politics
The Health Care Crisis
Part Two: What Are the Causes?
Introduction
In summary:
Projections indicate that we will not have the number of physicians that our growing population will require in coming decades.
There are identifiable causes for this impending crisis, some of which are presented here.
Potential remedies are available, but it is unlikely that we will implement any of them. The best case scenario is that we will do too little, too late.
Intelligent People, Intelligent Choices
Intelligent, well qualified prospects are wisely avoiding careers in medicine.
There is no doubt that the practice of medicine is becoming less and less attractive for the brightest members of our society. In fact, the brighter they are, the more likely they are to critically examine all that a career in medicine entails.
Such critical examination could only lead to a determination that they could do better in a variety of other fields.
Excellent physicians, seasoned veterans who represent the most talented clinicians currently providing our care, are investigating and embracing alternative careers. This leaves us with doctors of lessor caliber or minimal experience to step in and provide that essential care.
Added to the change in attitude toward a career in medicine demonstrated by qualified candidates is the fact that more and more young doctors are demanding shorter work weeks.
Economics
Remember, when physicians complete residency training and enter medical practice, they have accumulated at least 24 years of formal education, but at the expense of lost income and precious time with their families.
They have often fallen far behind their contemporaries in terms of the accumulation of wealth and usually have acquired substantial debt. They will continue to be faced with shrinking disposable incomes with which to retire this debt and will also continue to endure insufficient time for recreation and personal relationships.
Of course, we hope that financial compensation is not the principle reason that they chose medicine in the first place. Nonetheless, in addition to this educational debt, they are burdened by the same basic cost-of-living expenditures that everyone else struggles with day-to-day. We would be naïve to think that financial concerns will not rank high among their concerns.
In the past, lucrative earnings and professional satisfaction defined medical practice. For most physicians, those “perks” also served to offset their need to play “catch-up” with everyone else who occupied the mainstream of our society while physicians-in-training wallowed in relative poverty and worked excessively long hours for years.
The final insult came to those physicians who not only endured all of this, but persisted in practice in the face of dramatic unpleasant changes. It took the form of a downturn in the stock market in 1999, which deflated their prospects for retirement.
Unfortunately for us, by 2010, those same physicians will again be in a position to retire. It is difficult to imagine that most of them will not seize that opportunity.
Professional Dissatisfaction
Qiphysician.com portrays the decisions of some established and successful physicians to leave medical practice at the peak of their careers. One, a general surgeon, age 46, ceased to practice in favor of growing lychees (a tropical fruit). Another, age 56, sold his practice so that he could teach science at a local community college. Yet another, a 50 year old Orthopedic Surgeon, left clinical practice to become a consultant for a company that assists other physicians in making a transition into new occupations.
Professional satisfaction, the dimension of medical practice ranked highest by physicians, has deteriorated as the government and insurance companies have taken control of practice.
This has led to a new phenomenon that no one could have envisioned 20 or 30 years ago: a mass exodus of physicians who, at the peak of their careers, are abandoning medicine in favor of other, often unrelated, opportunities. These new pursuits, whatever they may be, are undoubtedly far more satisfying than their established practices had been.
The factors that compel physicians to make these seemingly radical changes are familiar and obvious to anyone who has practiced medicine in the last four decades. While their relative rank may vary between specialties, these reasons are fairly consistent and include: managed care, government regulation, declining reimbursement, litigation and accompanying rises in the cost of malpractice insurance and feeling alienated from their patients.
These clinicians are leaving the practice of medicine just as they have amassed the greatest amount of knowledge in their fields and sharply honed their clinical and interpersonal skills. They cannot simply be replaced by younger and less experienced recruits.
This phenomenon, coupled with changes in the numbers of qualified applicants to medical schools, compounds the anticipated crisis in health care.
Any business whose primary resource is its employees and the services they provide would conceptualize this as a serious problem; one related to both recruitment and retention. It is hard to imagine that they would not aggressively and expediently employ measures that would ultimately lead to a change in those trends.
Since apprentice employees could not immediately replace seasoned veterans, the initial emphasis would be, by necessity, on retention.
