What's in it for the doctors?

Why America's Doctors Should Support Universal Healthcare
Laura K. Altom, BS, MSIII; Larry R. Churchill, PhD
Medscape General Medicine. 2007;9(1):40.
©2007 Medscape


Even those who entered medicine for altruistic reasons and continue to be sustained by that motivation need to be compensated for their work. So one obvious answer to the question "What's in it for doctors?" is that they will have patients who have an assured way to deal with the bill. Whatever else their motivation, physicians have a powerful self-interest in being paid for the care they provide. Only the very wealthy can afford to routinely see physicians if they are uninsured.

Yet this reason may not be widely recognized or appreciated among physicians themselves. Here American history provides an exemplary tale. In 1965, the Medicare program was created, providing health benefits for all citizens aged 65 and over. The impact on the health of the elderly, and on their social status, was dramatic. Prior to the advent of Medicare, 35% of the elderly lived in poverty; in 2003 that number was at 9%. Medicare is also credited with desegregating US hospitals, being the largest funder of graduate medical education and creating the field of geriatrics. But for our purposes here, the critical change was creating millions of newly insured patients. In spite of the potential boon to physician incomes, organized medicine strenuously opposed Medicare, a situation in which a misidentified fear of socialism triumphed over common sense and economic self-interest.

The American Medical Association (AMA)'s well-organized campaign of lobbying and advertising against Medicare was dubbed "Operation Coffee Cup." The name bespeaks a strategy of building grass-roots opposition, and one feature of the campaign involved sending physicians' wives anti-Medicare phonograph records and tapes to play for their neighbors. One of the speeches on the records and tapes was given by Ronald Reagan and intoned that Medicare would mean that one day "we will awake to find we have socialism." The socialism charge was nothing new at the time, and has remained a staple ingredient of opposition to reform, including the defeat of Clinton's Health Security Act in 1994. Medicare was passed in spite of organized medicine's massive campaign of opposition. Yet our main point is less about the erroneous ideological charges that fueled the opposition of the AMA in 1965, and more about the great irony of organized medicine lobbying fiercely against the economic self-interest of its members. In retrospect, it is clear that Medicare has had a profound, beneficial effect on physician incomes, as well as on the health status of the elderly.

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Several years ago, one of us was talking to a surgeon who was host for a visiting lecture at his institution. Arriving in the early afternoon for an after-dinner talk, we went to the construction site of his new home and we walked together through the emerging shell of beams and girders. It was to be a grand house, roughly 15,000 square feet, with rooms for every possible activity, multiple garages, and every amenity imaginable for a private residence -- and all for 2 people. Clearly it represented the fulfillment of his and his wife's aspirations. His comment about the opulent new residence, half in apology, was: "It gives me a reason to keep working."

We tell this story not because we begrudge physicians, or anyone for that matter, wealth or fulfillment of their material aspirations. Rather, what was striking was that "conspicuous consumption" had become the rationale for continuing a medical practice beyond the point of engagement for intrinsic rewards. Such values might not be worrisome in a corporate CEO or an NBA star, but they are in a physician. They signal the usurpation of the altruistic rewards of medicine by monetary gain. We are not concerned with whether this physician and his spouse should have settled for less opulence, but with how professionalism could be maintained when the motivation that impels the scalpel is the price of the procedure.

Commercial forces have always been a force in medicine, but it is only recently that they have come to dominate. While physicians have consistently sought to portray themselves as purveyors of a social service, until recently in the United States they have functioned as small-business owners. For the greater part of the 20th century, American medicine was a cottage industry with a professional service ethos, populated by solo or group practices, run on fee-for-service, indemnity insurance or out-of-pocket patient financing, providing adequate to good returns for most generalists and handsome pecuniary rewards for specialists. Those who received care were largely those who could pay, either through insurance or out-of-pocket, while the uninsured were the sporadic recipients of charity. So the conduct of medical practice as a business and the use of market forces as the chief mechanism for the distribution of medical goods and services are nothing new in the United States.

