Why do we have to wait so long to see the doctor? It's all about the money...

I have seen a number of articles describing the difficulty of getting doctor’s appointments in the era of COVID-19. In many parts of the country it was difficult to get a quick appointment even before the pandemic, but it has become much worse. I hear from friends in a several different cities that they cannot get into their doctors offices for weeks or, commonly, months. This is not OK for routine care; it is certainly not ok when something urgent, or relatively urgent, or even a little bit “needs to happen before I get really sick” is going on. A recent article in the Wall Street Journal by Devorah Goldman (‘The doctor’s office becomes an assembly line’, December 30, 2021) describes a woman who came to her father’s Brooklyn office from New Jersey because she couldn’t get an appointment for 8 months!

There are Emergency Rooms, of course, but waiting (frequently for hours!) in them increases your risk of acquiring COVID infection. And, as in “regular” times, they should be for emergencies, not for care for chronic diseases or minor acute disease. Of course, if you cannot get regular care for your chronic disease, it can become an emergency. And, as I have written before (Emergency services, COVID, and the health system: Your life could well be at risk, Jan 19, 2021), when you have an emergency, like a ruptured appendix, waiting in an ER for hours is also very dangerous, and the more “non-emergent” people waiting the more likely this is to happen. There are Urgent Care Clinics, but these have their own issues: they can only take care of a limited (and variable by location) menu of problems, most of which are those your mother used to take care of, and they may not take your insurance (if you have it). Also the prices and profit margins are very high.

So why are the waits so long, and what can be done about it? Goldman’s emphasis is the takeover of physician private practices by hospital systems and large groups; she notes that, according to the AMA, 75% of physicians owned their own practices in 1983, but by 2018 it was 46%. This is part of the problem; even if an individual physician is compassionate and caring, the big corporation they work for probably is not. Another part is the maldistribution of physician specialists. Studies of efficient and effective health care systems indicate that 40-50%+ of physicians should be in primary care, seeing people for most problems, providing continuity of care for a patient panel, and diagnosing “undifferentiated patients” (those who do not have a specific diagnosis) and caring for them or appropriately referring them. In the US, however, it is less than 30% and dropping. Quite reasonably, subspecialists want to see people with the problems that they know how to take care of; this works well when they are referred by family physicians and other primary care clinicians, and much less well when people have to self-refer, essentially having to diagnose themselves. Such direct self-referral also backs up the subspecialist practices with patients whose problems could have been well taken care of by a primary care clinician (not everyone with a heart needs a cardiologist!) making it more difficult for those with complicated or rarer conditions that need the subspecialist’s care to get in. Medicare’s reimbursement method figures prominently in Goldman’s article; she identifies ways that it tends to give preference (i.e., pays more) to large, and especially hospital-owned, medical groups. And, of course, since COVID the demand for care has gone up, and the number of clinicians available (because of sickness and overwork) has gone down.

Many other articles claim to provide the reasons for this problem, and some even have proposed solutions, but most of them examine only one aspect of it. I am reminded of the old Indian story about the blind men and the elephant, each touching a different part of the beast and thus presuming, based on contact with the trunk, the tail, or a leg, that they knew what the whole elephant looked like. Often this is influenced by the agenda of the writer and whether (like, e.g., Goldman) they get their information mainly from groups like the AMA (“oh, for the days of physician-owned private practice!”), hospital associations (“consolidation is good!”), government agencies (“reimbursement policy is governed by competing needs”), or academics, think tanks, or nonprofits like the Commonwealth Fund, Kaiser Family Foundation, and Pew Trusts, often with their own biases. To me, it is clear what the whole elephant looks like, what is the common factor in this equation, what can be seen behind all of the decisions that have led us to where we are (and continue to make it worse) and, by implication, could show us the way out: Money. Corporate profit.

We live in a profit-driven capitalist society. More than that, we have moved well beyond simple “Adam Smithian” capitalism to what Noam Chomsky identifies as “gangster capitalism”. In this stage, merely making money is not sufficient – the only goal becomes to make ever more money, by any and every means possible, no matter who, or what is destroyed. This includes people, animals, plants and the earth itself -- it hurts, screws, destroys, even though neither those who control it nor their descendants could ever spend it all. Fewer and fewer people control more and more and it would be naïvete to assume this is not the case in health care.

Virtually all the systemic bad things (as opposed to the much less common individual error) in healthcare derive from corporate owners’ efforts to make more money, and to game the system to maximize profit. While huge practice groups owned by hospitals or investors could operate more efficiently to improve both the quality of and access to care for patients, they don’t since they are interested in squeezing every dollar of profit. Conversely, small physician-owned practices couid do better than they do, but often, in pursuit of income, do not care for significant portions (poor, uninsured, badly insured) of the population. Explicitly for-profit (as opposed to ostensibly non-profit, but still fixated on making as much as possible) healthcare entities, whether large hospitals and hospital systems or more ‘niche’ services like dialysis, physical therapy, and long-term care, are the worst. There is certainly plenty of blame to go around – healthcare systems blame insurance companies for not paying them enough and insurance companies blame healthcare systems for demanding too much, but both are seeking to earn money for themselves, not to ensure all people get the highest quality health care.

Pharmaceutical companies are notoriously rapacious. For example, see Aduhelm® (FDA approves Alzheimer's drug against the recommendation of its scientific panel. Be very concerned, June 21, 2021); every (60 million!) Medicare recipient’s Part B payments will now rise $11/month so some Alzheimer’s patients can receive this drug that, though probably ineffective, costs a huge amount (now, graciously, reduced to only $28,200/year!). It was approved by the FDA over the recommendation of its scientific advisory panel in a move completely reminiscent of the fraudulent labeling of Oxy-Contin® described in the film “Dopesick”, which I recently discussed ("Dopesick": The story of the marketing of killer opioids will really make you sick. Don't trust any of them!, Dec 7, 2021).

I have often advocated for a single-payer health insurance system, such as Medicare for All. The advantage of this would be that 1) everyone in the US is covered, and 2) everyone in the US has the SAME coverage, The second is not a minor point, as it means that the educated and powerful will make sure it works, also helping the disenfranchised and disempowered. A universal health insurance system (or something comparably effective) is necessary, but not sufficient. Medicate for All needs to be an improved and expanded Medicare, as described in the bills introduced by Sen. Bernie Sanders, Rep. Pramila Jayapal and others.(See this good analysis by Sen. Sanders on the “Vulgarity” of the US health system.) It must be expanded to cover not only everyone but everything (mental health, dental, vision, hearing, long-term care) and improved to cover them completely without co-pays, co-insurance, deductibles. This will eliminate the flaws Goldman describes in Medicare payments.

Since we already spend 2-3x as much per capita on health care as any other wealthy country, including premiums, deductibles, co-pays, government benefits, and the profits and administrative costs sucked out of the “healthcare” pool by insurers and providers, we don’t even need to tax the richest a lot more to pay for it. We just need to spend it on actually providing healthcare! Not that we shouldn’t make the billionaires and corporations pay at least their fair share of taxes; we can use that money to providea adequate housing, food and education to all our people – really, the biggest factors in health.

Don’t get distracted by the circuses and diversions created by those with a profit-motivated dog in the fight. Profit has little place in healthcare. Obscene profit has none.