“Will the Doctor See You?” More on the Crapification of US Medical Care

Yves here. The original headline at KFF Health News, “When Will the Doctor See You?” underplays the severity of the hollowing out of US health care. KFF has been writing from time to time of the shortfall in US primary care practitioners, with a recent piece on how rural communities entirely without a generalist MD are being served by osteopaths. Mind you, osteopaths have many of the skills of regular doctors, but they are less likely to have a good network for specialist referrals, particularly at tertiary care hospitals.

This article starts with how difficult it is to get good primary care doctors, and how many patients are losing them due to their former MD going to a concierge practice, or having their practice acquired by a bigger group (which means the patient is no longer assured of getting that doctor), or of being relegated to a nurse practitioner.

Now if you are young and/or basically healthy, this sort of downgrading of service might not seem so terrible. But the placebo effect is powerful in medicine. A revolving door of medical staffers will not engender patient trust and could also cause confusion (different doctors might use different language to describe the same condition). Trading trust for profits will lead to worse outcomes on average.

In addition to psychology, there’s considerable diagnostic value in having one person see the same patient over time. He will know if the patient over-reports or under-reports the seriousness of issues. He’ll learn if the patient really takes good care of himself (claims are often exaggerated). He will be in a position to recognize subtler symptoms, like irritability or loss of muscle mass or skin elasticity that could point to ailments.

By Julie Appleby, KFF Health News Senior Correspondent, who previously spent 10 years covering the health industry and policy at USA Today and also worked at the San Francisco Chronicle and the Contra Costa Times in Walnut Creek, California and Michelle Andrews is a contributing writer and former columnist for KFF Health News and whose work has appeared frequently in The New York Times, and also in Money, Fortune Small Business, National Geographic and Women’s Health magazines, among others. Originally published at KFF Health News

Lucia Agajanian, a 25-year-old freelance film producer in Chicago, doesn’t have a specific primary care doctor, preferring the convenience of visiting a local clinic for flu shots or going online for video visits. “You say what you need, and there’s a 15-minute wait time,” she said, explaining how her appointments usually work. “I really liked that.”

But Olga Lucia Torres, a 52-year-old who teaches narrative medicine classes at Columbia University in New York, misses her longtime primary care doctor, who kept tabs for two decades on her conditions, including lupus and rheumatoid arthritis, and made sure she was up to date on vaccines and screening tests. Two years ago, Torres received a letter informing her that he was changing to a “boutique practice” and would charge a retainer fee of $10,000 for her to stay on as a patient.

“I felt really sad and abandoned,” Torres said. “This was my PCP. I was like, ‘Dude, I thought we were in this together!’”

The two women reflect an ongoing reality: The primary care landscape is changing in ways that could shape patients’ access and quality of care now and for decades to come. A solid and enduring relationship with a primary care doctor — who knows a patient’s history and can monitor new problems — has long been regarded as the bedrock of a quality health care system. But investment in primary care in the U.S. lags that of other high-income countries, and America has a smaller share of primary care physicians than most of its European counterparts.

An estimated one-third of all physicians in the U.S. are primary care doctors — who include family medicine physicians, general internists, and pediatricians — according to the Robert Graham Center, a research and analysis organization that studies primary care. Other researchers say the numbers are lower, with the Peterson-KFF Health System Tracker reporting only 12% of U.S. doctors are generalists, compared with 23% in Germany and as many as 45% in the Netherlands.

That means it’s often hard to find a doctor and make an appointment that’s not weeks or months away.

“This is a problem that has been simmering and now beginning to erupt in some communities at a boil. It’s hard to find that front door of the health system,” said Ann Greiner, president and CEO of the Primary Care Collaborative, a nonprofit membership organization.

Today, a smaller percentage of physicians are entering the field than are practicing, suggesting that shortages will worsen over time.

Interest has waned partly because, in the U.S., primary care yields lower salaries than other medical and surgical specialties.

Some doctors now in practice also say they are burned out, facing cumbersome electronic health record systems and limits on appointment times, making it harder to get to know a patient and establish a relationship.