What is new is the pervasive presence of large corporations as owners and providers of health services, and the loss of physician autonomy in decision-making that goes with that change. While there were some healthcare corporations in the past, they were typically businesses owned by medical groups or nonprofit organizations that were governed by boards of local citizens and were community oriented. While not always altruistic in their aims, these organizations were often responsive to local needs. The new healthcare corporation has a Wall Street orientation and is responsive to markets and mergers. The new corporate providers are also far more skilled than the cottage industry entrepreneurs at advertising and selling their services, cutting costs, and shaping the way their customers think not only about the services they offer but also about the economic arrangements that undergird their profitability. The healthcare insurance industry's derailing of the Clinton healthcare reforms in 1994 is vivid testimony to their power.

The muscle of the new corporate health entrepreneurs can be documented by looking at the portion of healthcare services they now control, but our interest here is less in the size of their market share and more in the subtle but pervasive ways we have all been encouraged to talk and think about healthcare as a marketable product. For example, physicians are now "providers," while patients have become "consumers." The logic of these terminology changes is reinforced by the methods managed care organizations (MCOs) use to assure their members that quality is being maintained or enhanced -- through "consumer satisfaction surveys." The idea that consumer satisfaction is a good measure of quality means that patients now have the role of customers who, to be effective in this exchange, must be knowledgeable and shrewd in comparisons of price and quality. Health services are now "commodities," in which the cardinal defect is the absence of choice. The absence of choice prohibits the chief means of consumer assurances of value, viz., comparison shopping. In brief, commercialism means that going to see a doctor is increasingly portrayed as purchasing a product or claiming a service -- largely prepaid if one is insured -- rather than seeking help from a trusted professional.

Within the logic of the market, the goal of commercializing health services is to capture a market niche, to enlarge it, and to maximize profits. This, too, is reflected in changes in the idioms that describe the activity. Services to patients by physicians are registered in accountants' ledgers as "medical losses," precisely because these services reduce the fraction of income that can be counted as profit. Advertising is undertaken to attract and sustain the loyalty of carefully selected, low-risk groups, known as "revenue bodies," to whom the cheaper premiums are offered. Most physicians currently function under a variety of incentive systems designed to reduce utilization -- and thus costs -- in keeping with the aims of corporate profitability. If efficiency targets are not met, whatever portion of physicians' incomes that are "at risk" is lost. Thus, clinical choices about how much time to spend with a patient, or what services to provide or recommend, have substantial implications for physicians' incomes. Just how direct and severe these implications are depends on the model being used, and they range from those that simply produce a prudent cost-consciousness to those that are morally perverse because they create a conflict of interest for the physician.

The impact of corporate commercialization of medicine on physicians would be hard to overestimate. The literature of the past 15 years has been filled with carping, complaints, and other signs of demoralization. And this is entirely understandable. The experience of many practitioners has changed from patient care to patient and revenue management. Time spent in clinical activities is routinely cut short by conversations with benefit managers to gain approval for recommended diagnostic procedures or therapies, and the burdens of documentation are far greater as the consequences of nonconformity to insurance guidelines increase. The application of industrial, assembly-line management techniques to medical care has done perhaps more than anything else to reduce the self-esteem of physicians. Seeing more patients for shorter periods of time to meet a managerial quota has led, predictably, to less satisfying relationships for both physicians and patients.

Although we are painting a sobering picture, it is not a surprising one. It would be very strange if the logic of commercialism so pervasive in the rest of society had not invaded the medical sensibility. Physicians are subject to the same pressures as all Americans, increasingly measuring in dollars how they rank as good professionals, good family providers, and more generally as successful persons. In American society, these indices of merit and honor are all thought to be related, directly or indirectly, to the monetary resources one can muster. The result is that physicians are systematically encouraged to think about their most basic stewardship as one of protecting investor resources -- rather than, or at best in addition to, their stewardship of patients. But beyond patient vulnerability, management's claim to physician loyalty marks a profound shift in the sources of professional pride and self-esteem. In the past, this sense of worth was more firmly anchored in helping people, in developing and sustaining therapeutic relationships, and in a general altruism of purpose. The industrial-managerial model of care makes these sources of reward secondary and less available.

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