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Assembly Line Medicine & The Patient-Doctor Relationship

By Kenneth A. Fisher, M.D.

The latest data from The Organization of Economic Cooperation and Development is for 2008.

At that time the United Kingdom spent 8.7% of gross domestic product (GDP) on health care while the United States spent 16.0%. The amount spent in U.S. purchasing power parity dollars in the United Kingdom was $3129/person compared to $7538/person in the United States. The disparity in the amount of GDP spent on health care between the U.S. and other industrial countries is similar. A recent Rand Corporation study documents that this imbalance in the per-cent GDP devoted to health care has a negative impact on the U.S. economy and jobs.  Furthermore, this impact will become more evident when per-cent GDP for health care in the U.S. reaches 20% or more.  Unfortunately, the Chief Actuary for the Center for Medicare and Medicaid services predicts that per-cent GDP devoted to health care in the U.S. will exceed 20% when our new health care bill reaches fruition in 2014.  This is an issue of concern for many thoughtful Americans. In the U.S. in 1940 health care accounted for 4.5% of GDP, increasing to 12.2% in 1990 with an estimated 18% for 2010. Why has American medicine become so expensive compared to other countries despite having such a negative impact on the health of the economy?

I submit the major reason is the downgrading of the previous close-knit relationship between the doctor and patient. The causes for this are multiple, but the largest factor is the physician reimbursement schedule for Medicare and Medicaid. Medicare as the largest insurer in the U.S. drives private health insurance reimbursement rates. Initially Medicare adopted a Blue-Cross-Blue Shield (BCBS) payment schedule. BCBS was founded by surgeons and its payment schedule was procedurally oriented.  The Congress of the U.S. probably more than in other countries is heavily influenced by commercial entities and sub-specialty physician groups, both of which emphasize payments for technology and procedures. In 1992 Medicare adopted an even more complex system of reimbursement, Resource Based Relative Value Scale, which again favors technology and procedures.

The result of this 50 year odyssey is insufficient reimbursement for doctor-patient interactive time.   This decreased time has led to assembly-line medicine. Many if not most physicians in the U.S. spend about ten minutes face to face with a patient during a visit. This is grossly inadequate; core skills atrophy.  History taking and physical exam skills of many perhaps most physicians in the U.S. are inferior to those in Great Britain. Recently some prominent American physicians have commented and written about this problem (i.e. Dr. Abraham Verghese), but no formal rectifying action has taken place.  As confidence in and time for history taking and physical exam skills diminish, reliance on technology increases.  As patients consult with multiple physicians there is little coordination and care suffers.  As hospitals and pharmaceutical companies advertise, patients become less influenced by the decisions of their primary physician. As the trust relationship dwindles, patients are more confused as to the appropriateness of care, especially in end-of-life situations.

Congressional attempts to control spending, with the ever present lobbyists have only exacerbated this problem. One group, trial attorneys, seem to have an undue influence, increasing defensive medicine.  We seem to be in a deteriorating cycle, more assembly line medicine, less reliance on human skills, greater costs leading to more assembly line medicine and so forth. One could ask, “Where are the medical societies, why don’t they speak out about this issue?” I believe the answer is that our societies are looking at short term gains, see themselves as just another lobbying group and are afraid to impact the income of some segments of our profession.

In my opinion the U.S. must provide universal coverage at about 15% of GDP. This means that the documented approximately 30% of care that is non-beneficial, costing about $700 billion/year must be addressed and significantly decreased. This can only happen if physicians combine their efforts to dramatically improve the patient-doctor relationship by insisting on an increase in funding for patient visits, while working together to control non-beneficial activity. Being a physician is a person-to-person relationship involving humanity, judgment, knowledge and skills.

Signature: Doctor Fisher is a board certified Internist and Nephrologist. He has published many scientific articles and is the author of, In Defiance of Death: Exposing the Real costs of End of Life Care (Praeger 2008). Recently he published an electronic book, The Ten Questions Walter Cronkite Would Have Asked About Health Care Reform. He blogs at 

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