Doctor’s office turned into an assembly line

Since the start of the Covid-19 pandemic, my dad’s rheumatology clinic has been flooded with new patients, including many from distant cities or out-of-state. This is not thanks to a new marketing strategy or a dramatic increase in people with arthritis. An elderly woman who had traveled from New Jersey to my father’s Brooklyn, NY office, explained that many of the gyms near her home were closed. Those who are still open are so overwhelmed that she will have to wait eight months for an appointment.

This is not surprising. According to a 2020 survey by the Doctors Organization, 12% of all US doctors have closed their offices during the pandemic or plan to do so during the year. About 59% agree that the pandemic will “lead to a reduction in the number of independent practice physicians in their communities,” and half agree that “hospitals will exert a stronger influence on the organization and health care delivery as a result of the pandemic”.

But the pandemic has merely accelerated a decades-long trend. In 1983, more than 75% of doctors owned their own work, according to the American Medical Association’s survey of doctors. By 2018, that number had dropped to 46 percent. Many practices were acquired or merged by hospitals to form larger clinics, while local hospitals were lumped together into large health systems. Consolidation is the trend. An AMA report earlier this year found that for the first time, less than half of all doctors work in private facilities. This is a problem for patients like those who went looking for my father — there are simply fewer places to look for care, and more of the places available are bureaucratic facilities.

This is not good for medical care. Doctors are not — or shouldn’t be — natural subordinates. A significant part of their training includes learning to make independent judgments rooted in hard-earned authority. Write in the City Magazine in 2012, Theodore Dalrymple lamented the UK government’s influence on medicine, which he said “is becoming ever more solid; It now regulates working and employment conditions, hours worked, drugs and other treatments that can be prescribed. “Doctors” are fewer and fewer members of a profession; instead, they are productive workers under tight bureaucratic control.”

Former AMA President Barbara McAneny, who co-owns a private cancer center, echoes this ideas in a 2019 article. When she and her colleagues wanted to add new services to their patients, she wrote, they “didn’t have to go through 27 hospital committees and get permission from a bunch of vice presidents for a variety of things.” .

The shift from a small doctor’s office to a large medical care service can be attributed to many factors. Medicare reimbursement cuts for private practice services have pushed doctors out of business or into new business models. For a long time, the Medicare funding mechanism also encouraged hospitals to purchase private services, so that hospitals could bill Medicare for more lucrative outpatient hospital services.

Medicare also reimburses hospitals at a higher rate than private facilities for a variety of drugs and services — and the hospital system has more administrative resources to negotiate payments from insurance companies and the government. More recently, rules that push doctors to adopt complex, time-consuming electronic health records have hampered their ability to care for patients. The rise of EHR reflects the tension between companies interested in accumulating health data and doctors, who prefer to focus on individual needs.

For a long time, the AMA and other medical institutions like the Association of American Medical Colleges have quietly celebrated their turn away from petty medicine. They argue that larger, more integrated health systems will also be more efficient. Overall, this did not turn out to be the case. Kathleen Blake, AMA’s vice president of healthcare quality, this early year cited studies showing that hospital acquisitions by private institutions — which doubled from 2012 to 2018 — led to “modestly worse patient experiences and no change.” significant in terms of recurrence or mortality.”

The erroneous electronic health record system in hospitals has led to terrible medical errors and millions of people to deal with. And while doctors in many settings struggle with administrative and regulatory burdens, independent physicians are significantly more satisfied with their work than their hospital-based colleagues. In a 2018 survey of the Doctors’ Organization, only 13% of physicians agree that “doctors’ work in hospitals has the potential to improve quality of care and reduce costs”.

The AMA has begun to acknowledge this as a problem. In April 2021, the group launched a new initiative to support private operations. Among other things, the association is campaigning against impending Medicare cuts that could put doctors out of work. While important, this does not address the deeper issues of medical development in recent decades.

Bureaucratic structures often suffer from inflexibility. Throughout the Covid-19 pandemic, health regulators at the national level have struggled to adapt to sudden changes in health information in a way that frontline doctors can. Doctors must operate with the clear consciousness that they are serving the patient in front of them and not the government, data collection system, insurance company or hospital director.

When Amazon took over the independent bookstore, it inspired outrage of the kind captured in the 1998 film “You’ve Got Mail.” Unlike the book business, however, the replacement Replacing small doctors’ offices with large facilities has not made medicines cheaper or easier to access. It threatens to eliminate a core advantage of a small, privately owned operation: an immediate, personal sense of responsibility between doctor and patient.

Ms. Goldman is a visiting fellow at the Center for Ethics and Public Policy and senior editor of Mosaic magazine.

Wonder Land: What we needed most from the Government during the two long years of Covid were midway corrections. Politicians have instead opted for hardliners, such as Joe Biden’s mandate to vaccinate. Image: AFP via Getty Images Synthesis: Mark Kelly

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Ethan Gach

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