America’s health care system, much like Congress, is broken, and doctors have to be part of the solution. I don’t know a single doctor who doesn’t wish to improve our ability to increase access and the delivery of health services to our patients. Maintaining and/or improving the health of patients is our goal. That should be the goal of anyone associated with the health care system, but it’s not. Currently, our system is infiltrated and plagued by profit. There’s no quick fix or panacea. I have ideas on how to make improvements, but let me point out what I see as the biggest problems.
Economic structure
America’s capitalist economy works well for many industries—but not all, and health care is not one of them. Health care is often not subject to the same standards of supply and demand and, therefore, cannot be considered a standard market. Insurance companies limit your choices when they force you to see someone “in-network,” so your ability to choose the doctor you want is already curtailed, if not eliminated. When your family member is sick, the typical response is to do everything to get them better. When that is an emergent situation, you don’t stop and shop around for the best provider or cheapest deal. And despite what most people think, it’s actually against the law to turn away a patient with an emergency due to lack of insurance. This is, in part, why community hospitals can no longer stay open. Such hospitals have to compete with for-profit facilities—sometimes right next door–that usurp all the well-insured patients. Because they are bound to take care of emergent non-insured patients– who often make up a greater share of their population– they are bound to go broke. It’s already happening as a community, and rural hospitals are forced to close their doors.
Hospitals do budget for indigent care, which is reimbursed by the government (you and me). Similarly, all those patients who can’t afford to treat their chronic medical conditions who present in crisis to the ER with severe consequences of that neglect will get the services they need—which they cannot afford. So again, the government (you and I) are left to pay for that acute care—which is almost always much more than helping to subsidize the cost of maintaining their underlying diseases in the outpatient setting. So when you think about it, providing that basic level of health care to such patients is actually the economically smarter option. And clearly, it’s the more humane and ethically appropriate thing to help prevent such morbidity when possible. There will always be non-compliance for sure, but most patients actually do want to take their meds—if they don’t have to choose between that and paying for a roof over their head or putting food on the table. It’s a win-win, so why are we not doing it? It’s complicated—but I feel contributing factors are: corporate health care greed that gets its tailwind from capitalism, big players who pay the politicians, and polarized politics with taboo labels such as Obamacare and socialism.
The big players
I’d like to think that doctors are one of the big players. But as doctors, we know better. Physicians used to be considered the pillars of society. And sometimes, they still are. But more often, health care providers are often maligned and blamed for our current situation. Patients are shooting up doctors’ offices and hospitals. Society has demonized doctors—and in a handful of cases, rightly so. There are some bad doctors out there who got into medicine for money. Or others who are now disenchanted with the practice and provide care based on reimbursement as opposed to the standard of care. Those bad apples are tainting the whole profession. But that’s just it—they are bad apples among the bunch. Please know that most doctors really do want to help get you and keep you healthy.
Suffice it to say that physician salaries make up a minimal component of the overall health care expenditures at just 8.6% in 2011. And that was the 2nd lowest among Western nations with a “modern” health care system. More than a decade later, physician salaries remain at 8.6% of health care spending. What most people don’t recognize is that for the last 20 years, we’ve been getting paid a little less each year for the same services. What other industry is getting paid less each year for providing the same services? And it’s just doctors—the other health care players have been getting incrementally more over this same time period. This explains why doctors now have to see more patients than they used to just to earn the same amount and cover the expenses—while the latter go up each year. And you can’t pay your staff less each year—so that increase in overhead and staffing costs comes out of the doctor’s salary. The medical assistant (MA) can now earn more at Buc-ee’s or Costco than we can afford to pay them to work in our office. Therefore, the physician practice model pendulum has swung away from private practice and towards employment, being bought out by hospitals or, worse, private equity firms. The private practice solo physician is a dying breed; it’s just not sustainable in our current system.
