“Since the late 1970s, I have witnessed remarkable technological revolutions in medicine, from CT scans to robot-assisted surgery. But I have also watched as medicine slowly evolved into the domain of technicians, bookkeepers, and clerks.”Jeffrey Singer, MD
updated February 1, 2022
Since Dr. Singer wrote this article in 2013, most of the changes he predicted have or are in the process of occurring. Here are some of the changes that had already happened in 2013.
- Medicare imposed price controls based on the way the diagnosis and the doctor’s service were coded.
- Private insurers linked compensation to coding and diagnosis, not the service the doctor performed.
- Change from patients paying for their care to 3rd party payors, usually insurance companies.
- Health maintenance organizations, HMOs, required in-network care only, restricting patient choice (these largely have gone away)
- Practicing by evidence based medicine, treatment protocols, and guidelines, sometimes enforced with financial penalties
But some of what he wrote was yet to come-and it has .
- trend toward replacement of physicians by nurse practitioners and physician‐assistants
- all physicians and hospitals converted to electronic medical records (EMR) by 2014 or faced Medicare reimbursement penalties.
- Doctors increasingly selling their practices to hospitals, thus becoming hospital employees.
- Growth of a small but healthy market for cash‐only, personalized, private care.
What patients should know
(according to Dr. Singer)
The increased regimentation and regularization of medicine is a prelude to the replacement of physicians by nurse practitioners and physician‐assistants.
It is true that, in many cases, routine medical problems can be handled cheaply and efficiently by paraprofessionals. But these practitioners are limited by depth of knowledge, understanding, and experience. Patients should be able to decide for themselves if they want to be seen by a doctor. It is increasingly rare that patients are given a choice about such things.
Medicare continues to demand that specific coded services be redefined and subdivided into ever‐increasing levels of complexity. Harsh penalties are imposed on providers who accidentally use the wrong level code to bill for a service. Sometimes the penalty can even include prison.
A small but healthy market exists for cash‐only, personalized, private care. For those who can afford it, there will always be competitive, market‐driven clinics, hospitals, surgicenters, and other arrangements—including “medical tourism,” whereby health care packages are offered at competitive rates in overseas medical centers. Similar healthy markets already exist in areas such as Lasik eye surgery and cosmetic procedures. The medical profession will survive and even thrive in these small private niches.
In 2011, The New England Journal of Medicine reported that fully 50 percent of the nation’s doctors had become employees—either of hospitals, corporations, insurance companies, or the government. Just six years earlier, in 2005, more than two‐thirds of doctors were in private practice. As economic pressures on the sustainability of private clinical practice continued to mount, this trend continued and grew
exploring the HEART of physicians practicing medicine
I am more optimistic than Dr. Singer. I see doctors of my generation still actively practicing, many still in their own practices. And I see the younger generation of physicians entering practice with new skills, tech savvy, influencers, and just as dedicated to taking care of patients as we were 40 years ago.
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Who will be your next doctor? What will your future doctor look like? Your doctor within the next 10-20 years is likely in medical school or a residency program in a United States medical center right now. Within 1-10 years, they will join the ranks of practicing physicians, while some currently in practice will change…Keep reading