What Kind of Medicine Do We Want?

In an op-ed in the Wall Street Journal, a physician laments the direction his profession has taken:

For me and many of my colleagues, the real practice of medicine is supposed to involve an intimate encounter with each patient and a diagnosis of illness leading to a potential cure. In the future, however, a diagnosis of Lyme disease or the severity of a patient’s depression may be missed because showing the photo or taking an extensive mental-health history doesn’t fit squarely into the 10-minute visit authorized by insurance, along with mandatory computer documentation, insurance verifications and appointment scheduling.

The PPACA didn’t cause that. Sadly, it doesn’t remedy it, either, but rather pushes the practice of medicine even farther into the wrong direction. He continues:

Unfortunately, the kind of insurance that is growing under ObamaCare’s fertilizer is the exact kind that was jeopardizing the quality of health care in the first place: the kind that pays for seeing a doctor when you are well, but where guidelines and regulations predominate and choice is restricted when you are seriously ill.

What we’ve got is an unholy alliance between Big Business and Big Government, a development none of us should relish.

Someday, perhaps, we can start thinking about the kind of practice of medicine we’d like to see. I think it’s one in which physicians don’t worry about starving but don’t live like Renaissance princes, either, and, more importantly, don’t expect to. Patients can receive the care they need but maybe not as much care as they want and that decision is made by professionals rather than by administrative guideline. Something that more closely approximates the “old country doctor”, a physician who maintains a longitudinal relationship with his patients rather than a medical retailer. What we’re getting is the worst of all worlds: standardized care at high prices.

11 comments… add one
  • PD Shaw Link

    Perhaps, physicians could follow the lead of this guy:

    Russell Dohner, Illinois Doctor, Charges Patients $5 For Entire Physician Visit

    Unfortunately he retired last month. And there is also the business about farm income.

  • jan Link

    The PPACA didn’t cause that.

    The new HC law may not have directly caused impersonal and short doctor visits. However, it has increased paperwork, rules and regs, and mandated fee structures that oftentimes don’t even adequately cover overhead expenses in private practices. This in turn directly impacts the type of patient care doled out by doctors, making it more of an assembly line version, rather than one that is diagnosed and rendered with greater detail, personal patient considerations, and under a broader spectrum of health perimeters.

    While social progressives deem government to be the great overseer of social conduct, I find that human beings simply can’t control most behaviors other than ones in themselves. We certainly try to pull levers on others. But, it sadly only stirs resentments, oppositional tendencies, oftentimes leading to fraying civil restraints rather than augmenting them.

    Consequently HC to the masses will not become better by tightening the screws on physicians and/or arbitrarily layering more costs on some while subsidizing others. There’s an internal sense of fairness people have, which government can’t manipulate and control. And, when more people feel the thumb of government on their shoulders they tend to circumvent what they see as injustice, go underground, or openly rebel.

    The way to make a better society is to create incentives for better behavior, and disincentives for overreaching or selfish behavior. You do this by freeing up people — allowing more competition, tracking fraud and discouraging frivolous lawsuits, encouraging physician outreach to the poor, providing a greater variety of care options, etc. For instance the doctor PD posted, who provided office visits for $5, did so voluntarily, not through the prompting of the state or federal government. My guess is that had he been forced to keep his fees low he would have been out of there, as the primary rewards of doing a kind act and/or something ‘good’ for people is when it comes from the heart not a government crow bar.

    My grandfather was similar to that doctor, in that, as a small-town lawyer, he would waive monetary fees to the poor, taking baked goods and other small tokens as payment for his legal services. Unfortunately he died young, and penniless, which proved to be a hardship on his family. Nonetheless, everything he did for people was because he wanted to do it, which is quite a legacy for me to remember and follow.

