health care

How Government Killed the Medical Profession

As health care gets more bureaucratic, will doctors go Galt?

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I am a general surgeon with more than three decades in private clinical practice. And I am fed up. Since the late 1970s, I have witnessed remarkable technological revolutions in medicine, from CT scans to robot-assisted surgery. But I have also watched as medicine slowly evolved into the domain of technicians, bookkeepers, and clerks. 

Government interventions over the past four decades have yielded a cascade of perverse incentives, bureaucratic diktats, and economic pressures that together are forcing doctors to sacrifice their independent professional medical judgment, and their integrity. The consequence is clear: Many doctors from my generation are exiting the field. Others are seeing their private practices threatened with bankruptcy, or are giving up their autonomy for the life of a shift-working hospital employee. Governments and hospital administrators hold all the power, while doctors—and worse still, patients—hold none.

The Coding Revolution

At first, the decay was subtle. In the 1980s, Medicare imposed price controls upon physicians who treated anyone over 65. Any provider wishing to get compensated was required to use International Statistical Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes to describe the service when submitting a bill. The designers of these systems believed that standardized classifications would lead to more accurate adjudication of Medicare claims.

What it actually did was force doctors to wedge their patients and their services into predetermined, ill-fitting categories. This approach resembled the command-and-control models used in the Soviet bloc and the People's Republic of China, models that were already failing spectacularly by the end of the 1980s.

Before long, these codes were attached to a fee schedule based upon the amount of time a medical professional had to devote to each patient, a concept perilously close to another Marxist relic: the labor theory of value. Named the Resource-Based Relative Value System (RBRVS), each procedure code was assigned a specific value, by a panel of experts, based supposedly upon the amount of time and labor it required. It didn't matter if an operation was being performed by a renowned surgical expert—perhaps the inventor of the procedure—or by a doctor just out of residency doing the operation for the first time. They both got paid the same.

Hospitals' reimbursements for their Medicare-patient treatments were based on another coding system: the Diagnosis Related Group (DRG). Each diagnostic code is assigned a specific monetary value, and the hospital is paid based on one or a combination of diagnostic codes used to describe the reason for a patient's hospitalization. If, say, the diagnosis is pneumonia, then the hospital is given a flat amount for that diagnosis, regardless of the amount of equipment, staffing, and days used to treat a particular patient.

As a result, the hospital is incentivized to attach as many adjunct diagnostic codes as possible to try to increase the Medicare payday. It is common for hospital coders to contact the attending physicians and try to coax them into adding a few more diagnoses into the hospital record.

Medicare has used these two price-setting systems (RBRVS for doctors, DRG for hospitals) to maintain its price control system for more than 20 years. Doctors and their advocacy associations cooperated, trading their professional latitude for the lure of maintaining monopoly control of the ICD and CPT codes that determine their payday. The goal of setting their own prices has proved elusive, though—every year the industry's biggest trade group, the American Medical Association, squabbles with various medical specialty associations and the Centers for Medicare and Medicaid Services (CMS) over fees.

As goes Medicare, so goes the private insurance industry. Insurers, starting in the late 1980s, began the practice of using the Medicare fee schedule to serve as the basis for negotiation of compensation with the doctors and hospitals on their preferred provider lists. An insurance company might offer a hospital 130 percent of Medicare's reimbursement for a specific procedure code, for instance.

The coding system was supposed to improve the accuracy of adjudicating claims submitted by doctors and hospitals to Medicare, and later to non-Medicare insurance companies. Instead, it gave doctors and hospitals an incentive to find ways of describing procedures and services with the cluster of codes that would yield the biggest payment. Sometimes this required the assistance of consulting firms. A cottage industry of fee-maximizing advisors and seminars bloomed.

I recall more than one occasion when I discovered at such a seminar that I was "undercoding" for procedures I routinely perform; a small tweak meant a bigger check for me. That fact encouraged me to keep one eye on the codes at all times, leaving less attention for my patients. Today, most doctors in private practice employ coding specialists, a relatively new occupation, to oversee their billing departments.

Another goal of the coding system was to provide Medicare, regulatory agencies, research organizations, and insurance companies with a standardized method of collecting epidemiological data—the information medical professionals use to track ailments across different regions and populations. However, the developers of the coding system did not anticipate the unintended consequence of linking the laudable goal of epidemiologic data mining with a system of financial reward.

This coding system leads inevitably to distortions in epidemiological data. Because doctors are required to come up with a diagnostic code on each bill submitted in order to get paid, they pick the code that comes closest to describing the patient's problem while yielding maximum remuneration. The same process plays out when it comes to submitting procedure codes on bills. As a result, the accuracy of the data collected since the advent of compensation coding is suspect. 

