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Wednesday, March 24, 2010

The End of Medicine: Not With a Bang, But a Whimper

Social change can be revolutionary, sudden, and swift, but more commonly it moves at a glacial pace. Yet glaciers work great change, and great damage, given enough time.

There has been much talk of people leaving the medical profession if government further bureaucratizes health care. But the odds are great that there won’t be any dramatic job stoppage. No medical “Galt’s Gulch” will form where masses of physicians on strike will live in peace and solitude, some building cars and others mining copper, all vowing never to return to medicine until their demands are met. Such is the stuff of fiction. But the reality is much worse.

What will happen is more insidious, though over time no less damaging. There will be an increase in early retirement, as more physicians tire of their jobs. More physicians will take time off and let their practices suffer at the margin. Patients will have slightly more difficulty making appointments . . . each year . . . year after year, though never so quickly as to lead to mass complaints or a recognition that things are obviously worse.

Coverage will be shunted to physicians’ assistants, nurse practitioners, emergency department physicians, hospitalists, and partners. Fewer patients will feel they have their own doctors. This will not necessarily be worse—I don’t feel I have my own McDonald’s, yet the food remains as I expect—but it may be worse, to the extent quality of care depends on background knowledge of individuals.

The filter of who gets into medical school will change. Fewer will enter the field due to intellectual curiosity. More and more people who cannot tolerate bureaucracy will be weeded out. Questioning authority will become as dangerous in medicine as it is in policing or the military. The 40-hour physician work week, on the other hand, will become commonplace, and the type of person attracted to medicine will not be the type who is willing to work any longer, or any harder.

Health care will be less a service than a commodity. All your complaints will have answers, if not always the right answers. Workups will be standardized by “expert panels” allegedly educating physicians as to “best practices.” And if the “best practice” is to not treat you because it is not cost-effective to society, the fact that you want and are willing to pay for the treatment will be seen as a problem rather than a solution.

These panels are designed to save money by making workups more efficient and uniform, but the reality is different. More expensive imaging tests routinely substitute for less expensive physical exams because the quality of physical exams varies and doctors have little incentive to improve their own abilities at examination. Not only is it becoming something of a lost art (“Why use a stethoscope to listen for a heart murmur when we can just see it on a cardiac ultrasound exam?”), but it takes time. And since doctors are paid by third parties more concerned about efficiency than quality, taking time with patients—improving one’s diagnostic exam skills—is a luxury fewer and fewer physicians can afford.

Does this sound unbelievable? It is happening already. In the 1990s the Office of Inspector General investigated major teaching hospitals in America. Taxpayers are billed by such institutions for training new generations of physicians. PATH (Physicians at Teaching Hospitals) audits found patients in these hospitals were commonly evaluated by medical students or interns only. Attending senior physicians were fraudulently simply “signing off,” saying, “I agree,” without ever seeing the patient. The University of Pennsylvania Hospital settled a PATH dispute for $30 million, and Thomas Jefferson University Hospital did so for $12 million. Anecdotes describing such problems abound, including hospital charts saying, “Physical exam shows both pupils equally reactive to light,” when the patient had actually been blind in one eye for decades, a mistake much more easily attributable to the exam’s never having been done than to error.

Slowly and gradually community hospitals will come to resemble VA hospitals. Centers of excellence will be advocated in theory—evidence-based medicine will be the byword to “bend the cost curve downward” by eliminating “inefficiencies.” But will they really be excellent, or will they merely be better than whatever else is available? Will they be free to innovate? Will they be free to profit if their innovations are successful? Will they simply be the medical equivalents of the best cars on the road in Cuba?

Pharmaceutical innovation, produced by those evil for-profit companies that even doctors love to denounce, will drop off. Not precipitously, but eventually. And people will die, as they have died since time immemorial, without anyone ever knowing what drugs might have improved or extended their lives, if only there had been greater incentives to produce them.

As noted, imaging studies will become more important but will also become more difficult to schedule. And the quality spectrum between optimally interpreted exams and standardly interpreted exams will continue to widen. The Current Procedural Terminology (government billing) codes are the same, independent of the quality of the interpretation.

There is already a spectrum of quality available in medicine, and those with means can obtain better medical care than those without, just as O.J. Simpson was able to obtain better legal services than your average defendant—the first time. But that spectrum risks becoming more rigid, more settled. What has been, in America, health care for the poor will become health care for all but the very rich. But the cost curve will bend downward.

Or will it? Medical salaries will bend downward, certainly, but administrative costs associated with government programs are always huge, and always underestimated. Medicare spending now is an order of magnitude higher than the projections in 1965 of what it would be now. But we do know this: Bending the cost curve of medical care in either direction comes with costs.

If it’s bent downward people will wait longer for health care that is not as good as it could have been. We often buy things “not as good as they could have been,” Chryslers rather than Cadillacs, Range Rovers rather than Rolls Royces, but those choices are made at the individual level, not forced on us by “society.” And those choices are, well, choices—not a byproduct of a system we cannot control.

Or the cost curve can bend upward, perhaps due to hidden governmental administrative costs, perhaps because AARP is a strong lobby. And we’ll feel the pinch in other areas, as our debt grows, as our prosperity lags and falters and becomes a quaint piece of history we teach our children (or perhaps, in our guilt, hide from them).

We’ll pride ourselves, as we do now, on “the best health care system in the world,” even while we also brag that we have universal care, just like the great nations of Europe. And we’ll suffer with double-digit unemployment, just like the great nations of Europe. And we’ll have lower growth in productivity, just like the great nations of Europe. And we’ll have smaller houses and cars, just like the great nations of Europe. But it will be all right, because we’ll be able to wait . . . and wait . . . and wait . . . for our turn at the health care that is our right.