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Friday, October 22, 2010

Doctors Are Government Employees

Doctors speak frequently among themselves about problems in medicine: decreased collections; inability to spend more time with patients; difficulty getting consults from specialists, especially for Medicare/Medicaid patients; enormous time wasted with patients who aren’t really sick (sometimes they’re old and lonely; sometimes they’re unemployed with nothing else to do—visits to the doctor for the poor are often a family affair, with three generations crowding the waiting area); the incredible wasted resources in the emergency department. (Due to federal EMTALA laws, no one needing emergency care can be turned away from an ER.)

But there’s one thing doctors never talk about, even though it easily explains the problems patients have in getting good treatment and doctors have in providing it:

Doctors are government employees.

I’m not talking about only the doctors that work in the Department of Veterans Affairs or the hospitals run by the Bureau of Indian Affairs. I’m not talking about the training centers known as county hospitals, where students learning the practice get to make mistakes on poor people prior to actually going out in the real world.

I’m talking about all doctors—because the government contributes about 50 percent of all health care dollars to physician pay. And 40 percent more is contributed by third-party payers that are themselves highly regulated by government and routinely follow the government’s lead in pricing.

People in the United States don’t need to have it explained to them why FedEx and UPS do a better job than the U.S. Postal Service (USPS). They know why they stand in long lines when they use the USPS and face surly unpleasant employees behind the counter. It’s a government monopoly. For years, the post office I frequent had a number dispenser, like at a deli. You’d wait for your number to be called. I would typically walk in, pull the number—say, for example, 57—and find they were currently calling 13. Recently, this technique was discontinued. I asked the postal employee why, and he explained studies showed the system made people feel they were waiting too long, so the Postal Service got rid of the number dispensers—not to speed things up . . .  just to make it harder to know how long you had to wait.

People in the United States don’t need to be told why their garbage pickup is not always as dependable as their dry cleaning pickup. They know one is paid for out of taxes while the other is paid for out of pocket, that one is a monopoly you have no choice but to use while the other is a service you can take or leave, or change. They know the dry cleaning company will never berate them if they don’t pre-sort their clothes properly before pickup.

But the fact is, many post office employees are not happy either. Like doctors, they feel hampered by regulation; like doctors, they often find themselves drowning in paperwork. Every one of them sees inefficiencies they have to live with because the system doesn’t provide easy ways to correct or eliminate them.

Why should medicine be different? Because doctors are smart? Not smart enough, it seems, to avoid a field thoroughly transmogrified by government regulations. Because health is important? So are sanitation and communication. Epidemiology tells us improvements in the former account for a significant increase in longevity in the last century, and communication is so important we have essentially eliminated much of the post office’s work by a technological fix the government doesn’t control: email.

If doctors and patients want better health care, there’s an easy way to achieve it. Doctors have to start working only for patients, and patients have to start paying doctors for their services.

Granted, it’s not quite as simple as it sounds. Here are two quick difficulties:

•  Doctors are trapped in a system that likely overtrains them. This lowers supply and maintains a high physician income. That could change over time as people refuse the high fees, but only to the detriment of doctors already out of training.

•  Doctors have to operate on patients in hospitals or surgicenters, and both are highly regulated by state and federal governments, making efficient and cost-effective service more challenging.

But the first step is clear: Don’t expect good quality service from a government employee. And don’t expect, if you are a government employee, to be able to provide good quality service.