Others are retiring or selling their practices. Hospitals, insurers like Aetna-CVS Health, and other corporate entities like Amazon are on a buying spree, snapping up primary care practices, furthering a move away from the “Marcus Welby, M.D.”-style neighborhood doctor. About 48% of primary care physicians currently work in practices they do not own. Two-thirds of those doctors don’t work for other physicians but are employed by private equity investors or other corporate entities, according to data in the “Primary Care Chartbook,” which is collected and published by the Graham Center.

Patients who seek care at these offices may not be seen by the same doctor at every visit. Indeed, they may not be seen by a doctor at all but by a paraprofessional — a nurse practitioner or a physician assistant, for instance — who works under the doctor’s license. That trend has been accelerated by new state laws — as well as changes in Medicare policy — that loosen the requirements for physician supervisors and billing. And these jobs are expected to be among the decade’s fastest-growing in the health sector.

Overall, demand for primary care is up, spurred partly by record enrollment in Affordable Care Act plans. All those new patients, combined with the low supply of doctors, are contributing to a years-long downward trend in the number of people reporting they have a usual source of care, be it an individual doctor or a specific clinic or practice.

Researchers say that raises questions, including whether people can’t find a primary care doctor, can’t afford one, or simply no longer want an established relationship.

“Is it poor access or problems with the supply of providers? Does it reflect a societal disconnection, a go-it-alone phenomenon?” asked Christopher Koller, president of the Milbank Memorial Fund, a foundation whose nonpartisan analyses focus on state health policy.

For patients, frustrating wait times are one result. A recent survey by a physician staffing firm found it now takes an average of 21 days just to get in to see a doctor of family medicine, defined as a subgroup of primary care, which includes general internists and pediatricians. Those physicians are many patients’ first stop for health care. That runs counter to the trend in other countries, where patients complain of months- or years-long waits for elective procedures like hip replacements but generally experience short waits for primary care visits.

Another complication: All these factors are adding urgency to ongoing concerns about attracting new primary care physicians to the specialty.

When she was in medical school, Natalie A. Cameron said, she specifically chose primary care because she enjoyed forming relationships with patients and because “I’m specifically interested in prevention and women’s health, and you do a lot of that in primary care.” The 33-year-old is currently an instructor of medicine at Northwestern University, where she also sees patients at a primary care practice.

Still, she understands why many of her colleagues chose something else. For some, it’s the pay differential. For others, it’s because of primary care’s reputation for involving “a lot of care and paperwork and coordinating a lot of issues that may not just be medical,” Cameron said.

The million-dollar question, then, is how much does having a usual source of care influence medical outcomes and cost? And for which kinds of patients is having a close relationship with a doctor important? While studies show that many young people value the convenience of visiting urgent care — especially when it takes so long to see a primary care doctor — will their long-term health suffer because of that strategy?

Many patients — particularly the young and generally healthy ones — shrug at the new normal, embracing alternatives that require less waiting. These options are particularly attractive to millennials, who tell focus groups that the convenience of a one-off video call or visit to a big-box store clinic trumps a long-standing relationship with a doctor, especially if they have to wait days, weeks, or longer for a traditional appointment.

“The doctor I have is a family friend, but definitely I would take access and ease over a relationship,” said Matt Degn, 24, who says it can take two to three months to book a routine appointment in Salt Lake City, where he lives.

Patients are increasingly turning to what are dubbed “retail clinics,” such as CVS’ Minute Clinics, which tout “in-person and virtual care 7 days a week.” CVS Health’s more than 1,000 clinics inside stores across the U.S. treated more than 5 million people last year, Creagh Milford, a physician and the company’s senior vice president of retail health, said in a written statement. He cited a recent study by a data products firm showing the use of retail clinics has grown 200% over the past five years.

Health policy experts say increased access to alternatives can be good, but forgoing an ongoing relationship to a regular provider is not, especially as people get older and are more likely to develop chronic conditions or other medical problems.

“There’s a lot of data that show communities with a lot of primary care have better health,” said Koller.

