ISS:Medicine is in big trouble.  by David Nye MD

   In not too many more years the medical industry will be radically
different from what it is today. There will be widespread rationing of
medical services, decreased access to physicians, particularly in rural
areas, and generally a lower quality of care, except for those who can
afford to pay cash. Here are the reasons why:

   1) Although a small dip in medical malpractice rates has occurred in
some places this year, the expectation is that they will continue to
rise. Physicians in certain specialties in some states now pay up to
$300,000 per year for malpractice insurance. Many physicians in these
areas are changing their practices (for example, obstetrician-
gynecologists dropping obstetrics), moving to other states, or retiring
early.

   2) Medicare and Medicaid reimbursement is falling. Legislation is
being introduced to cut it back even further, as medical care costs
continue to rise. In our area, Medicaid pays only $4 for an hour of
psychotherapy. Many physicians therefore no longer see Medicaid
patients. We accept Medicare assignment (meaning we'll agree to take
only what Medicare pays, perhaps half of our usual fee) on a case by
case basis. We don't feel the need to extend charity to someone driving
up in a chauffered Rolls, for example. Even if we don't accept
assignment and the patient has to pay the balance, we are still
prevented by law from charging the full amount we would charge someone
with, say, Blue Cross Blue Shield. For this reason, some doctors are
also refusing to see patients with Medicare even if they have
coinsurance or are willing to pay that balance out of pocket.

   3) Medical school enrollment is plummeting. Not being able to find
enough qualified applicants, the Universities of Wisconsin and
Minnesota and Northwestern University, all top quality medical schools,
had to contract their freshman class sizes last year. The biggest
decline in applications has been from children of physicians, normally
making up about half of medical school enrollees. Their parents are
telling them that its not a good way to make a living anymore. Scores
on standardized tests in medical school (notably the three part Medical
Boards) are dropping, suggesting that the quality of those coming out
of medical school now is not what it once was. I'm told that college
advisors frequently try to dissuade their charges from a career in
medicine, pointing out that salaries are not keeping up with inflation.
A noted medical futurist has predicted that the average doctor will be
making $30,000 per year in ten years (in today's dollars).

   4) It's not just physicians who are in trouble. Even if by some
miracle physician's incomes remain essentially unchanged, the rest of
the health care industry is likely to go through some serious
convulsions. It is predicted that one third of all general hospitals
open today will close within ten years. There is currently a serious
shortage of nurses, physical therapists and other health care
professionals, and little likelihood of this being temporary. The
pharmaceutical industry is getting clobbered by rising product
liability insurance premiums just as we physicians are by rising
malpractice premiums. Some very useful medications have been taken off
the market because sales didn't pay the insurance. Many will never be
brought to market. The average price of a new medication today is much
higher than a few years ago.

   If malpractice rates keep rising, I don't see any way out of
national health care coverage (Medicare and Medicaid extended to
everyone), agreed to by physicians in exchange for the government
taking over our malpractice premiums. We'll become government
employees. If you sue me then, you'll have to get it out of Uncle Sam.
I predict this will cause some rapid and dramatic changes in the tort
laws. In fact, such changes may not even be necessary. When lawyers see
how much time and effort it takes to press a successful suit they may
think twice about taking such cases. But as a government employee
making $30,000 per year or whatever, you'll have a MUCH harder time
getting me out of bed at night to come into the emergency room. There
will also be many fewer of us willing to be doctors. There will still
be some, the cream of the crop, who can make a living serving the rich
on a cash-only basis. This is about the way things are in England right
now, with the projected salaries at about the same level. If you need
your gall bladder out or your hernia fixed there, you get put on a
waiting list for six months. If you develop kidney failure and you're
over a certain age (60, I think) then you are ineligible for either a
kidney transplant or dialysis. On the positive side, everyone will have
access to this care, even those who presently have no insurance and are
not getting adequate medical care because of it.

   Who should we blame for the decline and fall of American medicine?
Greedy physicians? Perhaps some specialties are ovepaid, and there are
certainly a few physicians who try to milk the system, but I submit
that the large majority are getting paid what they are worth,
particularly when you factor in the fact that many don't get out of
training until they are in their thirties and may have hundreds of
thousands in tuition debts. As a believer in a free market economy, I'd
say it looks like physicians are now underpaid, since there are not
enough students interested in going into medicine to maintain our
current numbers.

   Are the lawyers to blame? Not really, although it doesn't help when
they have a seminar at one of their recent national meetings entitled
"Dentistry -- A Great Untapped Reserve" or somthing to that effect (my
dentist told me about this one this morning). As long as there are
patients coming to their offices wanting to sue somebody, we can't
really expect them to nobly refuse the business. The insurance
companies? If they were all charging too much, some upstart would come
in charging less and clean up. Saved again by the free market economy.

   I think the real problem is that medicine has gotten too good. The
better we get at prolonging life and relieving suffering, the more it
will cost, even if we manage to trim off all the fat (unnecessary
tests, futile or marginally effective treatment, etc). We can no longer
afford to do everything we know how to do. Years ago we heard patient's
families say, "We know you did the best you could". When we could do
little, we were thanked for whatever help we could give. Now that we
can treat almost everything (with varying degrees of efficacy),
patients are instead angry and even litigious when our treatment
doesn't work. It is thus paradoxically the increasing quality of
medicine that fuels the upward spiral of malpractice insurance fees.
Patients somehow feel that everything should be fixable, so if an
individual physician can't fix them up, he must be incompetent. And if
you think patients are mad now, wait until rationing strikes and we
start trying to tell them that, yes we have a treatment, but they can't
have it! I'm sure they could have dealt much better with being told
there is no treatment.

   What can be done to maintain the quality of health care in the face
of declining health resources and personnel? I predict that computers,
particularly expert systems, will become increasingly important in
health care. There are lots of things that non-surgeons handle that
could be done just as well by an expert system running on a PC. Well,
maybe not just as well but well enough for what we as a nation may be
willing to pay. For example, diagnosis and treatment of most headaches
or management of high blood pressure (perhaps with an automated blood
pressure cuff plugged into the serial port). Expert systems could
monitor for dangerous side effects of medications, one of the main
reasons we like to keep seeing patients back in the office whose
ilnesses are otherwise well controlled. If the FDA could be convinced
that the expert systems are working well enough, many prescription
drugs might be made available over the counter. Of course, the software
and drugs would have to be sold by the government, again to get around
the medicolegal liability problems. Socialized medicine in a big way.

   I can envision a medical clinic of the future with many certified
medical assistants, each leading a patient through a computerized
medical history, then doing a physical examination, perhaps being told
specifically what to look for by the computer. A computer generated
history and exam summary followed by a list of possible diagnoses with
further test or treatment recommendations appears in the office of the
lone physician, who light-pens the recommendations with which he
agrees. The lab orders or prescriptions are electronically transmitted
to the selected lab or pharmacy, and a page or two of information about
the patient's diagnosis and his medications is printed out at the desk.
Only if he had some questions left unanswered by the computer would the
physician see the patient. Believe it or not, the technology to do this
is all available today, although not yet being sold commercially. It
would be a simple matter to set up such an office, run some patients
through it, and compare the quality of diagnosis and treatment against
an all-physician, non- computer-assisted clinic seeing the same
patients. Perhaps computers will allow us to continue to deliver
quality health care at a cost we can afford.

   David Nye MD
