Where have all the doctors gone?

By C. Richard Schott, M.D.

Those of us in southeastern Pennsylvania who are worrying how our hospitals will survive the current nursing and hospital bed shortage haven’t seen anything yet! There is an unrecognized rapidly growing physician shortage in this region that will severely affect patient access and quality of care. This is the result of high penetration of managed care, extreme market domination by monopolistic third party payers, and a malpractice crisis fueled by our out of control tort system.

Physician shortage

Years of personal and family sacrifice and debt to train as physicians are now “rewarded”

by a lifetime of endless stressful hours of under-appreciated work including on-call time, compounded by constant fears of frivolous litigation, endless manipulation by third party payers, impossible to comply with governmental regulations, and now by the criminalization of the practice of medicine by The Health Care Financing Administration and the Office of the Inspector General. Applications to medical school are understandably down. Our brightest students who were once directed towards careers in medicine are now better advised to pursue careers in economics, computer science, and business.

Over the past 20 years, medical education has de-emphasized specialty training in favor of primary care, and there has been a contraction of specialty training slots. Primary care physicians who were intensely trained in hospital practice are now being economically forced by HMOs to dedicate all of their time to their office practice, while the diminishing pool of critical care trained specialists are now doubling as “hospitalists,” rounding two to three times per day in order to try to keep up with the pressures of shortened hospital stays.

Managed Care and Market Domination

We work in an environment where every medical decision we make is questioned

by, and must be explained to utilization review nurses and quality assurance programs and care plans that are tainted by “bottom line” concerns of hospitals, third party payers, and practice administrators. We must restore medical decision making to physicians.

We are denied the right to collectively negotiate with anti-trust exempt, monopolistic HMOs that are the “only entity in our society that cannot be held legally accountable when they do harm” (D. Ted Lewers, MD, AMA Board Chairperson). Market dominant payers dictate to physicians what have become “take it or leave…” contracts knowing that we are powerless to negotiate with them. Our contracts contain all-products clauses, and “black box” reimbursement formulae that have resulted in under fair-market reimbursement to physicians. The near extinction of indemnity type insurance has left us with no base of “good insurance” upon which to shift our increasing costs. Healthcare under managed care is different and in many situations inferior. The Government and employers have lured the public into HMOs, not because they’re better, but because they’re cheaper.

Malpractice Costs

We are at the mercy of a tort system that denies us due process, or anything close to a “jury of peers,” and we bear the unfair cost of exorbitant malpractice awards at the hands of juries who have neither medical insight nor any concept of the value of the dollars they award. There is presently no fair way to properly compensate injured patients, while out- of-control malpractice costs in Philadelphia and Delaware County have added insult to injury. High-risk specialty practices simply cannot survive here.

Physician Exodus

We have been placed at such an economic disadvantage that we can no longer compete to attract new high quality specialists to this region. Established physicians are leaving through premature retirement, and by migration to more lucrative regions where there is less managed care penetration. Many of our most dedicated colleagues, demoralized by this practice environment, are forgoing medical practice for jobs with more decent hours and lucrative benefits within the pharmaceutical companies, with management consulting firms, and into medical director positions in the insurance industry. (Businesses lure more doctors from practice: AMNews, November 6, 2000, p. 14-15)

Access to quality healthcare will suffer. Waiting times for appointments to see specialists in suburban Philadelphia are growing into dangerous delays. The number of gastroenterologists and cardiologists in Delaware County are declining, largely due to economic conditions imposed under Keystone’s contact capitation arrangement. Unfilled vacancies in gastroenterology caused by physician relocations, retirements, illness, and death; and the inability of existing practices to attract new physicians, is causing a serious contraction and loss of services in Delaware County at a time when demands for these services have increased. One gastroenterology group has limit their practice to only one of three hospitals, driven by payer mix considerations. Cardiology groups also have been unable to attract new partners. High quality trainees are opting for more lucrative practice opportunities elsewhere.

Physicians’ ethics have prevented their withholding care to patients for economic gain, but now high-risk surgical and obstetrical specialty groups are being forced to make economic decisions to limit their practices because they cannot afford the exorbitant increases in their malpractice premiums. This threatens the ability of some hospitals to provide certain emergency department services, including trauma care.

HMO Profits

HMOs here continue to realize substantial profits, and their executives’ salaries are exorbitant. Independence Blue Cross receives very lucrative payments from HCFA for their Philadelphia area Medicare-Plus products. In addition, they have repeatedly increased premiums to employers by up to 20% annually for their employees’ health care benefits. Meanwhile there are indications that they have diverted their profits derived from payments that were intended for employees, and Medicare and Medicaid recipients in this area to support their unprofitable out of state subsidiaries! Physicians here are furious over “healthcare dollars” being wasted on bureaucratic and HMO extravagances and on trial lawyers, leaving inadequate funding for real patient care.

Call for Action

The Pennsylvania Medical Society has taken decisive action with a broad-based plan to deal with both the malpractice crisis and to restore balance in the marketplace. Specialty societies have become proactive, and new militant grass roots leadership has emerged demanding change. Our legislators and the courts need to recognize that “under-fair market” reimbursement by monopolistic third party payers in this region, and the hostile malpractice climate are destroying our health care system and will harm our patients. Society must decide to limit the diversion of health care dollars to trial lawyers. Employers must demand accountability by insurance companies so that their premium dollars go to providing services to their employees. If third party payers are unwilling to provide fair reimbursements under government-funded programs and commercial products, it is only fair that physicians should have the legal right to individually or collectively reject these contracts.

Perhaps third party payers will agree to cooperate with physicians, possibly through the Pennsylvania Medical Society’s Medical Directors’ Forum. If not, they will have to be responsible for serious disruption in access and deterioration in the quality of care for their subscribers that will result from existing market forces. Hopefully, our legislators and third party payers will wake up and come to the table to help us resolve this crisis before they have to ask, “Where have all the doctors gone?”

C. Richard Schott, M.D., FACC is past president of the Delaware County Medical Society and Chairman of the Division of Internal Medicine and Chief of the Subdivision of Cardiology at Riddle Memorial Hospital in Media, Pa