People with a regular primary care doctor or practice are more likely to get preventive care, such as cancer screenings or flu shots, studies show, and are less likely to die if they do suffer a heart attack.

Physicians who see patients regularly are better able to spot patterns of seemingly minor concerns that could add up to a serious health issue.

“What happens when you go to four different providers on four platforms for urinary tract infections because, well, they are just UTIs,” posed Yalda Jabbarpour, a family physician practicing in Washington, D.C., and the director of the Robert Graham Center for Policy Studies. “But actually, you have a large kidney stone that’s causing your UTI or have some sort of immune deficiency like diabetes that’s causing frequent UTIs. But no one tested you.”

Most experts agree that figuring out how to coordinate care amid this changing landscape and make it more accessible without undermining quality — even when different doctors, locations, health systems, and electronic health records are involved — will be as complex as the pressures causing long waits and less interest in today’s primary care market.

And experiences sometimes lead patients to change their minds.

There’s something to be said for establishing a relationship, said Agajanian, in Chicago. She’s rethinking her decision to cobble together care, rather than have a specific primary care doctor or clinic, following an injury at work last year that led to shoulder surgery.

“As I’m getting older, even though I’m still young,” she said, “I have all these problems with my body, and it would be nice to have a consistent person who knows all my problems to talk with.”

KFF Health News’ Colleen DeGuzman contributed to this report.

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  1. John R Moffett

    The system is so broken that I don’t see how they can fix it. I am in biomedical research, and ever since the 1990s, there has been a major shift away from doing science to a focus solely on drug development. But you don’t get a healthy population by giving people lots of pills and injections. If there was any concern for actual health, you would focus on diet, exercise, getting toxins out of the food and water and making sure people have clean air to breath. Preventing infections, especially in hospitals, would involve well documented improvements in ventilation, filtration and masking. Maybe the ventilation and filtration lobbies need to spend more time lobbying congress.

    1. Stephen

      I very much agree.

      There is a clearly a place for medicines but within the context of a holistic approach to health that focuses on the whole patient. This is rather than just the mechanism of: specific symptom, specific illness related to that symptom, take this medicine. Often times such a model misses root causes.

      The British approach, of course, is very broken too. In my youth one tended to see a specific general practitioner within the context of a group practice. Doctors were well known by name as members of the community. Today, the whole system has become similarly impersonal as the situation being described here. Being a GP cannot be a very satisfying job for these reasons either.

    2. Louis Fyne

      Allegory about American tone deafness re. prevention…..

      so the Canadian wildfire PM2.5 soot rolled in. Checked my air purifier and Corsi box filters. Just one week of running the Corsi box and those filters look worse than the furnace filters that are 3 months old.

      When there is a mere threat of the blizzard, the local news channels go into a coverage frenzy. With the wildfire pollution, lots of footage of the hazy skies, but no mention of Corsi boxes, or masks, or prevention-mitigation.

      This is with PM2.5 readings that are as bad or worse than the worst days in Asia.

      People who were mask-hardliners during Covid have zero concept that, ya, mask can help with PM2.5 too.

    3. DorothyT

      It’s chilling to read that doctors are fleeing the traditional medical system for ‘concierge’ practice. This is private equity/PE.

      I’m interested in the language used for issues regarding private equity. PE sounds rather ‘upper class.’ We need to include (not replace) language that people relate to on gov. healthcare and related private supplements, employer-provided (including employee mandatory contributions), as well as private health insurance. Also, people who aren’t insured at all but receive extraordinary bills and even legal recourse by providers when they can’t pay (foreclosures, payroll deductions, etc.). Non-healthcare issues (tuition, credit cards, paycheck loans, etc.) are included among these issues also. Before incurring their ‘debt’ they have no idea of the facts to which they are ‘made liable’. Think homelessness.

      Even employer-employee and private health insurance can include PE, which is only discovered when the ‘insured’ gets an unexpected out-of-network bill. This is all the more ominous when the users of such private services (healthcare and other) aren’t able to ascertain what services fall under this umbrella before they ‘use’ them.

