I recently wrote an article about the problems with our broken health care system, ending with a call for doctors to help develop solutions. In follow-up, here are some possible solutions to consider before the system self-implodes. There is concern that, without any changes, Medicare will run out of funding by 2031. Here are a few things that I think could help.
Address physician burnout
It’s real, and COVID-19 made it worse. Burnout among doctors is higher than in any other U.S. occupation studied. The American mindset needs a reset to better understand the frustrations of practicing physicians: Patients are not customers. Being healthy is hard and takes effort. There is no magic pill. Your satisfaction with your doctor should be based on their ability to educate you and help you keep yourself healthy. Making you happy and satisfied is not the goal of the physician—though keeping you healthy should make you happy and satisfied. That said, doctors should always treat you with respect and kindness because we are all human and deserve that.
The trend toward paying doctors based on patient outcomes is well-intended but poorly implemented. Doctors get rewarded when their patients do better, but in practice, these measures fail to take into account an inordinate number of uncontrolled factors—non-compliance being the biggest one. What about the doctors who take on all the complicated and most difficult cases, which from the start will have poorer outcomes? What about the fact that doctors can do everything right, but you, the patient, may still have a bad outcome? Forget the very real threat of being sued—now, we might not even get paid despite having done everything right. Again, this doesn’t happen in any other industry. Why is it OK in medicine?
Focus on quality primary care
It’s been shown that patients with low income, unemployment, and/or lack of insurance frequent the ER for non-urgent (primary care) issues more than those who are insured. Studies also demonstrate that access to primary care follow-up after ER visits for higher-risk populations reduces the rate of return visits to the ER. Those most at-risk patients do benefit from such access to care—and so does the system economically. Some studies even show that simply having nurses call and check on patients who were in the ER and discharged decreased their return visits, as well as the overall cost to the system. The same principle can be applied to reduce overall costs while simultaneously providing a minimum of basic health coverage.
In 2018, only 7 percent of men and 8 percent of women received the recommended preventive services. We already know that getting preventive care reduces overall costs to the health care system and even saves lives. So promoting and improving access to such care seems to be a no-brainer to this physician. An excellent way to ensure that is to provide some basic level of private or government-funded universal coverage. Yes, I said those words; please don’t hate me.
Use evidence-based medicine and common sense for smart spending
Elective procedures
In a system that has to limit resource expenditures to continue functioning, we must stop spending exorbitant amounts on arguably controversial and elective procedures. Fertility is a great example, which gets very personal very quickly. To what lengths do we go to achieve a person’s fertility? For example, consider uterine transplants. The idea is amazing, and the implementation is an incredible feat of medical science—but at what cost? Where does it end, ethically? Currently, the majority of fertility treatments are not covered by insurance, but some are. In fact, it’s becoming a common legislative agenda, with 19 states (and counting) having laws regarding such coverage. While this is clearly a popular idea and therefore supported by politicians, is it the right thing for the economic well-being of our health care system? The plain and simple answer is no.
Fertility procedures are elective and, therefore, economically similar to plastic surgery. You can do it, but you need to pay for it. For a sustainable system, paying for exorbitant fertility treatments is just not feasible. In my opinion, it’s also not ethical or moral to help pay for fertility treatments for some while others do not even have the bare minimum of basic health care coverage. I will add that in the U.S., one cycle of assisted reproductive treatment costs $15-30K, which definitely limits access. This is not fair for an economically challenged individual dealing with endometriosis or worse. But we have to make hard choices and cannot continue to increase coverage for elective, controversial, and exorbitant therapies. Also note: similar fertility treatments in other countries range from $2,750 to $6,200. If we didn’t have such a flawed system with respect to inflated prices, many more would have the ability to consider these treatments as a feasible option.
Advanced practitioners
The current health care system keeps pushing to get more for less—or at least the same for less. I argue that this system is dominated by insurance and drug company CEOs and business-minded health administrators, all people highly motivated by profit. Health administrators do need to be business-minded, but all persons in health care, including doctors, have to be in order to keep their hospitals and practices up and running. So they hire CRNAs (certified nurse anesthetists) instead of anesthesiologists and PAs and APRNs in place of doctors. CRNAs, PAs, APRNs, and all mid-level practitioners—which can be an offensive term, so rather, all “advanced practitioners”—are a vital component of the expanding needs of our health care system. But trying to expand the scope of advanced practitioner care is not the answer. Don’t get me wrong: I relied on those experienced floor nurses and my wonderful advanced practitioners when I was an intern and resident, but I was still in residency—training. I also had upper-level resident supervision and attending doctor instruction, and both were there to answer any and all of my questions and correct me where I may have strayed. Even after four years of college and four years of medical school, earning our official doctor of medicine title, we aren’t ready to practice medicine on our own—and we know it. And don’t even get me started on the Doctor of Nursing/Doctor of Nurse Practice and the confusion calling them “doctor” will bring. Let me just point out that after residency, a physician has accrued a minimum of 20,000 hours of clinical experience, while a DNP only needs 1,000 patient contact hours to graduate and start practicing on their own. Which one of those do you want to take care of you?
