By Henry Buchwald, MD, PhD
Professor Emeritus of Surgery and Biomedical Engineering
Owen H. and Sarah Davidson Wangensteen Chair in Experimental Surgery
University of Minnesota, Minneapolis
‘Dependence begets subservience
and paves the way to tyranny.’ —Thomas Jefferson
This is the black box warning for the state of U.S. healthcare in 2025. In my previous writings on this subject in “Healthcare Upside Down: A Critical Examination of Policy and Practice” (Springer, 2022), and General Surgery News (December, 2023), I focused on the statistics of the clinical outcomes of our current healthcare system: U.S. life expectancy is 26th of the 38 countries in the Organization for Economic Cooperation and Development. Infant mortality is 51st in the world, lower than all the Western European nations, Canada, Australia and New Zealand. The overall U.S. mortality rate is 150th of 227 nations, within the 35% highest of all rated nations. Similar numbers exist for the other five universal healthcare criteria.
Yet we pay the most of all nations for our healthcare: $14,000 per person annually, or 17% of the gross domestic product (GDP), compared with $6,000 per person, or 10% of the GDP for comparable nations. Roughly 60% of the costs of U.S. healthcare are met by the government, that is all taxpayers, fitting the primary definition of socialized medicine; 30% are paid by private insurers; and 10% are out-of- pocket payments, such as copays, uncovered services and others.
Of the top 10 Fortune 500 companies, five are in healthcare. About $5 trillion is invested in healthcare annually, with an average profit margin of 3.5%, yielding $40 billion in profits for administrators and shareholders. The CEOs of these companies, even the not-for-profit ones, rarely have annual incomes less than $10 million, with some as high as $25 million. The smart, wealthy and relatively healthy investor will never purchase private insurance; they collect their eligible government subsidies when qualified and meet their healthcare expenses through a fraction of their returns on investments, even profiting at times from the insurance payments of middle-class families that find it prudent and responsible to purchase health insurance.
Healthcare is a right, not a commodity. But even if it were a commodity, the basic tenet of a business is that a company that provides inferior goods or services at the highest prices cannot survive, but ultimately will lose out to competition. Yet the U.S. healthcare system is fairly unchallenged. In this thesis, I draw attention to that enigma. In addition, U.S. healthcare is unfriendly to its customers, the clients—formerly referred to as patients—and this system denigrates the actual healthcare providers, previously known as doctors.
Most people wish for a doctor–patient relationship apart from that available in emergency rooms or urgent care centers. They would like sustainability, availability and personal attention when they need healthcare. If patients recognize that the doctor assumes responsibility for their welfare, they will, in turn, offer the doctor their trust. This reciprocal accord has been a hallmark of good medical care and outcomes; this accord is, unfortunately, absent from today’s healthcare.
Today, initiating, or attempting to maintain, medical care starts with a phone call to an office practice or clinic. A robot answers the phone and tries to persuade the caller to call 911 instead. If this suggestion fails, the caller is given a list of options from which to choose by pressing a number on their phone. That done, there is often a prolonged interval of bad music before another robot, as cold and impersonal as the first, will ask further questions of the caller or tell them to call back another day. If the potential client/patient answers this robot’s questions satisfactorily, a human voice might answer, but only after another stretch of bad music. This is the first interrogator. The first and only concern of this individual is how the client is going to pay. If the client proves financially qualified, they will be passed on to a doctor’s assistant, possibly a nurse, who will now assume the interrogator role. The caller’s personal, occasionally intimate, information must now be revealed in a conversation the client had hoped to discuss with the doctor. If the prospective client/patient refuses to answer a specific inquiry, stating that they will only discuss that with the doctor, they can be refused further progress by the gatekeeper. Is this forced, mandatory interrogation of the patient by a stranger not in violation of HIPAA?
In this introduction to medical care, and from thereon, the client/patient is immediately, without their consent, referred to by their first name. This universal assumption of intimacy in today’s healthcare is, to my mind, not a sign of empathetic commonality but the imposition of inferiority on the client/patient-a status of servitude in the upcoming relationship.
In the healthcare facilities’ business model, client/patient outpatient visits are made to fill open, usually 15- or 30-minute time slots, with physicians or nurse practitioners who are available and have the least clientele. Requests for particular doctors can be denied by the intake staff, stating that the desired provider is not taking new patients. Requesting to have a fairly urgent visit with the provider first seen by the client/patient can be scheduled so far in the future that it is unreasonable for the patient’s needs.
After an interval wait in the examining room, the client/patient will see an assistant who, after addressing the client/patient by their first name, will sit at a computer terminal and take a complaint history, as well as ask a compulsory set of questions. This person, or a second assistant, will then record the client/patient’s blood pressure, pulse and oxygen saturation, and leave, stating that the doctor will be there shortly. The doctor, in today’s system, will sit in front of the computer console; briefly review salient computer-recorded data; possibly do a cursory physical; discuss the problem with the client/patient; and order multiple laboratory, radiology or other tests, services or consultations. The visit is completed by the client/patient being given a printout of instructions. All this takes place within an allocated time slot. FFew client/patients have ever experienced the transient doctor spending their time together face-to-face, or holding their hand as a comforting, empathetic gesture.