      Even under Medicare, Medicaid, ’employer-provided’ healthcare and other services related to healthcare (or not), it is impossible — not required by law — to discover ahead of usage if they will be covered.

      1. Rubicon

        Here’s a basic textbook definition of a:
        “Private equity, in a nutshell, is the investment of equity capital in private companies. In a typical private equity deal, an investor buys a stake in a private company with the hope of ultimately realising an increase in the value of that stake.”

        It’s similar to buying stock or bonds. Translation: a financial firm that would love to take your money and invest into…..in this case “private equities.” They love selling those, because they make profit off of you.

    4. Jason Boxman

      If there was any concern for actual health, you would focus on diet, exercise, getting toxins out of the food and water and making sure people have clean air to breath. Preventing infections, especially in hospitals, would involve well documented improvements in ventilation, filtration and masking.

      Yep. Public health. But there’s no monies in that, so we can’t have that!

  2. ambrit

    Under the rubric of Garbage In Garbage Out (GIGO) the ‘quality’ of the health care delivered depends on the primary motivations of the “providers.”
    As with everything else over the last decades, the progression from “Family Doctor” to ‘Healthcare Provider’ with the attendant degradation of overall outcomes is predictable once the Venture Capitalists become involved.
    When you make Money your G–, it becomes a very jealous one. Soon, the G– crowds out all but it’s proprietary benefits. The ‘patients’ become ‘financial resource units.’ The individual is thus demoted from ‘Person’ to ‘Object.’ There are many cases throughout history where that simple change in focus begets dire outcomes.
    It would not be out of line for me to cite the late Third Reich and it’s notorious treatments of it’s “lesser” populations. Certain classes of people were demonized and subsequently exterminated.
    There was a film made during WW-2 by the Reich’s Ministry of Propaganda that extolled the virtues of euthanasia. It was, as reported by viewers of the film, a well made and Hollywood quality production. It’s purpose was to calm the fears of those who worked at the killing centres attached to the various camps. Just like politics today in America, the Reich’s functionaries decided that, rather than question the evil practices being promoted, all they needed was better “messaging.”
    See: https://en.wikipedia.org/wiki/Ich_klage_an
    I fully expect to see in the near to medium term future a “lively debate” about how to apportion the increasingly “scarce” medical resources in our society. All the signs point in that direction.
    I wish I was wrong, but our recent experiences relating to the Coronavirus Pandemic tend to support my theory. Money, the G– of the Neo-liberals has been prioritized above the Public’s Health. It is all downhill from here.
    Stay safe all.

      1. NoFreeWill

        Moloch was actually a super chill Semitic sun god, bible/torah just totally made up the child sacrifice thing to make their enemies look bad, so much propaganda in the Bible gets treated as historical fact simply because it’s the only written source on certain things.

    1. JBird4049

      There was a film made during WW-2 by the Reich’s Ministry of Propaganda that extolled the virtues of euthanasia. It was, as reported by viewers of the film, a well made and Hollywood quality production. It’s purpose was to calm the fears of those who worked at the killing centres attached to the various camps. Just like politics today in America, the Reich’s functionaries decided that, rather than question the evil practices being promoted, all they needed was better “messaging.”

      Like Triumph of the Will? A really cool, and therefore a really disquieting film, which seems to be an underground favorite of our elites and their propagandists. Some of the current propaganda on Covid seems to be modeled on the propaganda for the Nazis’ Aktion T4. I am told that the Nazis lost the war, but sometimes it appears that they lost the battle, but not the war.

      1. ambrit

        I remember seeing “Triumph of the Will” presented as a teaching tool for an Advertising class in university. A lot of us sat in on that class to see the film. This was way before YouTube and the Internet in general. It was shown as an example of Propaganda, which is basically “official” advertising, done right.
        The film about euthanasia I mentioned is called “Ich klage an.”
        See: https://en.wikipedia.org/wiki/Ich_klage_an
        It was produced particularly to calm the misgivings of medical personnel about “euthanizing” the deplorables of that day.
        There is also the pre war short subject, “Das Erbe,” which promotes racial purity as a State policy.
        See: https://en.wikipedia.org/wiki/Das_Erbe
        How do you “promote” racial purity? You “eliminate” the transgressive genes.
        Eugenics is generally promoted as a science based endeavour. The truth is that such programs are always political in nature. This is unavoidable when Terran humans are involved.
        Some days I think that we deserve to go extinct. But then, that is me playing G–. Such is way above my pay grade.

