleteAnonymous,
ReplyDeleteActually, the Phantom is personally familiar with the model you describe: Doctor is paid by patient; patient submits bill to insurance company. As far as the Phantom could see, it did nothing to reduce overall costs for the system but it did surely improve the income of the doctor. The patient had little incentive to limit his or her own care because the patient was assured the insurance company would reimburse doctor's fees (at 80%.) In fact, the doctor's fees were modest, compared with lab and radiology bills, which the lab and radiology submitted to the insurance company directly.
No, the Phantom is beginning to think the best way to save money would be to:
1. Establish Medicare for everyone would wants it.
2. Look at expensive medical procedures: colonoscopy, endoscopy, dermatology excisions, arthroscopy and train technicians, physicians' assistants, nurses to do these and pay in the $100 to $300 range for this stuff.
3. Pay radiologists a straight salary, not for piece work, which could reduce the cost of an MRI to $70 (from $3000), a CT scan from $2500 to $100.
4. Have Medicare set prices for drugs, aka "negotiate" drug prices.
These changes would have to incorporate provisions for doctors who went into radiology with huge loans, expecting salaries in the $500K range, for doctors who signed leases for huge office spaces to accomodate big billing and administrative staffs, no longer needed. In other words, such drastic changes would have to be either phased in or structured to forgive debt entered into in good faith, with a reasonable prospect of re payment by practitioners who expected big pay offs for their investments in colonoscopes, MRI's and other expensive equipment. Now these instruments will no longer be a cash cow.
It could be done, in a world where one objective was ruthlessly pursued--efficiency in the medical market. But that is not our world, at least not now.