Second Opinion: Too Many Doctors? Hardly.

November 15, 2006

Our new column gives physicians a voice. This issue: Why economics is ruining healthcare and what to do about it.


In its article "Too Many Doctors in the House?" I believe Physicians Practice missed several essential points about physician supply and quality of care.

First, over the past 40 years or so, there has been a concerted effort to reduce the value of physicians in society. The public has stopped seeing the doctor as a caregiver and an asset to the community. Rather, we have become mere providers of services. Procedures that once were the exclusive domain of the doctor have been "farmed out" to ancillary personnel, who are less extensively trained and, in general, less qualified. This shifts the role of caregiving to nonphysicians, and shifts the role of the physician to supervisor. In doing this, the need for physicians is reduced for the sole purpose of saving money. As the public accepts service from lesser-qualified personnel, payment for these services can be reduced because nonphysicians are supplying them. And while this does save money, what is the cost in terms of quality of care?

How has the public come to view the modern doctor? Look at media portrayal of physicians. Television programs portray doctors as either foolish, incompetent, or outright greedy. Newspaper articles about alleged incompetence and medicine rife with mistakes are specifically designed to portray doctors as error-prone and, therefore, less valuable than they used to be. Unfortunately, we have not helped our case with internecine warfare in the rush to supply patients with services that are outside the domain of insurance control (such as cosmetic procedures). However, this lattermost issue results from physicians' earnings being affected by the insurance industry.

Medicine is undergoing a dangerous transformation, and it is due to the economics of healthcare. Whereas in the past, medicine was controlled by those who understood medicine, now it is controlled by those who know economics. Cutting reimbursement levels for physicians is exactly contrary to the spirit of quality patient care.

As physician reimbursement levels decline, two factors come into play.

First, physicians will need to see more patients within a set timeframe, reducing the quality of the experience for both doctor and patient. More tests will need to be scheduled, as the time necessary for quality hands-on physical diagnosis is limited. This will increase physician-driven costs. And as time spent with individual patients declines, the risk of errors and missing essential points in medical diagnoses and care increases.

Second, as earning possibilities decline, fewer people will go into the field. With the hassles of practicing medicine (imposed by government regulation and the insurance industry), the increasing costs of practicing medicine, and the decreasing personal satisfaction in being a physician, why would anyone want to be a doctor? Those interested in earning at a level appropriate to their training would be better served looking elsewhere for a career.

This means that medicine will no longer get the best and brightest. I agree with Dr. David C. Goodman (whose New York Times column is quoted in the article) that healthcare quality "does not rise with the number of doctors." Healthcare quality rises with the quality of doctors. In order to retain the vaunted quality of American medicine, we need to attract and retain the best and brightest. Cutting salaries and reimbursement will do just the opposite.

The argument that money is limited certainly has validity until one examines how the insurance industry has become the dominant force in American medicine. By demanding reams of onerous paperwork, precertifications, documentation, clarifications, etc., and by the failure to deal in a consistent and honest manner with physicians, the industry has driven skyrocketing costs. They have placed layer upon layer of personnel between the physician and the reimbursement entity. I cannot fathom how this ever-increasing bureaucracy can decrease costs. Increasing personnel increases costs.

As further evidence of the perfidy of the insurance industry, I offer the following:

Recently the Los Angeles Times reported that insurers are looking overseas to beat U.S. health costs, and they are willing to fly a patient to another country for surgery, then split the cost savings between the insurer and the patient.

And in the hospital where I work the DaVinci robotic surgery process is proceeding apace. Let's take an imaginative scenario. In the DaVinci system, the surgeon need not be in the same room as the patient. Well, if not in the same room, why bother even being in the same hospital? Or the same city? Or the same country? When you combine robotic surgery with the industry outsourcing of care, is it a far stretch to image a surgical procedure performed by someone overseas who has submitted a low-ball bid to perform the surgery? If the insurance industry has any say in this matter (which we all know they do), this scenario is not only likely, but highly probable. The only variable is not if they will do this, but when.

I do not pretend to have all the answers. This is a complex issue. But allowing control pass out of the hands of those who know medicine best was a terrible error. I would have one recommendation: As physicians, we should all resign from participation in insurance plans. Significant amount of paperwork can be eliminated, allowing the insurance entities to reduce their staffs and payroll. Perhaps then we can refocus on what is really important in American medicine: providing quality care to our patients.

David Wishnew, MD, PA, is a plastic and reconstructive surgeon who lives and practices in Austin, Texas. He has been chosen by his colleagues one of Texas' "Super Doctors" for the past three years.

This article originally appeared in the November/December 2006 issue of Physicians Practice.