  • steve Link

    I have no use for whiny doctors. I work with enough already. Any solution to our health care problems, primarily costs and lack of access, means that docs are probably going to take an income hit. Not that hard to figure out if you pay attention. Complaining about narrow networks and insurance companies that pay less, while working at Fox is beyond ironic. Has he even looked at the plans offered by right wing pundits? Granted, none of these ever get pushed by GOP politicians, but then he was expecting the status quo to just continue, and that suggests he is just stupid.

    Anyway, I think you are restricting yourself to a narrow PCP model. I dont see that working so well for specialists. However, I guess I do feel sorry for this guy, or rather people like him. You used to be able to make a good bit of money while spending a lot of time with each patient, though not quite like he describes it. Those days are gone. His challenge is to figure out to make more effective use of his time. One way he might try (we are doing this) is breaking out of the strict physician/midlevel/nurse paradigm. We are trying to leverage our physician skills so that they do the difficult stuff, the stuff that requires more training, while letting our midlevels do more stuff independently, but with an MD available for help if needed. This is kind of stressful, and is a lot of work to get started. Many midlevels really are not capable of working independently. You need to assess each one separately. Still, if he does so, then he can have his midlevels do those 10 minute visits and he can spend 30 minutes with those really sick ones who come in with charts 8 inches thick (revealing my age by referring to paper charts).


  • Anyway, I think you are restricting yourself to a narrow PCP model.

    Basically, I think that we’d be better off with a capitation system in which PCPs are the general contractors.

  • Red Barchetta Link

    “We are trying to leverage our physician skills so that they do the difficult stuff, the stuff that requires more training, while letting our midlevels do more stuff independently, but with an MD available for help if needed.”

    I’m dubious of carrying this too far, but willing to be convinced. By the way, I have a theory for saving money on quarterbacks. If he is just going to hand off instead of through an out route put in the quarterback assistant………..then tell the starting QB “hey, 30% pay cut for you, you only took 70% of the snaps.”

    Also, I’m thinking pro golfers should just take the tough shots. Simple layup with a 9 iron to a par 5? Assistant Tiger. Think of the time you would save as Tiger walks up from the tee shot but the assistant Tiger has already made the layup shot. Then Tiger tries to hit it in close. Its brilliant, really, and everyone will be happy……..

  • jan Link

    I don’t think Marc Siegel is stupid. For sure, he doesn’t like the PPACA. And, he’s also a medical contributor to Fox — both of which I guess, in the eyes of people like Steve, automatically calls for labeling his op-ed ‘whiny’ and seemingly unworthy of serious consideration. Nonetheless, Siegel is a practicing physician, and his association with a hated-by-the-progressive-left network, does not go hand-in-hand with discrediting his professional concerns about the downsides of what he has continuously seen as deeply flawed health care reform.

    Since insurers are being compelled to cover more folks with pre-existing conditions, with no lifetime limits, and to cover everyone in a family plan at least up to the age of 26—all popular provisions of the ACA—they reduce costs by cutting fees to vulnerable doctors while restricting the tests they can order. This makes the practice of quality medicine almost impossible, but it helps preserve an insurance company’s bottom line while complying with a government mandate.

    Such ‘Steve’ absolutism, castigating a differing POV, reminds me of another PPACA prognostication sidelined by ideological fervor — one predicting massive insurance policy cancellations due to the PPACA mandates — made by Mike Enzi in 2010, and then summarily dismissed by Congressional dems. In 2013, though, insurance cancellations of individual policies proved to indeed be an untoward side effect of the PPACA (spared for later, are big business cancellations), embarrassing those same dems, and putting them in reelection defensive modes for the 2014 midterms.

  • steve Link

    Drew- I think the proper analogy is paying Tiger his going rate to do groundskeeper work. We cant afford to pay the guy cutting the grass $10 million/year. That said, I am not entirely comfortable with this either. I much prefer the model where I get paid a lot no matter what I do, but that is not so affordable. We have to do things differently. We could just cut everyone’s salary in half, but that doesnt solve much either. That would be 3.5% cut in spending, and if we continued at the same rate of increase, in a few years we are back to things being just as bad.

    jan- The ACA has mandated no fee structures of which I am aware. The assembly line pre-dates the ACA. Siegel, as a proxy for conservative ideas, has advocated for just about everything he complains about here. And, he is only stupid if he thought we could sustain our pre-ACA path. Lastly, I just dont know where you get some of your ideas. Not making enough to cover expenses? Where? When?

