United States (U.S.) health care, once a citadel of innovation and quality, has sadly devolved into a complex, frustrating, and frequently inaccessible system. It is so disorganized and inefficient it might not even meet the definition of a “system.” U.S. health care fails to address the needs and expectations of patients on many occasions and in many ways. For most of my career, I have considered U.S. health care the best in the world. Now I think not. This distressing editorial enumerates the challenges and failures of a system that is increasingly unacceptable to patients and their physicians. What the U.S. health care system excels at is generating massive profits for hospitals, pharmaceutical companies, trial lawyers, and Medicare fraudsters.

If you are looking for answers to these enormous shortcomings of U.S. health care, read no further; I have no answers, only questions. You may wonder then what purpose will this editorial serve? Glad you asked. It will delineate, define, and validate health care problems. This editorial perspective is mine; I am a physician retired from clinical practice. At age 81, I am now a consumer of medical care rather than a provider. I want, you want, everyone wants high-quality, available, affordable health care. That is not what U.S. health care proffers.

Sadly, I am also a constant caregiver for my beloved 80-year-old wife of 58 years. Becky has severe vascular Parkinsonism and cognitive impairment. She is confined to a wheelchair, falls frequently, and lives in a nearby assisted living facility. Daily, I serve as her advocate and caregiver in a deteriorating, often indifferent, health care system. Months-long waits for her to see specialists, five- to six-hour ER visits, personal physicians that do not see urgent and emergent cases expeditiously. Been there, done that.

Unavailability will default primary care to non-physicians

Case in point: Becky has been hospitalized several times for leg cellulitis. Recently she developed another episode. I quickly called her physician’s office. He is a hospital-employed internist. I told the office gatekeeper my wife needed to be seen today, tomorrow at the latest, by her physician for an urgent condition. Unmoved, she said coldly, “The doctor can see her in a week.” I told her that was unacceptable, that my wife had been hospitalized for cellulitis before and in a week the infection would be out of control. “Sorry, as I said the soonest the doctor can see her is a week from now. But the nurse practitioner (NP) can see her this afternoon or tomorrow morning.” I immediately took that appointment in spite of my concerns about non-physician medical care. Any port in a storm.

The NP was terrific and the antithesis of most of our physician visits. Becky was seen on time. The NP was professional, pleasant, listened intently, asked nuanced questions, and didn’t interrupt. She projected competence, care, and concern. Amazingly, at the encounter bellwether 15-minute mark, the NP did not jump up and brusquely leave the room in the manner of many physicians. We did not feel rushed or unheard. She prescribed an appropriate antibiotic and said if we saw no improvement or worsening over the next 24 to 72 hours to call her and she would expeditiously get my wife in to see the internist. Becky got much better over the next couple of days. I shudder to think what would have happened if we had waited a week. Lesson: Physicians should have a capable RN, NP, or physician assistant (PA) triage all calls that request urgent, emergent, or expedited office visits. Spaces in the schedule should be created to accommodate these patients same day or next day as appropriate.

I note with pride that the physician-owned ophthalmology group, where I practiced for 23 years, would see patients reporting ominous symptoms, moderate to severe pain, or hyper-concern same or next day. And of course, always the same day at another physician’s request. Much of that has allegedly (don’t you get tired of that word?) changed for the worse since private equity (PE) bought the practice and instituted for-profit corporate medicine.

Given the existing scenarios, it is inevitable that the scope of practice for non-physicians will greatly expand. Frustrated patients will seek out the much more available non-physicians. Ersatz “doctors” will be NPs, PAs, podiatrists, optometrists, midwives, chiropractors, pharmacists, naturopaths, occupational and physical therapists, etc. They will practice, for the most part, autonomously without physician supervision. With prompt physician access denied, inevitably most primary care will default to non-physicians. An ever-increasing number of patients now consider Doctor Nurse their physician.

How do we as a profession and as a nation address a shortage of physicians estimated to be between 37,800 and 124,000 physicians within 12 years? Don’t ask me, I told you I don’t have any answers.

Medicine as a very profitable business

For-profit hospitals are straightforward in letting the public know they are trying to wring as much money as possible out of health care. Paradoxically, so-called “nonprofit” hospitals frequently operate in a like manner. They are often equally rapacious. Health care dollars, five trillion of them per year, flow in a green tsunami to health industry shareholders and exorbitantly compensated administrative staff. Your pain is their gain.

The U.S. spends much more money on health care administration than other wealthy countries. Hospitals, like colleges and universities, have large, unnecessary, and expensive administrative bureaucracies. There are now 10 health care administrators for every one physician in the United States. That bloat just won’t float.

