I trained at Cook County Hospital in Chicago thirty years ago. We did not have RVUs. We did not have prior authorization. We did not have a ratio of ten administrators for every physician. We had patients who came through a door where nobody asked for their insurance card, and we did our best for them. That was the system. It worked.

What replaced it is documented in public data that no one has assembled in one place until now. The numbers are not complicated. They are simply never said out loud.

Since 1970, the physician workforce in the United States has grown approximately 200 percent. In the same period, health care administrators have grown 3,800 percent. There are now ten administrators for every practicing physician in America.

In 1940, the ratio of hospital CEO compensation to physician compensation was 1.5 to 1. The administrator earned slightly more than the physician, handled scheduling and billing, and the physician ran the hospital. By 2026, that ratio stands at 12 to 1. The average nonprofit hospital CEO earns $3.8 million annually. The average primary care physician earns $287,000, after 11 to 15 years of post-secondary training, $250,000 to $350,000 in student debt, and a career of overnight call, malpractice exposure, and decisions made in 40 seconds that determine whether someone lives or dies.

Medicare physician reimbursement has declined 29 percent in real terms since 2001. Administrator compensation in the same system increased 443 percent in the same period.

The United States spends $12,600 per person per year on health care, nearly twice what any comparable nation spends. We rank 37th in outcomes. Administrative costs account for an estimated 15 to 25 percent of all U.S. health care expenditure, the highest of any developed nation in the world.

The money is not missing. It is in the administrative layer.

I want to name one specific consequence that receives almost no attention in the policy conversation: the prior authorization system. The American Medical Association has documented that the average physician loses 14 hours per week to prior authorization processes. Fourteen hours. There are no clinical trials showing that prior authorization improves patient outcomes. Not one. The process exists to deny care and reduce insurer costs. The administrative staff required to manage it are part of the same apparatus whose 3,800 percent growth I am describing.

Fourteen hours per week per physician. One million physicians in America. Fourteen million physician-hours per week. Gone. Into a system that produces no care and no healing and no benefit to any patient anywhere.

The burnout crisis in American medicine, where over 60 percent of U.S. physicians now report symptoms of burnout, is not a resilience problem. It is not a personality problem. It is the predictable result of asking highly trained, deeply committed people to spend four or more hours of every clinical day on administrative tasks that produce no patient benefit, while watching the people who manage the institutions where they work earn 12 times what they earn.

The physician is not asking to be made wealthy. The physician is asking for a system in which the work is valued in proportion to its difficulty, its importance, and the years required to master it.

The prescriptions are not complicated either:

• Reverse the 29 percent real-terms decline in Medicare physician reimbursement. It is a policy choice that can be unmade.
• Eliminate prior authorization requirements that have never been shown to improve outcomes.
• Require transparent public reporting of nonprofit hospital CEO compensation relative to physician and median worker pay.
• Place physicians on hospital boards with genuine clinical authority.

None of these require dismantling the system. They require applying to administrators the same accountability that has always been applied to physicians.

The physician who makes a wrong decision in the trauma room is sued. The administrator whose decisions produce a burnout epidemic, an access crisis, and a ranking of 37th in the world retains their $3.8 million and their car.

I went back to the data because I needed to understand what I was seeing in thirty years of practice. The data confirmed what every physician already knows and almost no one says clearly: The system has been reorganized, piece by piece, over fifty years, to serve administrative interests rather than patient interests.

The patient is the last item on the list. It is time to put them first again.

Dan Rusu is an anesthesiologist and critical care physician.