No similar measures are currently in place that might entice physicians to continue their careers in medicine. Indeed, observable activities seem to be focused on discouraging quality applicants from entering this profession or accelerating their retreat.
Not only are physicians leaving medicine, but many shift from one specialty to another, abandoning primary care specialties for specialties that don’t involve direct patient care. Others leave clinical medicine in favor of administration or academic positions.
Some locations seem to be less attractive than others. The California Medical Association’s report reflected this when they determined that a sizable percentage of physicians planned to abandon practice in this state by leaving medicine altogether, retiring early, or by moving to another state.
Regardless of the avenue they take, physicians are leaving, and rarely return to the practice of medicine.
Foreign Imports
Domestic applicants to medical schools and practitioners are being replaced with individuals whose undergraduate or medical school education, or residency training was completed outside of this country. Many are brilliant and accomplished students who make fine clinicians, although we are increasingly faced with the prospects of language barriers between patients and their doctors that did not exist only a few years ago.
While many foreign-trained clinicians have the same qualifications as their domestic counterparts educated in this country, some do not.
Affirmative Action
Many medical students and physicians who were domestically trained were selected based upon race or ethnicity rather than potential and achievement.
Linda Chavez made the following comments some years ago in an article, entitled “Is Racial Preference Unfair?”.1 Sadly, some of her concerns remain relevant today.
“The American Medical Association meets this week in Chicago for its annual conference, and there will be plenty of controversial public policy issues on its agenda. But one issue you can bet the AMA won't talk about is what effect the widespread practice of admitting blacks and Hispanics to medical school with lower qualifications than their white and Asian counterparts is having on the medical profession.
By now, most Americans have gotten used to the idea that colleges and universities apply double standards when it comes to admitting black and Hispanic undergraduates -- even if they don't like it very much. The assumption has been, however, that these students somehow catch up over the next four years and go on to be just as successful as their white and Asian peers. This notion was given a boost a few years ago when two influential former college presidents, William Bowen and Derek Bok, published the findings of a study on affirmative action, "The Shape of the River," in which they claimed that minority students who benefited from preferential admissions standards nonetheless went on to perform well, earning graduate degrees at higher numbers than might be expected.
What Bowen and Bok didn't say is that the same degree of racial preference being given to minority students at the undergraduate level applies to graduate schools, too, including medical schools. For the first time ever, we now have the hard numbers to prove that medical schools routinely give preference to less-qualified black (and sometimes Hispanic) applicants than to others. The Center for Equal Opportunity (CEO), which I head, has been studying the issue of racial preferences in college admissions for the past six years. We've now turned our focus to medical schools and are in the process of gathering information on every public school of medicine in the country.
So far, we've analyzed six medical schools, representing every geographic region of the country, and the pattern for medical schools is the same as it was for undergraduate institutions. Black and Hispanic students are being admitted to medical school with substantially lower college grades and test scores than whites or Asians. If you're a black or, to a lesser degree, Hispanic applicant, your chances of being admitted to medical school are far greater than whites or Asians with the same college grades and Medical College Admission Test (MCAT) scores.
At the University of Washington School of Medicine in 1997, the odds ratio of a black applicant being admitted over a white with the same grades and MCAT scores were nearly 30-to-1. At the State University of New York, Brooklyn, the odds were nearly 23-to-1 in 1996 and were 9-to-1 in 1999. At the University of Maryland in 1999, they were 21-to-1, and at the University of Georgia in 1996, they were 19-to-1. At Michigan State University College of Human Medicine they were 12-to-1 in 1997 and 14-to-1 in 1999.
But more disturbing even than the finding that medical schools seem to be admitting less-qualified students on the basis of race and ethnicity is that many of these students can't pass their licensing exams, despite greater resources directed toward helping them than other students received. At every medical school CEO studied, substantially larger numbers of black students than whites either did not take or failed their initial licensing exams, and, in most instances, failed their subsequent licensing tests as well.