Command and Control

Coding was one of the earliest manifestations of the cancer consuming the medical profession, but the disease is much more broad-based and systemic. The root of the problem is that patients are not payers. Through myriad tax and regulatory policies adopted on the federal and state level, the system rarely sees a direct interaction between a consumer and a provider of a health care good or service. Instead, a third party—either a private insurance company or a government payer, such as Medicare or Medicaid—covers almost all the costs. According to the National Center for Policy Analysis, on average, the consumer pays only 12 percent of the total health care bill directly out of pocket. There is no incentive, through a market system with transparent prices, for either the provider or the consumer to be cost-effective.

As the third party payment system led health care costs to escalate, the people footing the bill have attempted to rein in costs with yet more command-and-control solutions. In the 1990s, private insurance carriers did this through a form of health plan called a health maintenance organization, or HMO. Strict oversight, rationing, and practice protocols were imposed on both physicians and patients. Both groups protested loudly. Eventually, most of these top-down regulations were set aside, and many HMOs were watered down into little more than expensive prepaid health plans.

Then, as the 1990s gave way to the 21st century, demographic reality caught up with Medicare and Medicaid, the two principal drivers of federal health care spending. 

Twenty years after the fall of the Iron Curtain, protocols and regimentation were imposed on America's physicians through a centralized bureaucracy. Using so-called "evidence-based medicine," algorithms and protocols were based on statistically generalized, rather than individualized, outcomes in large population groups. 

While all physicians appreciate the development of general approaches to the work-up and treatment of various illnesses and disorders, we also realize that everyone is an individual—that every protocol or algorithm is based on the average, typical case. We want to be able to use our knowledge, years of experience, and sometimes even our intuition to deal with each patient as a unique person while bearing in mind what the data and research reveal.

Being pressured into following a pre-determined set of protocols inhibits clinical judgment, especially when it comes to atypical problems. Some medical educators are concerned that excessive reliance on these protocols could make students less likely to recognize and deal with complicated clinical presentations that don't follow standard patterns. It is easy to standardize treatment protocols. But it is difficult to standardize patients.

What began as guidelines eventually grew into requirements. In order for hospitals to maintain their Medicare certification, the Centers for Medicare and Medicaid Services began to require their medical staff to follow these protocols or face financial retribution.

Once again, the medical profession cooperated. The American College of Surgeons helped develop Surgical Care Improvement Project (SCIP) protocols, directing surgeons as to what antibiotics they may use and the day-to-day post-operative decisions they must make. If a surgeon deviates from the guidelines, he is usually required to document in the medical record an acceptable justification for that decision.

These requirements have consequences. On more than one occasion I have seen patients develop dramatic postoperative bruising and bleeding because of protocol-mandated therapies aimed at preventing the development of blood clots in the legs after surgery. Had these therapies been left up to the clinical judgment of the surgeon, many of these patients might not have had the complication.

Operating room and endoscopy suites now must follow protocols developed by the global World Health Organization—an even more remote agency. There are protocols for cardiac catheterization, stenting, and respirator management, just to name a few.

Patients should worry about doctors trying to make symptoms fit into a standardized clinical model and ignoring the vital nuances of their complaints. Even more, they should be alarmed that the protocols being used don't provide any measurable health benefits. Most were designed and implemented before any objective evidence existed as to their effectiveness.

A large Veterans Administration study released in March 2011 showed that SCIP protocols led to no improvement in surgical-site infection rate. If past is prologue, we should not expect the SCIP protocols to be repealed, just "improved"—or expanded, adding to the already existing glut.

These rules are being bred into the system. Young doctors and medical students are being trained to follow protocol. To them, command and control is normal. But to older physicians who have lived through the decline of medical culture, this only contributes to our angst.

One of my colleagues, a noted pulmonologist with over 30 years' experience, fears that teaching young physicians to follow guidelines and practice protocols discourages creative medical thinking and may lead to a decrease in diagnostic and therapeutic excellence. He laments that "?'evidence-based' means you are not interested in listening to anyone." Another colleague, a North Phoenix orthopedist of many years, decries the "cookie-cutter" approach mandated by protocols.

A noted gastroenterologist who has practiced more than 35 years has a more cynical take on things. He believes that the increased regimentation and regularization of medicine is a prelude to the replacement of physicians by nurse practitioners and physician-assistants, and that these people will be even more likely to follow the directives proclaimed by regulatory bureaus. It is true that, in many cases, routine medical problems can be handled more cheaply and efficiently by paraprofessionals. But these practitioners are also limited by depth of knowledge, understanding, and experience. Patients should be able to decide for themselves if they want to be seen by a doctor. It is increasingly rare that patients are given a choice about such things.

The partners in my practice all believe that protocols and guidelines will accomplish nothing more than giving us more work to do and more rules to comply with. But they implore me to keep my mouth shut—rather than risk angering hospital administrators, insurance company executives, and the other powerful entities that control our fates.

