Returning Control of Health Care to the Patient-Physician Nexus

Radical changes in the practice of medicine have been important to me for a decade. I write this paper from the career viewpoint of a former practicing gastroenterologist, an academic, and a bureaucrat. Before listing the problems with our current system, I want to emphasize that most people in the United States receive excellent medical care from extremely competent physicians, nurses and other caregivers. The defects in our system are: (1) Approximately 43,000,000 citizens have no, or inadequate, means to pay for health care. (2) Costs of medical care are too high because: (a) Neither patients, physicians, nor other caretakers, have any serious interest in controlling costs since virtually all costs are covered by a third party. (b) Technological costs have skyrocketed. Virtually whatever promising technique that is envisioned is developed, bought, and used. There is no flexibility in the system to accommodate new stresses, such as the current exploding demands for recombinant DNA diagnostic techniques. (c) The malpractice system is costly, both because of premiums and because it encourages defensive medicine. (d) Physicians’ salaries, although declining, are high compared to others involved in intellectual and technical pursuits. (e) Very high administrative costs, perhaps 27% of total health care costs, are spent in overseeing care, billing, and corporate (nonmedical) salaries. (3) Medical decisions are increasingly made by representatives of HMOs or insurance companies who do not have detailed knowledge of the clinical situation, adequate ability, or the ultimate responsibility. Furthermore, these ancillary personnel do not represent the interests of the patients. In order to understand how we reached such an unsatisfactory state, let us look at the major players.