        1. The Rev Kev

          We live in an Age of Science – or are supposed to do. So that is why such things are justified by “science-based” reasoning. That is how we got to be cool with war crimes. But if next century we found ourselves in an Age of Religion, then you can bet that priests will be the ones promoting such ideas for religious purity and “religious-based” reasoning. We don’t deserve to go extinct – but the people that always push for such ideas definitely do. In the meantime we should listen to the better angels of our nature.

  3. Dr. John Carpenter

    This is very relevant to me. I had to make an appointment yesterday for an issue I am having now. Next available appointment? August 30th. Absolutely ridiculous.

    1. LilD

      Just this morning…
      My wife who had a ruptured appendix last year and major surgery plus issues, recovering slowly but recovering
      Scheduled for a follow up appointment with her gp next month
      Got a call, “Dr. XXXX is leaving the practice, we have to reschedule you for December with Dr. YYYY who just joined the group.”
      The surgeon is responsive (70 year old Hungarian, old school…) and has influence with local practice groups, so we will be able to get something for August with someone else who knows nothing about the case…
      And another well regarded GP just left the PE owned practice for her own concierge service, similarly requiring current patients to pay a retainer to remain her patients. She is not fully comfortable with that path but explained (over drinks at our tennis club, not in a professional setting) that she was no longer able to provide adequate care following the rules of her practice group. Expects to have fewer patients and be able to provide quality care, but needed to get out of the insurance business to get back to the medical business.

  4. Gregorio

    Here in Mexico where I live, the accessibility and quality of the medical care is phenomenal, I can usually get an appointment with my primary care physician or a specialist within one or two days, and often the same day. I can call my doctors directly or message them on WhatsApp if I have any questions or issues, and they will typically respond within an hour. If a test or procedure is warranted, like an ultra-sound, they will perform it as part of the regular office visit without having to schedule a separate appointment, if any lab tests will be necessary, they will have me go to the lab before the office visit, to facilitate the diagnosis. The best thing is that they spend way more time with their patients than I have ever experienced in the U.S., it’s not unusual to be in front of the doctor for 30-45 minutes during a regular visit. So far, after living here more than 30 years, I have had very good luck with the medical care system keeping me healthy. When I turned 65, I thought that I would take advantage of being eligible for Medicare, but I quickly found that it is much better for my health and sanity to pay for my own care here, than to deal with the health care merry-go-round up in the states.

    1. juno mas

      Medicare requires US based medical treatment. Opting out of Medicare, a program a US worker pays for over their work lifetime, is enervating.

      1. Yves Smith Post author

        No, it isn’t.

        You don’t lose Medicare A regardless. So it’s potentially losing B and D.

        If you are not a resident of the US AND buy insurance in your country of residence, you can re-join Medicare B and I am pretty sure D (but check!!!) with no penalty

    2. JonnyJames

      Gregorio: if millions of gringos found out about this, Mexico would have to build a wall to keep them out. Or maybe the wall the US built is to keep US denizens from escaping? (only half-joking)

      1. ArcadiaMommy

        Our family vacations in puerto penasco (four hours from Phoenix) and there are bus loads of people getting dental and medical treatment and prescriptions.

        Many of the offices are very fancy and modern in a very small, rustic town.

      2. Gregorio

        Gringos are invading Mexico at what seems like an exponential rate. When we moved here in our 30s we were kind of an anomaly because most of the expatriates who lived here were retired folks looking to stretch their retirement savings, now it’s mainly wealthy and semi wealthy 30-50 year olds taking advantage of the ability to work remotely. They are driving a wave of uber-gentrification, with property values quadrupling here over the last 5 years. One disturbing new trend is people using helicopters to shop for real estate.