Electronic Records and Financial Burdens

When Congress passed the stimulus, a.k.a. the American Reinvestment and Recovery Act of 2009, it included a requirement that all physicians and hospitals convert to electronic medical records (EMR) by 2014 or face Medicare reimbursement penalties. There has never been a peer-reviewed study clearly demonstrating that requiring all doctors and hospitals to switch to electronic records will decrease error and increase efficiency, but that didn't stop Washington policymakers from repeating that claim over and over again in advance of the stimulus.

Some institutions, such as Kaiser Permanente Health Systems, the Mayo Clinic, and the Veterans Administration Hospitals, have seen big benefits after going digital voluntarily. But if the same benefits could reasonably be expected to play out universally, government coercion would not be needed. 

Instead, Congress made that business decision on behalf of thousands of doctors and hospitals, who must now spend huge sums on the purchase of EMR systems and take staff off other important jobs to task them with entering thousands of old-style paper medical records into the new database. For a period of weeks or months after the new system is in place, doctors must see fewer patients as they adapt to the demands of the technology. 

The persistence of price controls has coincided with a steady ratcheting down of fees for doctors. As a result, private insurance payments, which are typically pegged to Medicare payment schedules, have been ratcheting down as well. Meanwhile, Medicare's regulatory burdens on physician practices continue to increase, adding on compliance costs. Medicare continues to demand that specific coded services be redefined and subdivided into ever-increasing levels of complexity. Harsh penalties are imposed on providers who accidentally use the wrong level code to bill for a service. Sometimes—as in the case of John Natale of Arlington, Illinois, who began a 10-month sentence in November because he miscoded bills on five patients upon whom he repaired complicated abdominal aortic aneurysms—the penalty can even include prison.

For many physicians in private practice, the EMR requirement is the final straw. Doctors are increasingly selling their practices to hospitals, thus becoming hospital employees. This allows them to offload the high costs of regulatory compliance and converting to EMR.

As doctors become shift workers, they work less intensely and watch the clock much more than they did when they were in private practice. Additionally, the doctor-patient relationship is adversely affected as doctors come to increasingly view their customers as the hospitals' patients rather than their own. 

In 2011, The New England Journal of Medicine reported that fully 50 percent of the nation's doctors had become employees—either of hospitals, corporations, insurance companies, or the government. Just six years earlier, in 2005, more than two-thirds of doctors were in private practice. As economic pressures on the sustainability of private clinical practice continue to mount, we can expect this trend to continue. 

Accountable Care Organizations

For the next 19 years, an average of 10,000 Americans will turn 65 every day, increasing the fiscal strain on Medicare. Bureaucrats are trying to deal with this partly by reinstating an old concept under a new name: Accountable Care Organization, or ACO, which harkens back to the infamous HMO system of the early 1990s. 

In a nutshell, hospitals, clinics, and health care providers have been given incentives to organize into teams that will get assigned groups of 5,000 or more Medicare patients. They will be expected to follow practice guidelines and protocols approved by Medicare. If they achieve certain benchmarks established by Medicare with respect to cost, length of hospital stay, re-admissions, and other measures, they will get to share a portion of Medicare's savings. If the reverse happens, there will be economic penalties. 

Naturally, private insurance companies are following suit with non-Medicare versions of the ACO, intended primarily for new markets created by ObamaCare. In this model, an ACO is given a lump sum, or bundled payment, by the insurance company. That chunk of money is intended to cover the cost of all the care for a large group of insurance beneficiaries. The private ACOs are expected to follow the same Medicare-approved practice protocols, but all of the financial risks are assumed by the ACOs. If the ACOs keep costs down, the team of providers and hospitals reap the financial reward: surplus from the lump sum payment. If they lose money, the providers and hospitals eat the loss.

In both the Medicare and non-Medicare varieties of the ACO, cost control and compliance with centrally planned practice guidelines are the primary goal.

ACOs are meant to replace a fee-for-service payment model that critics argue encourages providers to perform more services and procedures on patients than they otherwise would do. This assumes that all providers are unethical, motivated only by the desire for money. But the salaried and prepaid models of provider-reimbursement are also subject to unethical behavior in our current system. There is no reward for increased productivity with the salary model. With the prepaid model there is actually an incentive to maximize profit by withholding services.

Each of these models has its pros and cons. In a true market-based system, where competition rewards positive results, the consumer would be free to choose among the various competing compensation arrangements.

With increasing numbers of health care providers becoming salaried employees of hospitals, that's not likely. Instead, we'll see greater bureaucratization. Hospitals might be able to get ACOs to work better than their ancestor HMOs, because hospital administrators will have more control over their medical staff. If doctors don't follow the protocols and guidelines, and desired outcomes are not reached, hospitals can replace the "problem" doctors.

Doctors Going Galt? 

Once free to be creative and innovative in their own practices, doctors are becoming more like assembly-line workers, constrained by rules and regulations aimed to systemize their craft. It's no surprise that retirement is starting to look more attractive. The advent of the Affordable Care Act of 2010, which put the medical profession's already bad trajectory on steroids, has for many doctors become the straw that broke the camel's back.

