1. Most physicians are intellectually gifted and therefore rarely make mistakes. Perhaps Hollywood is to blame for this misconception, or maybe we simply find comfort in believing that exceptionally brilliant diagnosticians abound. Either way, I wish it weren’t a myth. But the truth is that the vast majority of physicians are average in virtually every way. Despite all claims to the contrary, we are no smarter than teachers or engineers, no braver than soldiers or firefighters, and no more infallible or crucial to human health than nurses or sanitation workers. If you want to find brilliance, look to the individual, not the career. No profession has a monopoly on intellect.
2. Physicians are underpaid. It pains me to say it, but given our current economy, most physicians are not underpaid. Some argue that, due to the cost and length of medical education or the demanding nature of their jobs, physicians’ salaries are unacceptably low, particularly in primary care. That might be true in some utopian society where education and work ethic always correlate nicely with compensation, but in this country, that simply isn’t the case in any industry. In less than a decade, annual salaries for primary care physicians and subspecialists will average $90,000 and $150,000, respectively — so plan accordingly.
3. Physicians are more altruistic than most people. Becoming a physician is not, and has probably never been, a purely altruistic endeavor. Physicians, on average, are just as interested in money or prestige as anyone else, despite the content of most medical school application essays or the profession’s overly romanticized notion of itself. And in this country, there is absolutely nothing wrong with that. So there’s no need for hypocrisy; trying to convince the public that all members of any profession are driven purely by altruism, and not by making as much money as possible for themselves and their families, is both disingenuous and counterproductive.
4. We should abandon our sick care system and strive to develop a true health care system. No system or individual can thrive by doing many different things poorly. Doing a few things exceedingly well is the key to success. And in health care, that means providing high-quality medical care to the ill at the lowest possible cost. Disease prevention is indeed critical, and physicians can and should provide basic counseling on health behaviors during office visits. But most prevention is best addressed elsewhere in our society. Good health does not (and can never) originate in any hospital or doctor’s office. And violating that universal truth is both exorbitantly expensive and stunningly ineffective.
5. Technology will save health care. Google Glass, surgical robots, digital pedometers or calorie counters, cloud-based glucose or blood pressure monitors, handheld ultrasound machines, EMRs, CPOEs — all of these technologies have great potential. But technology is a tool, a hammer, nothing more. And like any tool, it can only be as effective as the hand that wields it, or the mind that determines if its use is appropriate for a particular task. Good technology can certainly help, but only good people, good judgment, and good intentions can truly improve our health care system.
6. Big pharma is evil. No single industry is responsible for all that ails our health care system. Does big pharma deserve some of the blame? Sure. But so do our federal and state governments, the insurance industry, pharmacy benefit managers, hospital and health system administrators, and even the medical profession itself. There’s certainly plenty of blame to go around, but unlike most of those other entities, big pharma occasionally contributes something of value. And here’s one irrefutable truth: Were it not for the biopharmaceutical industry, there would be virtually no reason for any patient to ever visit a physician (except maybe for reassurance or a crude surgical procedure — but don’t expect any anesthetics).
7. Independently owned concierge and direct-pay practices will revolutionize health care delivery. No they won’t. Any business model whose primary value proposition for patients consists of “I’ll spend more time with you” or “You can call me anytime” or “I’ll always act in your best interests” is destined to remain a small, albeit thriving, niche. Why? Because most patients will rightly ask, “Why should I pay ‘extra’ for this? Shouldn’t all physicians offer these things?” Over the next decade, then, payers will adjust their business models accordingly and lobby aggressively. And independent concierge and DPC practices will either be acquired by large corporations or become increasingly regulated, eliminating most of the professional or lifestyle benefits that attract physicians to them in the first place.
8. Recent advances in medicine have been so great that physicians can now cure almost anything. Not really. Don’t get me wrong, we’ve made much progress in recent decades (HIV, HCV, and some malignancies come to mind), but compared to centuries past, we’re well behind schedule with regard to true medical breakthroughs. The bottom line is that most modern pharmaceutical drugs don’t cure a damn thing. That’s not an indictment (drug discovery is tough work), but it does form the basis of some sound advice for most Americans: eat well, exercise regularly, laugh frequently, sleep soundly, learn often, embrace faith, cherish the few, shun the rest, know yourself, love yourself, and be yourself. Nobody can do these things for you, and no pill will ever offer comparable benefits.
9. Employers have an ethical responsibility to provide health benefits to their employees. We already know that health insurance doesn’t really make anyone healthier. But the assumption that employers should play any role whatsoever in directly financing their employees’ health care is equally flawed. Why? Because future health care expenditures are difficult to predict with certainty, and health care costs generally increase at a rate greater than inflation. As long as health benefits represent a significant portion of employee compensation, then, real wages will continue to stagnate or decline.
Ironically, because income is a much stronger determinant of health than health insurance coverage, these employer-provided benefits are, in many ways, unethical. And employers should therefore be prohibited from offering what is often little more than a large, employee-paid deductible and calling it compensation. In short, cash is king, even (or perhaps especially) when it comes to your health.
10. Pay-for-performance is the key to fixing our health care system because it doesn’t create the perverse incentives of the fee-for-service payment model. This is blatantly false. For proof, we need only look to the legal profession. Lawyers will provide virtually any service if you pay their hourly rate and reimburse their expenses. But they only accept work on a contingency basis if they firmly believe they can win the case. Similarly, if pay-for-performance becomes the dominant payment model in healthcare, then all providers, from hospitals to individual clinicians, will have little financial incentive to care for any patients they believe they can’t fix, at least on paper. And that will disproportionately affect the seriously or chronically ill and the socioeconomically disadvantaged.
Additionally, once we accept the false premise that physicians have the ability, or right, to unilaterally manipulate health outcomes or modify patient behavior — anything from diet or exercise habits, to medication adherence, to choice of birth control — then it logically follows that all payors, including government agencies and large employers, have the right to monitor and control those same behaviors. In short, pay-for-performance will unfairly penalize the sickest patients and threaten every citizen’s privacy, autonomy, and dignity. And that, my friends, is the definition of a perverse payment model.
Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.
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