A Former Practitioners Reflections On Health Care Reform

Tuesday, April 9, 2013 // Uncategorized


  • The Wall Street Journal
  • April 7, 2013, 6:12 p.m. ET

Reflections of a Medical Ex-Practitioner

The glow of the personal relationship with patients is being extinguished.



A fundamental principle in medicine is that if you get the diagnosis wrong, you’ll probably apply the wrong therapy. A corollary is that if the therapy isn’t working, increasing the dose may make things worse. That’s where we are with ObamaCare.

There are shortcomings aplenty in the health-care field, and changes and improvements are required. But never have I seen so many good intentions leading irreversibly to hell.

Personal experience is by its nature parochial. Yet when it invalidates much of what passes for wisdom, there may be value in sharing it. Here are some facts that may illuminate:

When I graduated from medical school in 1962, the profession of medicine was for many graduates an opportunity to provide care—as distinguished from, though aligned with, treatment—and to provide it to individuals, not to populations or governmentally specified groups. Young doctors hoped to establish an independent business, enjoy lifelong intellectual excitement as knowledge and therapies expanded, and have an income sufficient to live decently and support a family. There have always been some who entered medicine, as with any vocation, to maximize income. Yet most of us who came into the profession in the early 1960s had modest financial aspirations and substantial social commitment.

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After eight years of postgraduate study, I opened a solo pediatrics practice in a community of 10,000 souls an hour from Boston. A number of lean years passed before I could build a robust practice. Yet the experience was exactly what I—and I think many of my colleagues—sought: a personal, direct and unimpeded relationship between me and those who chose to become my patients.

A major cause of financial stringency was that there was almost no insurance that covered pediatric care in the office setting. Many pediatricians felt denigrated because the care that they were providing was not regarded as sufficiently consequential to be covered by third parties, as was that of their brethren in internal medicine. Surveys always showed pediatricians to be the poorest-paid of all the specialties.

By current standards, the lack of third-party coverage would be impermissible. But treating patients without insurance meant that I had to give my acute attention to the price of every medical intervention. The costs could have a direct and painful impact on a family’s budget. So I had to know the prices for most of the medications I prescribed and of most of the tests I might order. I learned to play for time by waiting, when it was safe to, before ordering an X-ray or a test—and to substitute less-expensive medications for more costly ones wherever possible.

Chad Crowe

I developed pastimes that were diverting but would permit me to be available to patients 24-7, requiring coverage by a substitute only for a two-week vacation annually. Few physicians nowadays would undertake such an onerous schedule, and yet many of the inconveniences are offset by benefits. If you are caring for your own patients, you know them and their ailments and can manage a great deal over the telephone (or by email these days), with minimal cost to them and minimal intrusion into your own life. By contrast, covering for another physician almost invariably means inefficiency—additional time to learn the patients’ relevant history, and often either a direct patient encounter or an outpatient facility visit, all of which greatly add to the cost.

Then, in the mid-1970s, things changed, and we became enlightened. Third parties, typically the insurance companies, were interpolated between the physician and the patient. Some of the consequences were unfortunate.

Patients knew that any suggestions I might make would have negligible consequences for their own budgets, so “more” became the expectation. A sense of entitlement developed. Why would the doctor hesitate to do some procedure, or hesitate to request a test? Everything was already paid for. If I was reluctant, perhaps weighing the cost to them, patients speculated there must be some hidden reason. Perhaps I was, in some obscure way, feathering my own nest. Misgivings arose.

This mistrust heightened—and became rational—when “prepaid” group practices became more prevalent. Physician compensation is tied to “efficiencies,” which means reducing the outlays and costs to the group (translation: skimp where possible) and thus generating for internal distribution a larger share of the prepaid premiums.

Second opinions proliferated, upping the costs. Patients could get two opinions for the same price: near zero. I could acquire additional knowledge from the feedback of the consultant and was better positioned should some legal controversy arise. One underexamined aspect of defensive medicine is those excessive referrals to diminish responsibility.

My income rose substantially and pediatricians in general thought that they had arrived in the Promised Land. The submission of some paper to some anonymous third party would not put a dent in any patient’s grocery bills. And the consequences of profligacy disappeared, while rational income-building strategies—aka gaming the system—appeared. For instance, since telephone calls weren’t reimbursable, additional office visits, which were, supervened.

“Preventive care” became the touchstone. The concept is obvious, but the evidence for its value, and especially its potential for savings, is rarely conclusive.

Insurance relationships drove practice relationships. Patients were more likely to come to me because their insurance told them to, and more likely to leave, despite our congeniality, because their insurance required it. Thus our dealings were less personally rewarding, for my patients and for me.

When it became increasingly difficult to work according to my principles, I closed my practice, first joining a “prepaid” group for 15 years, and then leaving patient care altogether. As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one’s patients is being extinguished.

The medical economist Rashi Fein observed in 1986 that there are only three ways to limit the extravagant demand for medical care: “Inconvenience,” the practice used in the military, where one must wait interminably for care. “Rules,” the third-party approach by which layers of rules and thousands of regulations are devised, most recently in a fool’s quest to contain costs under ObamaCare. And “Price.” This last option elicits gasps and chest-clutching from bien pensants who insist that all financial impediments to care must be removed. Yet it has one incontestably beneficial attribute: It requires the physician to study the true cost and benefits of a course of action, and then to present that data to the patient. Who is better suited than the patient to assess the value to him of the proposed treatment? Kathleen Sebelius? You gotta be kidding.

There is no shortage of evidence. ObamaCare will, deliberately and by design, destroy what—while imperfect—has served very well. We have gotten to this point after years of good intentions making bad problems worse. To double down on the very therapy that has brought the system to its present sorry pass is a toe-ticket to the morgue.

Dr. Marsh now raises Christmas trees in Ipswich, Mass.


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