    Dave- The Intermountain model, IIRC. A lot of people like the model. No one knows how to start one.


  • jan Link

    I just dont know where you get some of your ideas. Not making enough to cover expenses? Where? When?

    ….direct interviews from doctors, describing the payment differential they receive from medicare and medicaid payments. As so many are now signing up for expanded medicaid, in accessing the HC promised by the PPACA, these patients will only increase in numbers. Many physicians categorize these patients as ‘charity’ cases, as the government stipend is so low.

  • jan Link

    Just a side reflection about health care…I don’t know why people are hitting on doctors so much dealing with raising medical costs. The ones in private practice have seen malpractice insurance costs continuously rise, along with rents on commercial suites, and/or routine replacement of medical equipment with more advanced versions etc. But somehow it’s seems to be the practitioners who are being targeted for the lowering of incomes, when IMO the cost abuses seem more endemic in the spiking of hospital charges — patient rooms, surgical theaters, special treatments. Every requisition is tallied and seemingly overcharged when going over one’s hospital statement. A gauze roll/bandage, tissue box, the plastic wash basins/urinals/bed pans you have to take home with you, every little item is added up as an expenditure, whether you actually use it or not. It can be pages of codes and entries that people have little understanding of what it entails, or having validation that they were the actual recipient of the product(s) charged to them.

    But, the finger-pointing seems to be exercised in the direction of physicians — the highly educated facilitators of care, who one puts their life and limb in the hands of, and who generally is the one who gets the credit or blame for whatever the outcome is. Is this really who you want to pin all our HC woes onto, discouraging those who might want to go into the profession in the future? Those who are unethical or show poor judgment in their profession, take them to task. But, those who are diligent and skilled, who may have the long-term trust and genuine interest of their patients prominently anchored in their relationships — why mess with them, limiting their participation in government approved exchanges, and/or demonizing the money they make in a job that is needed and they excel in?

  • steve Link

    “….direct interviews from doctors, describing the payment differential they receive from medicare and medicaid payments.”

    These patients had no insurance before the ACA. They would have received zero dollars if they cared for those patients. At any rate, if you look at the actual data, doctor offices are not closing.

    As to your general comments, it is the spending that physicians control, not their actual salaries, that make up the bulk of spending. Docs are part of the problem and they need to be part of the solution. Unfortunately, most want to reminisce about the good old days, your guy, or they are just signing up to be hospital/network employees, most new grads, and letting professional administrators manage things.


  • Wages are an economic phenomenon but they are also a social phenomenon. Wages are not only determined by some absolute and undeterminable utility but in relation to other wages. When docs’ wages go up so do the wages of the people who trains docs. And the wages of presidents of healthcare companies, chief administrators at hospitals, and so on. One wage affects another.

    When I say “physicians” I don’t just mean physicians. I mean healthcare providers. I mean the healthcare sector. When I say “wages” I mean both amplitude and frequency, so to speak. The area under the curve as well as how high it gets.

    The reality is that since 1965 real total aggregate wages in the healthcare sector have far outstripped wages, generally, although for the last couple of decades they’ve gone up at roughly the rate of inflation. Not the rate of inflation less healthcare but the rate of inflation which, since healthcare is rising faster than anything else, means that wages in healthcare continue to rise faster than wages, generally.

    Try as you might to rationalize it there is no explanation for this other than willingness to pay. Since something between half and 70% of that “willingness to pay” consists of Medicare, Medicaid, the VA, the employer-paid healthcare plans of government employees, and the 1,001 other ways that government at all levels subsidizes healthcare, thinking of that as a market phenomenon is an error. What goes up must come down.

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