If doctor salaries are not the problem, what is? Let’s start with the biggest player: insurance companies. It’s in the interest of insurance companies to deny coverage and care as often as possible. It’s expensive to keep you healthy. But it’s even more expensive to try to treat you when you are sick. When we make being healthy (preventative care) a priority, in the long run, we all do better. But health care companies are in it for the bottom line—which is here and now. Denials of coverage for things practicing physicians have ordered are the norm. Prior authorizations have become such a nuisance that we are making state laws to help deal with this. Texas led the way with the gold card bill, which intended to exempt physicians with prior authorization approval rates of more than 90% from having to get prior authorizations at all. Unfortunately, it’s rare for a doctor to even know of their gold card status, and there is no punitive component when an insurance company doesn’t comply.
Similarly, the Affordable Health Care Act (ACA), a.k.a. “Obamacare,” enforced the 80/20 rule—which said that 80% of the premiums they collected had to be spent on medical claims. This was to both reduce insurance company profits and hopefully decrease premiums. My family and I got a check from my insurance company that next year for more than $500. But no surprise, we never got another check again because the insurance companies implemented workarounds—namely, increasing the costs of medical claims. So these laws end up having great intentions but with absolutely no practical impact.
While insurance companies placed the blame for rising rates on the ACA (which is technically accurate as it was their own reaction to the 80/20 rule), they still were able to increase the pay of their CEOs. The combined CEO salaries of the eight largest publicly traded insurance companies—including pharmacy CVS, which acquired insurer Aetna—was $143.5 million in 2017, up 14.4% from the year before. As of 2023, the top-paid insurance CEO made over $22 million. Meanwhile, premiums are rising at a much faster rate than overall wages—leaving the average American unable to even afford health insurance.
The next big player is drug companies. While the drug companies are paying their CEOs tens of millions, most Americans can’t afford their prescriptions. In 2022, the top 10 pharmaceutical company CEOs made $28 million/year or more, with the highest paid getting more than $124.9 million/year. Thank God for Mark Cuban, Alexander Oshmyansky, and Cost Plus Drugs. Although they are a company seeking profits in order to stay in business, that’s clearly not their motivation. The mission is clearly stated on their website: “We will provide low-cost, high-quality pharmaceuticals to the consumer…by any means possible.” While Mark Cuban states, “I could make a fortune from this … But I won’t. I’ve got enough money. I’d rather f— up the drug industry in every way possible.“ Why can’t the government do something like this? Because the politicians are in the pockets of the big players.
The final big player is the health care administration. From 1990 to 2012, the U.S. health care workforce grew by 75 percent. All but five percent of that job growth was in administrative staff, not doctors. For every doctor, there were 16 health care workers, and only six of those were involved in actual patient care (nurses/aides). The other 10 represented purely administrative roles. And it’s not from increased utilization as the number of days Americans spent in the hospital decreased by 12 percent, while hospital staff grew by 11 percent from 2002-2012. Why were all these people added? What are they doing? We do need someone to run a hospital and its staff, but what are all those extra people doing? Some even project this field will grow by 32% from 2019 to 2029! I cannot comprehend how the exorbitant 75% of the layers we now have are truly needed, nor that they result in improvement in patient care.
The economic structure that allows anyone and everyone to reap profits from the health care system, the insurance and drug company domination of the market and politicians, and the outsized ballooning of health administration are the biggest insults to the American health care system as this practicing physician sees it. The goal of our system needs to be the health and welfare of patients—which is almost uniformly the goal of all physicians practicing medicine. Physicians should not only be at the table of discussions regarding health care, but leading the inception and implementation of the solutions. Why aren’t we? In part because we are too busy taking care of our patients to spend the time and money to educate and influence politicians. But politicians need to step aside and defer to those actually practicing medicine for solutions. As doctors, we also fight about the politics of medicine, but at the end of the day, patient care is what unites us—not getting re-elected. I’m ready to start addressing these problems and finding some practical solutions. Let’s let doctors lead the way.
Alisa Berger is a urologist.