    3. Rubicon

      I’ve informed my West European friends about US health care along with the costs of being double covered under insurance.
      They keep telling me, “If you become sick, fly to Mexico.” The health care is much, much cheaper and better quality.”
      We’ve known of thousands of Americans who have flown there, simply because US Health Care is operated and managed by Multi-millionaires/Billionaires: whether they’re part of Private Equities, or Hedge Funds, Mexico is NOT!

  5. ksw

    “Mind you, osteopaths have many of the skills of regular doctors, but they are less likely to have a good network for specialist referrals, particularly at tertiary care hospitals.” Simply not true. In some communities, osteopaths are associated with hospital chains such as Adventists in Orlando area. In the 1930s, the AMA waged a war on osteopaths and pushed to close down nearly a third of their medical schools. Today, the two coexist.

    1. Brunches with Cats

      Thank you! One of the best medical doctors I had at the VA was an osteopath — and he was only a resident. He took the time, he listened attentively, heard and understood the problems I was having getting the care I needed, actually read the EHR notes (astonishing how many others didn’t bother), and, consequently, found the solution that eluded others. Sadly for me when his residency was complete, he left the VA, for one of those osteopath-centered hospitals you mention. I’m pretty sure it had to do with his values — exactly what we say we want from our doctors. Although the VA has some very competent, caring and compassionate providers, the system makes it so hard for them to survive that many leave. Not that this is unique to the VA; we’ve all read about the travails of IM Doc.

      Anyway, adding my voice of support for osteopaths. I was happy to read the earlier post about how there were more of them on the way.

    2. Yves Smith Post author

      I can tell you that in practice, that’s not true. A blind referral to a hospital chain is not remotely the same as a referral by an MD to a particular specialist he knows and regards well. MDs will be in the loop of MD information about the caliber of various specialists. An osteopath won’t be.

      I can tell you that with absolute certainty with respect to the osteopath I used in NYC, admittedly while also having a regular PCP. He never would have been able to get me to the guy who did my hips, which were difficult due to how long I had waited to get the procedure and my oddball structure (he had to model 100 parts, wasn’t happy with any, and used a cemented replacement that he modified slightly).

      Similarly when I had my other procedure, my very good OB/GYN (I had avoided seeing them because most are not interested in women who are not having babies and give cookie cutter advice, but I have a friend who is pretty demanding about her MDs who had had found a good one) referred me to a great surgeon for a recent outpatient procedure. Very happy with her. And had interviewed other candidates who sucked.

      1. Brunches with Cats

        The hospital where the DO resident at the VA I mentioned above isn’t a large chain, but one of three hospitals operated by nonprofit Garnet Health in a tri-county area northwest of NYC. Garnet also has several outpatient locations and its own doctors’ network, plus it works with a college of osteopathic medicine in Middletown.

        FWIW, osteopaths don’t just have “many of the skills of regular doctors” — they actually have more, because they have additional hours of med school for hands-on training. After four years of med school, they do residencies, same as “regular doctors,” and often have “regular doctors” as their supervisors and mentors. And, like “regular doctors,” they have to choose a specialty. While many do choose family medicine/general practice, many others become orthopedic surgeons, cardiologists, gynecologists, psychiatrists, ER docs — essentially all of the specialties of “regular doctors,” with identical training and residency and board certification requirements. And, their residencies afford them the same networking opportunities as their MD counterparts.

        According to the Association of American Medical Colleges, which tracks the percentage of DOs among active physicians in 48 different specialties, the top five are sports medicine (19.7%), family/general practice (16.4%), physical medicine and rehab (14.6%), ER care, (11.9%), and pain medicine/management (10%). Of active orthopedic surgeons, 5.9% are DOs.

        DOs are not any way “less than” MDs. In my mind, they actually are “more than,” given that their extra training makes them more attuned to all aspects of the patient, body and mind, so they’re not just treating symptoms, as “regular doctors” do.

