Below the Fold: Is There a Doctor in the House?

Michael Blim

I lost my family doctor last week. Or rather, he has decided to undertake a boutique practice, and I can’t afford the annual fee. So, in a way, he is leaving me, and I am not happy about it.

Last week a friend of mine received a “Dear John” letter from her family physician. He is cutting 400 patients from his list, and he had selected her to be one of them. He is leaving her, and she is not happy either.

My friend and I are medically well connected. Both my partner and my friend work at a major research hospital in Boston. They know lots of doctors who know lots of doctors. And still, both of us are scrambling to find a family physician. Many have closed their practices to new patients, and even a well-placed word doesn’t always unlock their availability.

There must be primary care doctors who are not being overrun by patient demand, but in my quest to find a new doctor, I haven’t come across any with good track records in Boston that are not.

There are a lot of reasons why my friend and I have lost our doctors. First, it would seem pretty obvious that some doctors, particularly primary care doctors, would like to make more money. The average salary for an internist in 2005, according to the US Department of Labor, was $166,000, while surgeons, for instance, made $282,000. My now former family doctor and his new partner plan to serve only 800 patients at a time. As minimum annual membership in the practice costs $3500, this means that they begin each year with $2.8 million in income from their patients that is in addition to insurance reimbursements they will receive for services rendered. Clearly, money is an important motivation.

(For the record, it should be noted that the federal government limits the number of doctors that can be trained, and the medical profession has not founded new medical faculties that could produce more doctors. As the number of doctors has actually declined 17% since 1983, according to the federal government, this would seem to be an odd set of decisions given the rising demand for medical care.)

Second, if we consider the doctor reducing his patient load, money is not likely his concern. He sold his practice some time ago to a large research hospital that covers all office expenses and pays him a very good salary, much more I would guess than the national average. The load-reducing doctor easily earns his keep by providing the hospital with millions of dollars in “billables” through referrals for treatment.

The load-reducing doctor doubtless wants to return some sanity to his professional life, and the same could probably be said for my doctor starting up the boutique practice. My doctor going boutique is doing it with money by increasing his yield per patient, and in effect lowering the demand for his services. He is also no longer subject to the possible productivity demands of hospital overlords who seek in turn to boost hospital profits. He is regaining some professional autonomy, though at a very high price for his patients.

The rub, it seems to me, lies with the load-reducing doctor who has remained with the hospital. It likely makes good sense to slim down his patient list, unless his hospital is paying a per capita bonus, or it pays him for exceeding a goal for the number of patient he sees per year. He probably will not be paid less because of his market value and reputation. His practice has been closed for years, and his remaining patients are likely to cling to him for his competence and for the security of having a family doctor. He will not want for patients, though the hospital might miss some referrals.

In all though, I bet he will barely feel the difference. It might work out a bit better for his patients, whose access to him might marginally increase. But his workload and work routine probably won’t change much, as the remaining patients will take advantage of the opportunity to get more care.

This is because our health is so valuable to us that we will seek as much care possible because we can never tell what is enough. The more opportunities that are offered, the more care we seek. As our demand for care increases, more care is offered.

Here are a few examples of how our consumption of medical care is growing. In 2004, according to the Centers for Disease Control, Americans made 1 billion doctor visits, and the rate of increases in doctor visits is running about three times the rate of our population growth. We made 35 million visits to the hospital in 2004, and the number of stays is growing by about 3% a year.

Services such as diagnostic radiology and commodities such as prescription drugs are growing much faster, both in quantity and cost. Radiology billings are increasing at the rate of 20% a year, hitting $100 billion in 2006. Americans now consume an average of 11 drug prescriptions yearly, and their costs are rising faster than the rate of inflation.

We spent $2 trillion on health care in 2005, a figure that amounts to 16% of our gross domestic product. By 2015, we will be spending $4 trillion a year, thus devoting 20% of our gross domestic product to health care.

We are definitely consuming more health care, even though we cannot determine how much health care is enough. In addition, as the population ages, and our collective health faces more challenges, we are likely to seek more care. And as one national scheme or another covers millions of uninsured Americans, they can finally and fully meet their health needs, and will consume more care. The good news for the currently uninsured, if Medicare is any guide, their health status will improve measurably, as did the health status of the elderly.

Thus, there is surely unmet need, even in the face of galloping demand. This anomaly dissolves once one recognizes that there are many in America who don’t get enough, and many who can’t get enough. For people who just can’t get enough, their desire for more is transforming health care into a “quality experience,” from boutique medical practices to boutique wings of hospitals.

In the past, rank and wealth surely had its privileges in towns and cities where the rich could support society doctors and special hospital accommodations. The new, more numerous class of well paid managers and professionals that has grown up since World War II has recreated American health care as a growth industry which they run and from which they profit. They have pushed the medical profession to provide care as Henry Ford pushed his workers to make Fords. Doctors, once accorded elite status by virtue of their profession, now pursue entrepreneurial projects via boutiques, incorporation and refusing insurance. Many are converting medical practice into a business model.

Even as some doctors rebel, escape, or go out their own in some out of the way place, others like the load-reducer looking for sanity for himself and better service for his patients, are becoming cogs in the wheel of large vertically integrated firms. They refer clients to a capital-intensive medical machine run by managers and doctors with profit-based business plans. Every hospital caught up in the race believes that it will soak up the growing demand by providing an ever growing supply of machines, beds, day surgeries, and importantly innovative cures for the very sick.

As the supply grows, so in turn does demand once more, fed by our unquenchable desire for more health and more well being. We return once again to the question: What is enough? The answer is presently unknowable for three reasons.

First, enough is defined now in terms of differential resources. If you have money or even proxy money such as insurance, private or federal, you can answer the question much more robustly. The lack of money or insurance for others defines in effect what is enough for them. The fact that persons making less than $20,000 a year spend 15% of their income on medical care and those making more than $70,000 spend just 3% of their income on medical care suggests how much more low income individuals are affected by medical costs than those with high incomes. I suspect, though I cannot prove it here, that high income individuals not only are better protected by insurance, but that they have more disposable income to devote to more health care consumption. This last might explain why hospitals are installing those hotel-like hospital wings complete with chefs and concierges, and thus making health care into a “quality experience.”

Second, the private system of medical care today is driven by the profit motive in which expanding our notion of what is enough in part creates greater demand for their products. For them, more is better, particularly as professional medical knowledge and ethics are being subjected to a business model. They can answer for their own interests, but their opinions of necessity are partial, and would probably boil down to the argument that we can never have enough, as health is more generally treated as an immeasurable human good.

Third, self-preservation being keenly desired by many does not necessarily encourage rational choices. To the question of what is enough, for many, the answer is simply the egoistic reply of what is best for them.

Our two practitioners, like us, are struggling to answer the same question in their ethically loosened and bureaucratized world. Their choices – one to ration care by making it expensive, and the other to ration care by eliminating patients – are the unfortunate products of a system incapable of rationalizing itself.

When we think of national health insurance, I believe that we think largely of satisfying the unmet demands of a near majority of Americans for quality medical care. However, we often fail to realize that any national health system will come to pass as a descendant of the one we have now, one in which the question of what is enough is answered by an anxious, insatiable demand for care in an environment of relative indifference to the needs of others. As so often happens in America, it is hard to note the suffering of others at the same time resources are expanding for the things that other individuals value.

A new national system must not only provide medical care equitably for the first time in American history, but it also must develop a collective answer to the question of what is enough. It involves answering the practical question of how much of our national income we want to devote to medical care as against other goods and services. It also involves re-setting the moral terrain through collective agreement based upon an ongoing investigation of what care is necessary for a decent life.