These higher failure rates don't just mean personal disappointment. Since medical education requires a huge allocation of resources -- and at state schools, this usually means tax-payer funding -- medical students who do not go on to become doctors are a poor investment. More than 3,500 white and Asian students were not admitted to the schools CEO studied, despite having better grades and test scores than black and Hispanic applicants who were given preferential treatment.
Since grades and, in particular, MCAT scores are very good predictors of performance on the licensing exams, we know that a higher percentage of these students would have passed the exams if they had been admitted. So, who wins? Certainly not the whites and Asians denied the opportunity to study medicine. But neither do the blacks and Hispanics who were admitted to medical school but could not survive there. And all of the rest of us -- of all colors -- suffer, too, from a shortage of qualified doctors."
Foreign Training/Affirmative Action: Comments
We will never compensate for the injustices forced upon our fellow citizens by the generations that came before us, not with Affirmative Action or any other similar measures. We can only move forward and ensure that those inequities live on only in the annals of history. Reversing prejudices by establishing and perpetuating new preferential treatment stagnates our society and breeds new contempt and resentment between the very people we seek to unite.
Furthermore, our responsibility as a country is to first provide opportunities for our citizens, provided they possess the requisite inherent abilities to seize and expand upon those opportunities. Having accomplished this, we can turn our attentions to the issues of immigration and ensure that everyone receives identical opportunities.
Because some foreign trained physicians are willing to work for less or may be more likely to accept unattractive positions, they become likely replacements for other doctors who are unwilling to accept these same conditions.
Just as jobs migrate to other countries because products can be assembled there at a fraction of the cost of assembly here, so have professional positions been displaced in a similar fashion. We have allowed nothing beyond economics to shape our decisions as they relate to business practices in general. While these practices may temporarily benefit immigrants, sadly, their children will face the same issues when they seek training and enter the job market.
In the process, medicine has become nothing more than another business that is subject to these same disturbing business principles and practices.
Female Doctors
No rational person could dispute the fact that women make excellent physicians. Anyone who has trained with them and practiced beside them is familiar with exceptional performance in every respect.
However, unwittingly, but justifiably, they may have a negative impact on this projected shortage.
The percentage of female physicians-in-training (medical students and resident physicians) and practicing physicians has grown steadily since the early 1970s, and so it should, but they still are more likely to opt for hospital based practices and will always as a group, by design, require additional time away from their professional activities.
Does this mean that we should attempt to reverse the trend of increasing numbers of female physicians? Of course not! It simply means that this is yet another factor that may impact on the number of available clinicians in the years ahead; one that must also be considered as we plan for the future.
The Baby Boomer Glut
As a “Boomer”, I stand among the accused. In the next decade fellow “Baby Boomers” will be entering retirement age and the period in their lives when they begin to consume a greater share of health care services and resources. This translates simply into a greater need for those resources and clinicians to provide services. If no other factor was considered, this phenomenon alone should prompt us to increase the number of physicians in training.
Malpractice
Higher malpractice insurance costs represent an substantial hardship for practitioners in some specialties and a deterrent for those who are considering those specialties. With time, this added cost is becoming significant for all specialties, even for physicians with no prior record of claims. Awards by juries continue to multiply. Few states limit the costs of malpractice insurance coverage. Reimbursement for clinical services remains relatively static. Do the math.
Inflation
Practice expenses for doctors are increasing twice as fast as reimbursement.
The Origins of This Dilemma
Without a doubt, our federal government is responsible for creating and maintaining the current status of healthcare.
Ironically, other “more socialized” countries offer a better standard of living and better healthcare for their citizens.
As we became aware of this discrepancy, critics were quick to point out that this was at the expense of much higher taxes in those countries. Instead of mounting a critical examination of this statement, we simply hung our heads in detached resignation, acknowledging that, indeed, this must be true. We failed to recognize that we were being taxed to the same extent as the citizens of those countries.
The difference is that they receive valuable tangible benefits for forfeiting this sizable portion of their income, namely, quality healthcare and retirement benefits.
Americans give up almost 50% of their earnings, only to find that little (or at least inadequate amounts) of that money has been directed toward healthcare or retirement benefits.