Hospitalization of a client/patient follows a similar, impersonal business model. The actual referring physician may lose control of the client/patient to the physician on-service. Night events are managed by hospitalists. The floor nurses spend more time with their computers than with the client/patients. There are today even instances of surgeons on clock-monitored shifts in performing an operation. In major surgery institutions, an assembly-line system is in place, with surgeons going from OR to OR without time for a preoperative or postoperative visit with the client/patient or their families—a time-consuming task assigned to others.
Administration encourages admissions to hospitals, and, on the other hand, early hospital discharge. At the beginning of hospitalization, money is made by laboratory services, consultations and therapies. If the admission is for surgery, that money-generating event occurs before or early, during admission. Recuperation, pain and comfort control after surgery are accelerated because the hospital bed can be used for more lucrative activities. Referral to an affiliated in- or outpatient, income-producing rehabilitation facility is an alternative.
For the most part, physicians serve an integral role in the current healthcare system. Most physicians in urban settings, including surgeons, are now employees of a healthcare conglomerate. They have elected for a job, an employer–employee relationship, rather than living the responsibilities and hardships of independence in pursuing a calling. They have accepted the prescribed clinic hours, divided in-hospital management, and impersonal assembly-line model of providing care to clients/patients. Further, they have agreed to having administration make some of their practice decisions, such as what drugs are preferred, and which operations are approved and which are not.
A recent, almost unbelievable, egregious violation of medical practice was the imposition by a healthcare payor of a time limit for OR anesthesia. If the operation lasted longer than anticipated, the cost of the anesthesia would have become a client/patient, or provider, responsibility. After some hue and cry, this mandate was rescinded. However, it may only be a prequel of what is to come and what will be tolerated.
The great majority of today’s physicians accept this denigration of the ethos of our profession in exchange for prescribed working hours, limited and scheduled night call shifts, planned vacations, extended maternal and paternal leave, paid-for insurance, retirement benefits and additional perks, as well as freedom from billing and other administrative chores. This generation of physicians is concerned with achieving personal and family quality of life. They justify their belief in this system as actually resulting in better medical care. The statistics of the ever-increasing rate of physician burnout and early retirement do not support that conclusion.
In his farewell address, former President Dwight D. Eisenhower warned the nation of the dangers of the military–industrial complex, if left unchecked, to our democracy. The healthcare industry lobby influences our legislature, which is mostly composed of lawyers. Although most law firms insist on 50 hours annually of pro bono work from their attorneys, the federal government lawyers have passed four laws severely limiting that same right to doctors: the Anti-Kickback Statute of 1986, the Stark Law of 1989, the False Claims Act of 1863-2009, and the Civil Monitoring Penalties Law of 2015. Convictions under these edicts include monetary damages, jail time and loss of licensure. The language of these acts is applicable to waiving a copayment, not charging indigent patients and providing professional courtesy medical care to another physician’s family member (an actual requirement of the Hippocratic Oath). Thus, a mechanic at an automobile company can fix a neighbor’s car after hours, but a hospital-employed physician may not offer free medical advice to their neighbor after their designated work hours.
Some physicians have opted out of today’s healthcare system. A few with established reputations have managed to remain independent and only accept payment up front, leaving the patient out-of-pocket or to fend for themselves to collect retroactively for their care from their health insurance companies. Others have taken ownership in a hospital, and therefore reaped the system’s managerial benefits. In wealthy communities, a new class of practitioners has risen: the concierge doctors. For $2,500 to $25,000 annually, potential patients can pay to have a personal doctor who will answer their phone calls, see them at the patient’s convenience and take responsibility for their medical needs. This payment is independent of the concierge doctor’s charges to their client’s insurance—government or personal—for the actual care they provide.
There have been a few attempts by physicians or their group practices to fight the current healthcare status, usually without success. Physician organizations, for example the American Medical Association and the American College of Surgeons—formed to promote education, set standards and provide networking—have not taken, individually or jointly, strong positions in opposition to the business–healthcare complex. The most cogent reason imaginable for this lack of involvement is that the greater percentage of their younger dues-paying members have embraced or yielded to the current system.
Our country’s inhabitants, in one way or another, have exhibited the age-old response to this healthcare system: Don’t make trouble. If trouble is to be made in the future, I believe it will have to come from organizations, labor unions, encompassing professional institutions; or even one or more billionaires offering a successful business model that, at a reasonable cost, benefits the consumer—all of us as patients, sooner or later.
Paying to grovel should not be the American way!
Editor’s note: The views expressed in this opinion belong to the author and do not necessarily reflect those of the publication.
Originally published by our sister publication General Surgery News