  6. Utah

    After reading this, I feel very fortunate. I’ve never had to wait too long for a primary care visit. A few weeks for a routine checkup, and I got in the same day with my doctor when I thought I might have a kidney stone (I did, it hurt.) I’ve found that doctors will fit you in if you’re established with them.

    My problem is actually that too many doctors aren’t paneled with very many insurance providers. I’ve had three different insurance companies in 5 years and have had to change doctors each time. That’s because of two hospital monopolies (IHC and the University of Utah) that have a set group of insurances that they take. There is no overlap.

    Where I landed is an old school primary care doctor who takes her time at a group clinic that has a few specialists, a few primary care doctors, and a lot of PAs and NPs, which adds evidence to the claim of this article. I think their practice is 1/3 paraprofessionals, as the article calls them. They take the majority of insurances so hopefully I don’t ever have to change doctors, until my doctor retires, anyway.

  7. pretzelattack

    I lost 2 pcp’s to concierge practices before I finally bit the bullet, an extra $2500 a year for life (till the fee goes up) but I get to see my doctor when I need to, and being a geezer that’s important.

    oh and concierge fees aren’t covered by health insurance or medicare. at least not my health insurance.

  8. Felix_47

    Concierge practices make some sense. Primary care doctors can hardly make it. In fact, PAs and NPs seem to do better because they do not have the malpractice insurance costs and they have to cover the overhead. And most of what a concierge doctor provides is not billable so the doctor is working for free. No lawyer would work under such conditions.

  9. Rob

    There will be no solution to the morass known as the American health care system until private investors and corporations are removed from their current positions of near total control. The profit motive must be taken out of decision-making. Am I calling for socialization of the entire system? Indeed I am. As both a physician and a patient, I have seen the damaged wreaked by corporatization from both sides. There is no hope other than to dump the current system and reorganize it based on the simple principle of optimizing patient and societal welfare. The insurance companies, giant health care delivery monopolies and big Pharma can be broken up or disappear altogether as far as I’m concerned.

  10. JBird4049

    People say to go to Mexico, but as with the many people planning on exiting the United States, many, if not most Americans just do not have the resources or have responsibilities especially with family members that do not permit this. It is another form of inequality, isn’t?

    1. ambrit

      “It is another form of inequality, isn’t?”
      Yes, it is. Until someone from the downtrodden masses rises up and begins “actively recycling” oligarchs, nothing will change.

  11. Sea Sched

    Private practice docs have to resort to concierge fees/subscription services and/or dropping most insurance plans because insurance reimbursement has not increased since 2000 and in some cases even decreased. Would anyone in their right mind keep working at a job where your pay has stayed the same for the last 20 years- or even worse- decreased? And with inflation, it is even more outrageous that reimbursement rates stay static for decades. It is insanely demoralizing, and a huge part of why doctors burn out. The moral injury of working with corrupt insurance companies is more extreme than people realize and of course the practice, not the insurance co., takes the brunt of the anger/frustration when a patient ends up stuck with a surprise bill because the insurance denies it for no reason aside from them being incentivized to keep the interest on the money they can hold on for a few months longer, or the desire to send the profits of denials essentially directly to their shareholders, etc…
    If your doctor is lucky enough to have a steady salary at a large hospital, they will be overworked because the hospital is held hostage by the same measly reimbursement from insurance which means volume of visits, not quality of care is the goal. And you have probably noticed plenty of hospitals are no longer in-network with many insurance companies anymore it has gotten so bad.

    It is a horrible, unethical, unsustainable system and everyone suffers except the CEO/stockholders at Regence, United, Cigna, Aetna, Kaiser, etc…
    They say physicians have a higher rate of suicide than the general population- I’d like to see that statistic broken down further to reflect physicians who took insurance during their career and those who didn’t…

  12. Jane Doe

    The disappearing PCP problem is going to make middle class people start going to the ER for regular but unexpected care. I’ve lost 2 PCPs in the past 5 years and since they haven’t been replaced at my local MegaHealthMart (which is loaded with cardiologists & surgeons of all stripes), my annual physical is with a PA (scheduled 10 months out!) that I’ve never met before. No offense to her, but at 62 I’d rather have an MD.

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