What does it mean for our health care system when we replace doctors with practitioners with less training? And, more importantly, for our patients? It means the initial bottom line of salaries for practitioners is lower. However, it’s also been shown that advanced practitioners tend to order more unnecessary exams and miss more diagnoses than physicians. Ultimately, missed and/or delayed diagnoses add to the economic burden of the system—not to mention the morbidity and possibly mortality of patients. Please use these advanced practitioners to increase access, but they must still have supervision from those with more experience. Those supervising them need to be compensated for that because it’s the supervising physician who is still ultimately responsible for the patient, especially when something goes wrong. This is an area where the administrators take advantage of employed physicians; they tell doctors they will now be the supervising physician for advanced practitioners, which was not at all part of their original job description, leaving them with all the responsibility without any benefit. Such doctors have little or no ability to negotiate that request—or rather, demand. See “Address Physician Burnout” above.
Remove the politics and middlemen from health care
That’s a Herculean task, but first, start by eliminating health care money in politics. Get exorbitant profits out of the health care system. The ACA was full of good intentions to try to regulate those skewed motivations (ensuring coverage of pre-existing conditions, which we all love!), but the implementation was awful. It became so politically charged and associated with an individual that people started calling it “Obamacare.”
Look at where we are today.
In 2023, Kaiser Permanente, United Health Group, and Blue Cross Blue Shield gave about $6 million, $10 million, and $28 million, respectively, in annual lobbying efforts employing over 10, 60, and 135 lobbyists, according to the Center for Responsive Politics. Those amounts have more than tripled in the past 25 years. Meanwhile, the American Medical Association (certainly not the only organization representing physicians, but one of the most prominent) gave about $21 million in 2023, employing 65 lobbyists. They gave a bit more than that in 2007, so have a relatively flat curve without any appreciable increase in the past 25 years. That money is coming directly out of doctors’ pockets/contributions. Insurance companies give their (really our) money to both Republicans and Democrats in order to influence policy. The pharmaceutical and health product industry spent $4.7 billion from 1999–2018—averaging $233 million per year—on lobbying the U.S. federal government, targeting senior legislators in Congress involved in drafting health care laws as well as state committees participating in drug pricing and regulation.
Prescription Justice is a non-partisan, non-profit organization with the goal of supporting policies that work to bring drug prices down. They also rank and judge politicians on the money they accept and the job they’ve done in working towards that goal. If you exclude presidential candidates, the top 9/10 politicians who accepted the most money from a pharmaceutical company received a D or F on their grading system. That money is successfully working to keep prices high. We all need to look into our own representatives’ records and stop voting for or supporting candidates who impede progress. Or consider banning or further regulating political contributions from these massive, for-profit organizations in the first place. Call, write, and visit your representatives and start holding them accountable.
Remove the complexity of billing. It shouldn’t take hiring a whole separate company for a doctor to bill and get paid for services. Remove the ease of and/or limit denials—punish denials when accurate documentation already exists and/or they are flagrantly implemented. This would also simultaneously eliminate some of the jobs required in mid-level insurance and administration—which is a good thing from our health care system standpoint. Ban or at least put some limits on advertising to laypersons. Eliminate the need for drug representatives by changing the way doctors learn about drugs. Incorporate new drug information as CME; this would allow learning of medications based on their efficacy and not be dependent on the looks and personality of their representatives. Our health care system does not need the burden of salespersons.
Despite the controversy, mandating insurance coverage seems to be a necessary component of a fiscally responsible, economically sustainable health care system. I personally do not understand the objection to this idea—other than the knee-jerk “liberty/don’t tell me what to do” notion. We all agree to certain limitations of our freedoms to live in a civil, functional, and orderly society. You have to buy insurance if you are going to own and drive a car. Where’s the outrage for that? To buy and drive a car is something you can choose to do. What you don’t choose to do is get in an accident, and that’s why you have to buy insurance. So when you get in an accident, you can usually afford to get your car fixed. Health care and our access to it—other than for preventive care, which accounts for about 6 percent of our overall spending—is never chosen nor something for which you’ve planned. You don’t plan on needing to go to the ER after that car accident. But you will still go and receive the care. You don’t plan to get cancer, but you will still utilize a huge amount of health care resources fighting to cure it. One more argument against basic universal coverage is about the long wait times it would potentially lead to in order to see a doctor—or especially a specialist. Sorry to break it to you; we are already there. Our inability to increase the number of doctors trained as our population increases has contributed to massive doctor shortages—which leads to longer wait times. So, long and short, everyone needs to pay something for the basic right—or call it a privilege—of health insurance.
Summary
I don’t have all the answers, and these “solutions” are sure to have significant objections. But the goal of the system needs to be the health and welfare of patients, which is almost uniformly the goal of all physicians practicing medicine. As I’ve stated before, physicians should not only be at the table of discussions regarding health care but leading the inception and implementation of the solutions. Why aren’t we? In part because we are too busy taking care of our patients to spend the time and money to educate and influence politicians. But politicians need to step aside and defer to those actually in medicine for solutions. As doctors, we also fight about the politics of medicine, but at the end of the day, patient care is what unites us—not getting re-elected. Let doctors help lead the way.
Alisa Berger is a urologist.
