Who Killed U.S. Medicine?

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By Regina E. Herzlinger
Wednesday, July 25, 2007

America's physicians are the most trusted and valuable resources in our health-care system. Yet doctors' professionalism and incomes have taken a terrible beating recently. The American Medical Association, which received $286 million in revenue last year to protect the profession, has served physicians poorly.

Physician incomes, when adjusted for inflation, declined 7 percent from 1995 to 2003, while those of professional and technical workers rose. But unlike other professionals -- lawyers, architects, authors and economists -- doctors' work is dictated by the policies of insurers and governments. Increasingly, independent physicians, accountable only to their patients and the Hippocratic oath, have been replaced by salaried doctors who are accountable to the hospitals or insurers that employ them. Salaried physicians are closely policed for productivity, leading to ever-shorter and more numerous appointments per day.

Meanwhile, academic medical journals routinely publish studies that supposedly document the cupidity and ignorance of practicing physicians while lauding the virtues of single-payer health-care systems, such as those in Canada or Britain, in which the physician is paid only by the government. German physicians unhappy with their salaries and work hours under this kind of system had no recourse against their monopolistic bosses but to go on strike last year.

Small wonder that applications to medical schools have declined by nearly 20 percent in the past decade. When I ask the many physicians who are enrolling at Harvard Business School for an MBA degree about their decision to switch occupations, they frequently answer, "I can no longer practice medicine." You might expect that the AMA would fight the insurers, hospitals, government bureaucrats and ivory tower academics who have diminished physicians' incomes, besmirched their ethical reputations and compromised their professionalism -- but you would be wrong. No, instead, at its annual meeting last month, the AMA declared war on retail medical clinics, located in places such as CVS and Wal-Mart.

These clinics do a lot of good: Their convenient locations and extended hours -- they are usually open every day -- enable ready access so that busy people need not defer important medical care such as flu shots. Their availability helps to unclog crowded emergency rooms, and their prices enable the uninsured to obtain care at reasonable costs rather than face the high prices that hospital emergency rooms all too often reserve solely for the uninsured.

Unlike many physicians' offices, many such clinics foster continuity of care with electronic medical records that transfer information about the visit to patients and their doctors. These clinics are not performing brain surgeries but rather are attending to routine care, such as for a child's earache, and prevention. Quality is ensured through the use of nationally certified nurse practitioners, registered nurses with master's degrees or comparable advanced training, collaboration with local physicians (which is required in most states), and the use of standardized treatment protocols that facilitate continuity of care when other clinicians are involved.

Yet the AMA is fighting the clinics. The association claims that health insurers allow clinics to waive or lower patient co-payments while forcing doctors to collect these fees. Isn't the AMA's beef with insurers, then? No, AMA doctors complain that clinics do not offer comprehensive care and that they disrupt the standard physician-patient relationship. "Our concerns are very simple: safety and patient care," said Rodney Osborn, president of the Illinois State Medical Society. The AMA also says these clinics represent the intrusion of profit-seeking corporations into medicine.

Nonsense. This is all about protecting the doctors' turf. After all, when Congress imposed a moratorium on physician-owned, for-profit specialty hospitals in 2004, the AMA went all out to repel that threat. Its issue is not profit but pure and simple empire building.

Unfortunately, while the AMA engages in trivial turf warfare, physicians are increasingly forced to become salaried employees of hospitals and insurers and are constrained by recipes for the practice of medicine that are cooked up by government and insurance company bureaucrats.

The cycle is bringing about the imminent collapse of the medical profession -- which gravely endangers our health-care system. We and doctors deserve better advocates.

The writer is a professor of business administration atHarvard Business Schooland a senior fellow of theManhattan Institute. Her book "Who Killed Health Care?" was released last month.


© 2007 The Washington Post Company

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