A June 2012 survey of 36,000 doctors in active clinical practice by the Doctors and Patients Medical Association found 90 percent of doctors believe the medical system is "on the wrong track" and 83 percent are thinking about quitting. Another 85 percent said "the medical profession is in a tailspin." 65 percent say that "government involvement is most to blame for current problems." In addition, 2 out of 3 physicians surveyed in private clinical practice stated they were "just squeaking by or in the red financially."

A separate survey of 2,218 physicians, conducted online by the national health care recruiter Jackson Healthcare, found that 34 percent of physicians plan to leave the field over the next decade. What's more, 16 percent said they would retire or move to part-time in 2012. "Of those physicians who said they plan to retire or leave medicine this year," the study noted, "56% cited economic factors and 51% cited health reform as among the major factors. Of those physicians who said they are strongly considering leaving medicine in 2012, 55% or 97 physicians, were under age 55."

Interestingly, these surveys were completed two years after a pre-ObamaCare survey reported in The New England Journal of Medicine found 46.3 percent of primary care physicians stated passage of the new health law would "either force them out of medicine or make them want to leave medicine."

It has certainly affected my plans. Starting in 2012, I cut back on my general surgery practice. As co-founder of my private group surgical practice in 1986, I reached an arrangement with my partners freeing me from taking night calls, weekend calls, or emergency daytime calls. I now work 40 hours per week, down from 60 or 70. While I had originally planned to practice at least another 12 to 14 years, I am now heading for an exit—and a career change—in the next four years. I didn't sign up for the kind of medical profession that awaits me a few years from now.

Many of my generational peers in medicine have made similar arrangements, taken early retirement, or quit practice and gone to work for hospitals or as consultants to insurance companies. Some of my colleagues who practice primary care are starting cash-only "concierge" medical practices, in which they accept no Medicare, Medicaid, or any private insurance.

As old-school independent-thinking doctors leave, they are replaced by protocol-followers. Medicine in just one generation is transforming from a craft to just another rote occupation.

Medicine in the Future

In the not-too-distant future, a small but healthy market will arise for cash-only, personalized, private care. For those who can afford it, there will always be competitive, market-driven clinics, hospitals, surgicenters, and other arrangements—including "medical tourism," whereby health care packages are offered at competitive rates in overseas medical centers. Similar healthy markets already exist in areas such as Lasik eye surgery and cosmetic procedures. The medical profession will survive and even thrive in these small private niches.

In other words, we're about to experience the two-tiered system that already exists in most parts of the world that provide "universal coverage." Those who have the financial means will still be able to get prompt, courteous, personalized, state-of-the-art health care from providers who consider themselves professionals. But the majority can expect long lines, mediocre and impersonal care from shift-working providers, subtle but definite rationing, and slowly deteriorating outcomes.

We already see this in Canada, where cash-only clinics are beginning to spring up, and the United Kingdom, where a small but healthy private system exists side-by-side with the National Health Service, providing high-end, fee-for-service, private health care, with little or no waiting.

Ayn Rand's philosophical novel Atlas Shrugged describes a dystopian near-future America. One of its characters is Dr. Thomas Hendricks, a prominent and innovative neurosurgeon who one day just disappears. He could no longer be a part of a medical system that denied him autonomy and dignity. Dr. Hendricks' warning deserves repeating:

"Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn't."  

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  1. Stupid doctors, thinking they know more about medicine than the President.

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      2. “It didn’t matter if an operation was being performed by a renowned surgical expert?perhaps the inventor of the procedure?or by a doctor just out of residency doing the operation for the first time. They both got paid the same.”

        This just stuck with me. Diversity = Bad. Individuality = Bad. We are living the dystopia. People rage against Marxism, I think we are living the 10 planks now.

    1. s/president/king

      1. s/president/king/i

    2. what the fuck has a doctor ever done for anyone

      1. If you heal patients, you don’t heal those patients. Somebody else made that happen.

        Now some statist will chime in and say that physicians would never have learned their skills without state-supported medical schools.

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  2. I am trying hard to feel bad for someone who’s complaining about the government fucking with the preferred operations of the cartel granted a monopoly on services by that same government and…it’s not working very well.

    1. Exactly. In the end we’re the ones getting screwed by both.

    2. I didn’t really get that vibe. But even if he’s a strident defender of the AMA, I think most of his points are still valid.

      1. No, he’s against the AMA, as most doctors are, and bitching about their role in all this. Less than 8% of docs were members as of last count, and I would bet it has gone down by a lot since then. The AMA owns the coding system and is usually more interested in that than serving physicians.

        Just about every doc I know absolutely loathes the AMA. I don’t know if I ever hear anyone supporting them.

