“Navigating the Noise of Medical Bureaucracy” Dr. Sandeep Jauhar Summary of Presentation- March 19th, 2015 Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented, and anxious about the future. In surveys a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. Many doctors complain that they do not have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether. In contrast, only a few decades ago, physicians were seen as the pillars of their community. How did the American Medical system evolve to this point? In the halcyon days of the mid-20th century, American medicine was in its golden age. During this period life expectancy increased sharply (from sixty-five in 1940 to seventy-one years in 1970), aided by such triumphs of medical science as polio vaccination, heart-lung bypass, and cardiac pacemakers. Doctors largely set their own hours and determined their own fees. Depictions of physicians on TV were overwhelmingly positive, almost heroic, and doctors were generally content with their circumstances. They were prospering under the private fee-for-service model and they were free to regulate fees based on a patient’s ability to pay. They were not subordinated to bureaucratic hierarchy. When nationalized health insurance plans, such as Medicare, were proposed, doctors initially opposed them. They were afraid that the introduction of Medicare would be the end of medicine as they knew it. It turned out they were right, but not in the way they imagined. After Medicare was created in 1965, doctors’ salaries actually increased, as more people sought medical care. Year after year, healthcare spending grew faster than the economy as a whole. Premiums for insurers like Blue Cross - whose reimbursement rates were determined by doctors - increased twenty-five to fifty percent annually. Meanwhile, reports of waste and fraud were rampant. This is where Health Maintenance Organizations (HMO) and managed care came in. Beginning in 1970, HMOs were championed to promote a new kind of health care delivery built around price controls and fixed payments. Doctors themselves would be held responsible for excess spending. There were also other mechanisms for curtailing health spending, including greater cost sharing by patients and insurer review of the necessity of medical services. This loss of control had a profound 1 effect on the morale of doctors. In 1973, the year of the HMO Act, fewer than 15% percent of physicians reported any doubts that they had made the right career choice. By 1981, half said they would not recommend the practice of medicine as highly as they would have a decade earlier. Public opinion of doctors shifted distinctly downward, too. Doctors were no longer unquestioningly exalted. As managed care grew, physicians’ confidence plummeted further. There are many reasons for this disillusionment besides managed care. Physicians increasingly say they have inadequate time to spend with patients. In some ways, medicine has become a victim of its own success. Medical advances have transformed once terminal diseases - cancer, AIDS, congestive heart failure - into complex chronic conditions that must be managed long term. Adding to the dissatisfaction is that salaries under managed care have not kept pace with doctors’ expectations. The average inflation-adjusted income of general practitioners has dropped about 13% between 1970 and 2010 despite a near doubling of the number of patients that doctors see per day. While patients today are undoubtedly paying more for medical care, less and less of that money is actually going to the people who provide that care. Other factors affecting doctor’s morale include a bloated payer bureaucracy; fear of lawsuits; runaway malpractice liability premiums; and finally, the loss of professional autonomy that has led many physicians to view themselves as pawns in a battle between insurers and the government. The growing discontent has serious consequences for patients. One is a looming shortage of doctors. A recent report projected a shortage of as many as 150,000 physicians by 2025, particularly in primary care. Today, medical care is widely dispersed, leading to a weakening of personal relationships between doctor and patient. In a given year, Medicare patients see on average two different primarycare physicians and five specialists. Perhaps the most serious downside, however, is that unhappy doctor’s make for unhappy patients. Patients today are increasingly disenchanted with a medical system that often seems indifferent to their needs. There are big challenges for American medicine in the decade ahead. How can doctors take back the reins of their profession? How can they rediscover their professional ethic and repair the doctor-patient relationship? Dr. Jauhar believes answers to all these problems will involve doctors looking within themselves, deciding what is most important to them, what they are willing to fight for, and what they are willing to let go. Even unhappy doctors say the best part of their job is the human moments when interacting with patients. If they don’t find these answers, American medicine is going to continue to falter. Solutions to some of these problems will help restore American medicine, already technically the most advanced, to its rightful place as the best in the world. 2