The U.S. also spends more on all health care than other developed countries. What does that buy our country? Sadly, too much of bad things: the highest rates of obesity, autism, substance abuse, type 2 diabetes, maternal and child mortality, violent deaths, suicide, and a falling life expectancy. America is spending an almost incomprehensibly large amount of money but not getting in return the healthier, longer, quality lives we seek. In the vernacular, we are getting ripped off.

Just when you think it can’t get worse, enter stage left the private equity firms. They are scarfing up physicians’ practices at breakneck speed. This includes right here in River City. Most of the major Kansas City ophthalmology groups have already sold out to PE. I have witnessed the deleterious changes made in practices acquired by PEs. These include, but are not limited to, staff reductions, patient encounter time limits (usually 15 minutes), mandatory referrals within the group, raised fees, higher billing expectations, more surgery, and promoting high-profit procedures when less expensive options are adequate. Often minimal monthly billings are assigned to each physician by the PE money mongers. Those unfortunate physicians that frequently miss their quotas are pilloried, threatened, and sometimes actually fired for low production.

So-called “routine” primary care is often shunted off to non-physicians by PE so physicians and surgeons can do the more profitable procedures or surgery. In ophthalmology this means primary eye care is diverted to optometrists. The implementation of extreme profit-generating measures is not in the interest of patients but boosts financial return to PE stockholders. Every independent study documents lower quality and higher patient cost when PEs buy a practice. Physician employees are cajoled to turn the money crank with a vengeance.

OMG then there is pharma! The prices of many drugs are often unaffordable and far beyond ridiculous. For example, Lenmeldy is priced at $4.25 million and Beqvez $3.5 million for one treatment. Who can afford that other than Jeff Bezos and Bill Gates? How does pharma get away with this? New drug development costs are intentionally kept arcane and obfuscated allowing pharma to kite prices and profits to obscene levels. Also, pharmaceutical companies have lots of friends in Congress. In 2024, to influence Congress and state legislatures, pharma doled out $150 million, a sum greater than any other industry or group. Money can’t buy you love but it sure buys Congressional votes.

I have personal experience with pharma cupidity. The innovative Migliazzo-Hagan-Kosa treatment of acute migraine with liquid timolol 0.5 percent is effective, safe, inexpensive, and available. What is not to like about that? We have been pitching its development to pharma for over a decade. I’ve lost count of the number of pharmaceutical companies that have passed. They have acknowledged the treatment is innovative and effective. They feel it would generate a profit but not a large enough profit to suit their insatiable greed. They callously ignore there are an estimated one billion world migraine patients. Hundreds of millions might benefit from timolol 0.5 percent topical to eye, sublingual, or nasal spray.

How to address the profound unavailability of physician care?

Suggestions from assorted pundits include: more medical schools, larger medical school classes, shortening medical school from four years to three years, import more international medical graduates, expand the number of residencies and truncate their duration. Every legislative session in Jefferson City we see the default solution which is to expand the scope of practice of non-physicians and have them do a greater amount of primary care.

“Minute Clinics,” usually staffed by nurses in shopping centers and commercial areas, offer excellent accessibility but variable quality. Other evolving solutions include “Be your own doctor” kits presently hawked on TV. Costing about $300 to $400, the manufacturers shill physician unavailability and emphasize the kit contains a variety of prescription medicines, mostly antibiotics, for common diseases. A small booklet on self-treatment is thoughtfully included. Implied is that is not difficult to be a doctor. What if things (inevitably) go bad? I guess the patient can sue themselves for malpractice.

Medical tourism is where people leave the United States for treatment or procedures on foreign shores. It is used presently for cosmetic and extremely expensive procedures. It will be a nonstarter for most people. Telemedicine, expanded greatly during COVID-19, may help. But most doctor visits require physical exams or procedures and are outside the purview of telemedicine.

Then there is (blow the horns, sound the trumpets) artificial intelligence (AI) which is paradoxically touted as the solution to all the world’s problems and/or the biggest threat to our continued existence as a species. AI hallucinations aside, there is real promise in AI diagnosis, for example in pathology, radiology, and dermatology. AI does not provide sympathetic care or concern and AI does not hold the patient’s hand or pat their back. Maybe future AI will do these comforting gestures. However, I think compassion cannot be digitalized.

By regular methods, which I designate “Call and Plead,” I rarely can get my wife a physician appointment in reasonable time. I confess to playing the “I’m a doctor” card. If that doesn’t work then I usually can inveigle a physician colleague to assist me with an appointment in reasonable time. Obviously, that option is not open to most patients.

As a nation and as a profession we must do much better. Lives depend on it.

John C. Hagan III is an ophthalmologist.