        1. The AMA writes all the medical legislation.

      2. what Patrick said I’m shocked that a mom able to get paid $5552 in four weeks on the internet. did you read this site link wow65.com
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    3. You’ll need to clarify on this one. Do you mean the current system of having physicians go through a minimum of seven years to ten years of training post-college to get to board-certified status in their specialty makes them a monopoly? Would you prefer that anyone who wanted to can hang out a shingle calling themselves doctor? I’m confused.

      It’s not quite the same thing as requiring licenses for hair washing.

      1. There’s no reason competing private entities couldn’t handle licensing. People should be free to choose a physician on whatever criteria they choose, including what kind of license (if any) he has.

        Malpractice insurers have a pretty big incentive to determine whether or not they are insuring quacks.

        1. I don’t disagree with you. There are plenty of “alternative” healers out there with no license at all if you are interested, and the medical boards do nothing to stop them (crystals, etc).

          I’d have no problem with competing private licensing boards. But state medical boards were not created by doctors — and they actually limit our ability to practice (such as across state lines) rather than giving us a protected monopoly to our advantage like cab licenses.

          1. and they actually limit our ability to practice (such as across state lines) rather than giving us a protected monopoly to our advantage like cab licenses.

            Cognitive dissonance much?

          2. and they actually limit our ability to practice (such as across state lines) rather than giving us a protected monopoly to our advantage like cab licenses.

            Sure, and the FDA limits doctors’ ability as well, but it limits consumer choices much, much more.

          3. Wait a minute.

            By not allowing doctors in other states to practice over state lines, are you are not granted a protected monopoly within your state?

            1. The state license monopoly is not one most docs asked for and it hurts us rather than protects us. If you wish to take a job in another state, you can’t move until you can get a license in that state, which can take up to a year, and is very expensive and time-consuming. Similarly, when we have a staffing shortage in our ER, we can only hire CA licensed docs as temps. I can’t even write a prescription for a patient leaving town that they can fill in their new state.

              Many of us have been advocating for a national medical license. We don’t want to be isolated to states. Difference is, if you threaten to open up competition for taxis, cab drivers will protest. Try to open up the state monopoly on medical licenses, and docs will likely contribute to the cause.

      2. Socialism, like the ancient ideas from which it springs, confuses the distinction between government and society. As a result of this, every time we object to a thing being done by government, the socialists conclude that we object to its being done at all.

        We disapprove of state education. Then the socialists say that we are opposed to any education. We object to a state religion. Then the socialists say that we want no religion at all. We object to a state-enforced equality. Then they say that we are against equality. And so on, and so on. It is as if the socialists were to accuse us of not wanting persons to eat because we do not want the state to raise grain.

        It is as if the socialists were to accuse us of not wanting there to be any certifications for physicians because we do not want the state to license them.

        1. Thank you Bastiat.

        2. I’ve been having trouble with this tread, that makes sense. Leave it to Bastiat to help me.

          I don’t think though that it diminishes a good article with many solid points. He seems to advocate against Medicare and Obamacare. Also he seemed very much for the private pay system. He was against the current employee/insurance system, which would mean the government getting out to the tax preferential system driving that abomination as well. I didn’t see the author weighing in for or against alternative certifications or for or against state licensing.

          I’d have to weigh in against all state licensing, State or National level.

      3. I definitely think that anyone who wants should be legally allowed to hang out a shingle calling himself “doctor” — or, more properly, that anyone, calling himself doctor or otherwise, should be legally allowed to perform medical procedures on consenting parties.

        And I think all “licensing” type issues can be handled by private entities.

      4. Do you mean the current system of having physicians go through a minimum of seven years to ten years of training post-college to get to board-certified status in their specialty makes them a monopoly?

        I don’t know about him, but I do. More like a cartel enforced by the police power of the government.

        Would you prefer that anyone who wanted to can hang out a shingle calling themselves doctor?

        Yes. And independent certifiers would spring up too. If the medical school cartel lost its government protection, there wold be more competition there too.

        1. +1

          I’d have no problem with this, I’d prefer it. The degradation of personal responsbility is the problem.

      5. Would you prefer that anyone who wanted to can hang out a shingle calling themselves doctor?

        Sure, why not?

        There’s an enormous amount of inherent paternalism in America’s healthcare system that isn’t tolerated (almost) anywhere else. The implication being that patients are just too stupid to be responsible for their own healthcare or even have any ability to judge the quality of it’s providers.

        1. Absolutely.

          A pharmacist would have sufficed perfectly well for about 90% of the doctor visits I’ve had in the past 40 years.

          1. Yeah I would love to see the statistics on how much time general practitioners spend just prescribing antibiotics, muscle relaxers, and pain pills.

        2. As a physician I couldn’t agree more. I obviously have a vested interest and I say end licensing. End the FDA. And make most drugs, save perhaps antibiotics, OTC.

      6. I got poison ivy a few years back and had to get a prescription from a physician with 7-10 yrs of post college training and board certifications. For fucking poison ivy. The charges to my insurance company were absurd, in part because the AMA, FDA, and the Medical Board decided I needed a physician to buy topical cream for poison…frickin… ivy.