As if throwing a parched bone to a hungry dog, the federal government recently asked us to rejoice in the expansion of Medicare benefits to include payment for some of our prescription medications.
Unfortunately, our government has again exercised the same measure that undermined the quality of healthcare in the first place: They defined what yet another commodity was worth and agreed to pay for it accordingly. In this case, the commodity was prescription medication, rather than clinical services. Nonetheless, they set the price and then pay something less that this amount.
Medicare
The demise of quality healthcare began when the federal government established Medicare and state governments followed suit by introducing their own versions: Medicaid, Medical Assistance, Title 19, etc.
By doing so, government entities determined how much a unit of healthcare was worth, or more precisely, what they were willing to pay for it. Never before, or since, has the government been able to determine not only what they would pay for a commodity or service, but what could be charged, even if it meant that two purchasers would be charged two different prices for identical commodities.
Yes, Medicare recipients are charged a different amount for healthcare services and related items, than are customers without Medicare. Then, a complicated formula is applied that reduces the ultimate payment to whatever Medicare is willing to pay.
While the managers of insurance companies may be greedy, they are not stupid. They very quickly determined that if the government could do this, they too could justify paying less for the same services and products, and promptly adjusted their reimbursement to reflect the government’s standards.
This behavior was not merely tolerated, but to some extent was condoned and supported, since we were forced to acknowledge that insurance companies for some time had been paying more than their fair share. For a time they compensated for care delivered to patients who had no insurance or government supported benefits.
However, these insurance company practices have persisted long after the majority of people gained access to healthcare benefits.
The Parable of the Merchant and Bread
To better illustrate this phenomenon, let us consider a hypothetical merchant who suddenly finds himself at the mercy of these practices. John operates a marginally successful grocery store in a small town in the middle of nowhere. Some of John’s patrons use Food Stamps to purchase the food that they and their families need.
In John’s store we find that a basic loaf of bread is sold for one dollar. One day, John finds that bread can be purchased with Food Stamps, but that he will only receive 50 cents in reimbursement for each loaf of bread.
Additionally, the government limits what John can charge for a loaf of bread to 75 cents, if the purchaser pays with Food Stamps. This creates the illusion that the government’s reimbursement is 2/3 of the price of the bread (instead of 1/2). Everyone else, mind you, continues to be charged and is required to pay one dollar.
Of course, John is afforded some options to deal with the government’s new rules. He could remove bread from his store or he could charge more for a jar of pickles and for a bunch of bananas to compensate for the loss he is forced to absorb each time he sells a loaf of bread.
As no surprise to anyone, the government responds to John’s attempts to stay in business by making it illegal for John to eliminate bread from his store and goes on to fix the price that he can charge and the amount they will pay for pickles and bananas.
The government has just created a system for purchasing food at a greatly reduced rate. At the same time, they present the illusion that they were saving us, the taxpayers, a great deal of money. We are overjoyed.
We abruptly lose site of the fact that nothing is ever gained, except at the expense of someone else. In this case, John. We might counter that the purchasers of food and we, the taxpayers, both benefit from this scheme.
However, tax payers are still paying for the bread that other people purchase at a reduced cost, and likely ultimately pay even more than the original cost for their bread to compensate for the discounted bread.
This revelation becomes particularly distasteful when we recognize that the government could have purchased the bread in the first place, and paid full price. Furthermore, they could have done so without raising taxes or shortchanging John, the grocer.
Of course, this would demand that tax payers have some role in determining precisely how their tax dollars are spent; for example, ensuring that identified tax dollars go to provide public assistance, rather than toward other expenditures.
We all know that the Food Stamps John redeems bring him the full price. Our society would never stand for this scenario when it comes to food, but we do for healthcare. Public assistance programs purchase healthcare at roughly 50 cents on the dollar.
While John would never tolerate this healthcare providers do.
When insurance companies attempted to force policy holders to tolerate the use of after-market parts to repair their cars and to choose the lessor of three estimates, we were outraged. When the government and insurance companies apply the same tactics to healthcare services we do not so much as flinch.