        1. This is the point I was trying to make a couple weeks ago. It’s absurd that health insurance is used at all in service transactions like this. Even if you needed to go to the doctor, the charges for the whole ordeal go through the roof due to the presence of third-party payer systems being used for every procedure under the sun.

          There’s a legitimate need for health insurance, but it should be for severe trauma and life-threatening incidents only. Health insurance–both public and private–is so costly because we use it as a general funding mechanism, not an emergency resource.

          1. The problem is isn’t insurance though, some of the comments seem to make the amount of coverage the issue. If I wanted to buy insurance to cover my over the counter band-aids, it’s not the State’s business, not would it be a problem in a free market. Same for insuring a building against wear and tear versus storm damage. Their may not be much of an industry develop, but the offering and procuing of the service is not the problem.

            The healt care system is broken because it’s a State created system and not free market. This goes for both “private” and public. The issue of depth of coverage has only become an issue because of the state involvement. Same for flood insurance, a private flood insurance program would not be an issue in and of itself.

            1. Sorry for all the typos.

        2. In Taiwan, I go into a pharmacy with an eye infection, spend $2, and am on my way in thirty seconds.

    4. I mean, even if a doctor doesn’t support the AMA, they still have to abide by their rules, and more importantly, they have to abide by the regulations cited here.

      1. The AMA doesn’t have any rules short of the coding system. It is a free-will organization that has nothing to do with your ability to practice. You might as well say docs have to abide by the rules of their local Lions Club.

        Rules to abide by are your state licensing system, your state medical board, and your specialty board.

        1. Ok, well then I guess Nicole’s comment was regarding state licensing boards then.

          1. Yes, my complaint is about state licensing boards.

            1. I see your complaint and raise you government medical school accreditation.

              1. Well duh.

                And I raise you government.

        2. The rules are written by the AMA.

  3. If you want to be even more depressed, here’s another outstanding article that goes into great detail about how badly government has screwed up the healthcare industry:

    Question: “How much does it cost?” US healthcare: “How much have you got?”

  4. ” giving up their autonomy for the life of a shift-working hospital employee. ”

    Doctors no longer being treated like royalty? It may sound a bit come-uppancy but I’d rather the old way. A doctor or surgeon who was a Prima Donna would actually take better care of you than one who has been beaten into the Government approved generic Jiffy Lube style of assembly line medical care.

    1. my age parents treat their doctors like writ from heaven.

      I treat them like the servants they are.

      1. Doctors used to get a lot more respect. Stil do they are top tier network TV fodder up there with detectives and lawyers.

    2. Soon doctors will care about their patients’ health as much as public school teachers care about childrens’ education.

  5. like doctors are always walking around in white coats.

    /derp to the PR stunt

  6. ” giving up their autonomy for the life of a shift-working hospital employee. “

    Bigger is better. Central control is the best control. Henry Ford was a visionary. The assembly line model is the solution to everything!

    1. All praise His Fordship, World Controller Barack Obama!

      1. You Libertarians are a bunch of Savages.

  7. I see this same article (in content, not in authorship) over and over again, and though they tend to throw in an anecdote here and a digressional argument there, I feel that the main point conveyed is often one of physician fear of personal financial woe in the guise of genuine concern for the future of the medical field. While it would not lead me to sympathize more with the author, I would at least commend his or her honesty were he or she to make this point more directly.

    This article also makes mention of the failures of an evidence-based medical practice. While I cannot agree more that each and every patient is unique, I have trouble shaking this feeling that the true qualm with evidence-based practice is damage to physician hubris. For a single provider, regardless of experience, to truly believe that his or her personal insight and opinion should be weighted more than research-established protocol and procedure seems nonsensical and more like hubris than wisdom and sound judgement.

    1. If I ever become grievously ill, I would prefer to have my doctor – that is familiar with me, my lifestyle, medical history and is physically present determining treatment than politically appointed faceless central committee members who have never met me or read my file.

      1. I understand (and respect) your desire to be treated by your personal physician, but I think you misunderstand the concept of evidence-based practice and protocol formation. The protocols I am making reference to are means to standardization of care in accordance with research regarding various treatment regimens. These are continually subject to review and stand only until a new treatment plan is deemed to be superior through research trials. The end-goal is to ensure high quality care with dependable outcomes as opposed to guesswork on a case-by-case basis. The ability to reason and determine treatment is still of utmost importance in special cases or cases that deviate from the set standard. Otherwise, I think that many of the protocols are in place to protect.

        1. Except that not following rigid protocol can be cause for disciplinary action/fines if the doctor/surgeon chooses to deviate based on “evidence on the ground” that would be a better course of treatment for the patient.

          Some professions it’s OK to have automatons roaming about with checklists – doctors? Not so much.

        2. Brad,

          Perhaps a few organizations protocols for very specific disease entities. The way CMS/Medicare apply protocols are applied FAR too broadly, are seemingly random and are certainly not constantly reviewed.

        3. You are talking about disease-specific protocols that are promulgated by physician organizations not the hospital and ACA/JACHO protocols. Although there are still problems with the disease specific protocols (e.g. the original Surviving Sepsis campaign by the SCCM which promulgated Xigris for severe sepsis — which actually killed people, the “tight glucose control” craze — which actually killed people, the steroids for spinal cord injury craze — which, well you get the idea); the real problems are with the totally NON evidence based protocols that ACA promulgates such as SCIP (no evidence that it works, costs a lot of money) that are tied to hospital reimbursement and therefore are rigidly enforced despite lack of efficacy.

        4. I think artists (painters, musicians, etc.) should stick to strict, evidenced based protocols!

    2. Not hubris at all. I use evidence based medicine daily, mainly through evidence based decision rules. The problem comes in when CMS-Medicare come in and dictate a protocol to be followed, sometimes evidenced based, sometimes not at all. They do not allow for utilizing a deep knowledge base and experience to decide when it’s not necessary, adding more wasteful spending and as he points out future generations of physicians that do not think critically. And of course when these protocols are proven to be based on a fallacy, they just don’t go away.

  8. The last section in which he describes the two-tiered approach is already happening. My doctor has revamped his practice such that I pay $2K a year for the privilege of having using his services (including things like having his cell phone number and email address). Had I not signed up for that plan, I would not have personal access to my physician and instead would be seen by PAs and nurse practitioners. Personally, I am fine with paying the annual fee. Seems like a reasonable free market solution to the government’s interference.
    One other note with regard to the two-tierd approach. Back in the early 2000s, I was a part of a company expanding offices globally. I was working on a project to open and office in London. We were working with local market advisors who asked us what health insurance benefits we planned to provide. We asked why we would do that, given they had a national health system. The advisors just laughed, and said, we’d never be able to hire anyone if we didn’t provide additional health coverage.

  9. Unfortunately most liberals haven’t a clue how many ways government intervention has damaged the healthcare system. Government intervention in healthcare is the major reason for rising healthcare prices. Liberals tend to fear corporate influence over politics, so we need to stress that issue. Often free market advocates argue against Obamacare using arguments we understand but don’t catch their attention. By focusing on concerns they share with us like “crony capitalism” there is a chance to get through to them. This page details many ways crony capitalism drives up prices and why Obamacare makes things worse (including some most healthcare pundits missed):
    http://www.politicsdebunked.co…..healthcare

    It is long, but challenge Obamacare supporters to read it and then explain why they support Obamacare, or steal the arguments at least.
    In addition it make the analogy to food, which is more critical to life than medical care, yet there is no push for “single payer food”.

    1. In addition it make the analogy to food, which is more critical to life than medical care, yet there is no push for “single payer food”.

      I believe Obama’s quest to put as many people on food stamps as possible is the de facto form of this.

      1. Government charity isn’t a good approach, but at least food stamps don’t muck up the entire food system the way government interventions in healthcare do. There are other government interventions that need to be gotten rid of, but food stamps themselves are less at least minimally invasive. if we can’t have a libertarian government all at once, at least we can limit the damage.

        Yup, unfortunately government wants to expand its customer base (re: increasing food stamps), and fails the poor, as well as the taxpayer. An essay on that here suggesting a way to wean the public from that, starting with a tax credit for charity (eventually getting rid of it and getting government out of the charity biz):
        http://www.politicsdebunked.co…..s-the-poor

  10. I was a professional nurse for thirty years, APRN for the last 14. I retired early because I could no longer tolerate the bureaucratic/corporate, Medicare BS, and could see the handwriting on the wall of some form of “national health care – single payer, coming down the line.

    I had not truly been able to honestly take care of my patients for a long time, being obligated to the paperwork and insane “rules” for many years… and my own health began to break up. My health and wellness was restored after I retired.

    I have since watched many old friends and colleagues leave the ranks…

    Mark my words… there will come a time, not to distant, when the only “health care” workers left are the young and untaught, the incompetent, the avaricious, and the evil ones…

    Find an alternative now. And stop taking the chemical drugs. You won’t regret it.

  11. Ryan. even though Jane`s artlclee is exceptional, last week I got a brand new Car after having earned $4290 this-last/month and-in excess of, 10/k this past-munth. this is actually my favourite work I’ve ever had. I actually started 6 months ago and pretty much immediately earned at least $84… per/hr. I work through this link, http://www.wow92.com

  12. like Don implied I am dazzled that any one can get paid $7368 in a few weeks on the internet. have you seen this link http://www.app70.com

  13. Dr. Singer — you mention Ayn Rand (as though it were actually pertinent, sigh) and specifically “Shrugging” as an option for yourself. You say it like a threat though. Please, if you really want out, then do so: resign your postion at Phoenix Hospital; turn in your medical licence; and just disappear like the fellow in Atlas Shrugged. This is a free country, you don’t have to participate in any profession you no longer wish to engage in. Now in a real totalitarian state you wouldn’t have that option, but here you do. But for the love of all that is decent rise above the ideological crapola and work to make medicine better than it is now if you continue. We do need good physicians — we don’t need whining people who live in greater privilege than 99.99% of all the other human beings on the planet huffing and puffing about their imagined ills.