Therefore, the government can not be expected to bear all of the burden of responsibility. We must assume some of the blame, if not as accomplices, certainly as negligent spectators.
The bread in the parable is healthcare. The government manages to “look good”, but at everyone’s expense. In the process, the quality of healthcare declines, the government fails to meet the needs of its citizens and insurance companies realize unrivaled profits. Despite all of the smoke and mirrors, there still isn’t enough bread (healthcare) to go around.
In 2003, Medicare reduced practice reimbursement for the second year and The Center for Medicare and Medicaid Services is currently pursuing a three-year goal of reducing physician payments by 15%. They recently announced that physicians would be spared the anticipated reduction in 2007, but reimbursement would not be increased to account for cost-of-living increases.
Many states effectively reduced Medicaid reimbursement by eliminating cost-of-living adjustments for payments to physicians.
Managed Care
To complicate matters further, based upon the pretense that no one else was interested or capable, the government and insurance companies seized control of every aspect of bread production (healthcare) and made life intolerable for the bakers and shop keepers (physicians). An undesirable consequence of these practices is that fewer young talented people want to become bakers, and existing excellent bakers decide to work in the local hardware store or sell used cars instead of baking and selling bread.
Managed care originally appointed primary care “gatekeepers” to limit service utilization and referrals. While they have for the most part abandoned these restrictions, they are now well established and effectively monopolize medical care is some regions.
Perspectives and Attitude
There are many among us who would assert that doctors, clinics and hospitals have always made more than their fair share. (No one seems to be saying this about attorneys or acknowledging that they have effectively made it impossible to manage any encounter with the judicial system without their costly assistance.)
This perspective totally discounts the fact that physicians represent the most highly educated and extensively trained professionals in our society and provide what is unquestionably the most essential service that we require.
The local auto dealership charges about the same rate per hour to service an automobile as a psychiatrist or family practitioner receives for an hour of their services.
The local veterinarian charges fees similar to many medical doctors, but in most cases will not allow your pet to leave the clinic until you have paid for their services.
Dentists, who are apparently much smarter than physicians, charge large sums for their work, but usually don’t take payments from government programs.
Eyeglasses and contacts cost an arm, and hearing aids an arm and a leg, but there are few insurance programs that provide benefits to pay for these necessary items.
Do dentists and veterinarians charge too much? No, they simply manage to get paid for their services.
While I am not pointing any fingers, I would propose that Medicare be allowed to determine what attorneys charge and then set payment at some level that is a fraction of that amount.
Familiarity and Indifference
We as recipients of healthcare services have grown accustomed to, and dependent upon, insurance plans (public or private) to pay for our healthcare. At the same time, we have been totally negligent when it comes to monitoring insurance company practices and examining their profit margins.
According to Forbes Magazine, William McGuire, the CEO of United Health Group, the nation’s leading insurer, was the third-highest-paid CEO in 2004, at $124.8 million.
$124.8 million would buy a lot of loafs of bread.
Incidentally, Forbes also reported that Mr. McGuire ranked only 33/189 in terms of performance. We can only be thankful that the United Health Care Group stock holders aren’t running the federal government. They appear to be "asleep at the wheel".
In many regions of the country insurance companies have effectively created monopolies, sometimes with the complacency, or even the complicity, of legislative bodies.2
Conclusions
There are several historical developments that appear to have contributed to the anticipated shortage of physicians. As is the case with most of the current problems in medicine, this one can be traced back to government intervention.
Until we as a society look realistically at all related factors and develop a plan to address each of them, we can only expect further difficulties.
Sadly, while we are currently experiencing a frenzy of activity in our effort to describe the problem, I can not foresee definitive efforts to resolve this or any other healthcare related difficulty.
For more information related to this topic access the links below.
1Linda Chavez Tuesday, June 19, 2001 Copyright 2001 Creators Syndicate, Inc. aad.english.ucsb.edu/docs/chavel.html
2Minnesota has excluded healthcare plans that are not “Managed Care”, even if they offer better services at lower rates.
(Sources: The author's knowledge base, unless otherwise noted.)
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