    1. Seriously???

      Your suggested option is to just stop working? What if he needs to work to make ends meet? What if he just wishes to work in the occupation he trained umpteen years for??? And he lives in “greater privilege???” WTF?? Working hard and earning a good living is now a fucking privilege??? Is freedom just a fucking privilege??? “Imagined ills???” He just explained why the medical system has been seriously fucked up by the government, a medical system people depend on to prevent suffering and untimely death, and you conclude he’s whining about “imagined ills???”

      What a load of statist bullshit.

      I have a suggestion. I just looked at your xray and realize your problem. You might want to pull your head out of your ass.

      Dr. Incredulous, M.D.

  14. I just have to ask since I am 5 years old today: What kind of diktat would a bureaucrat get, anyway? An image of the Dear Leader?

  15. as Rachel answered I’m blown away that a person can make $7310 in 1 month on the internet. did you look at this link http://www.app70.com

  16. upto I saw the receipt for $8881, I accept that…my… mother in law woz like truley receiving money part-time at their computer.. there aunt has done this 4 only about thirteen months and resently repayed the debts on their appartment and got a new volvo. read more at, http://www.wow92.com

  17. Easy to bitch .. hard to come up with solutions.
    What’s YOUR suggestion for how to improve access to medicine?
    Let the wealthy get care and to hell with all your other patients?

    I find little difference between private insurance companies telling me what medical care I can and can not have and the government regulating it … and at least the government tries to do so impartially.

    I’ve had 3 major surgeries in my 68 years. Luckily my insurance covered all … if not, my parents and I would all be bankrupt. 1 of the surgeries was an emergency open appendectomy with pertitonitis – in Canada. The total cost there was between 1/2 and 2/3 what it would have been in the states. The standard of care was roughly equivalent in all cases … if anything the standard of care in my case in Canada was in the middle, not quite as good as that I received in a small community hospital and slightly better than that I received in a major well-respected hospital.

  18. Yeah, Ayn Rand alright.

    While the Soviet Empire is dead, social medicine *thrives* in Western Europe. It does a **stellar** job.

    Oh, and can you name America’s neighbor to the North? There too…

  19. I have worked in the Emergency Room for nearly a decade and the same bureaucratic hurdles that exist in the surgical world permeate the ER as well, which is why your three hour stay for a stomach virus can end up costing thousands of dollars. It is the very existence of insurance itself that drives up prices, since the consumer is shielded from the real costs and demand is set by the suppliers of care … the doctors and hospitals. Real insurance coverage should not be molded from the current paradigm, where it is warranted for routine, preventative access to care.

    Current trends have also “corporatized” medicine, where the patient is no longer a patient but a consumer. Reimbursement is no longer tied just to care but how the patient “felt about” their “medical experience.” Hence, having access to an over-sized leather recliner with satellite TV while you’re recovering from open heart surgery factors into the same equation as your medical outcome.

    There are many other physicians across the country who have “opted-out” by either leaving the medical field, or re-starting their own practices that provide price transparency and equal access to all. No one is seeking pity, but the system is perpetually designed for the docs to submit and obey, making alternative approaches increasingly difficult.

    If anyone think healthcare is expensive now, what until its free.

    http://www.chesadaphal.com/the-downward-spiral/
    http://www.chesadaphal.com/a-r…..gh-the-ed/

  20. This gives me an idea, if the only place to get good medicine in the future will be in foreign countries like Mexico or other countries, then maybe you could start a medical-travel insurance business. People pay premiums to help cover the risk that they have to travel for medicine.
    One good thing about such a business is it’s unregulated… unless the feds decide to declare that it is a form of medical insurance.

    You wouldn’t always be able to offer significant savings – the cost of travel is the cost of travel, after all. But it would be worth it for some customers.
    The same company would have to own and run the actual buses/vans, to keep the costs low enough to make it worth it for them to do this business – except of course in the case of air-travel, in which case you have to use airlines.

    On a less related not, The whole medical travel thing makes me think that it’s another reason to move to Texas, since you’re close to Mexico.

  21. Related to this article: As a retired surgeon, I posted my thoughts on medical care in comments in 2008 entitled Can There Be a Right to Medical Care on my blog, http://davids-home-now.blogspo…..-results=1
    Many have appreciate the insights given. In a recent month, 600 views were made.

  22. 1980s, Medicare imposed price controls upon physicians

  23. their private practices threatened with bankruptcy, or are

  24. Doctors show no interest in abolishing the occupational licensing and prescription drug laws that enrich them and increase their paternalistic status.

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