The physician condition: the age of economic medicine.

The prescriptions to reform health care--such as the passage of a Maryland state legislature bill that would require companies with more than 10,000 employees to devote at least eight percent of their company payroll to health insurance--will do nothing to resolve the despair most people feel over the exhaustion of the old order of health care and the absence of any new one.

They are placebos more certain to aggravate the ills of the system they have been designed to reform because what is known but not yet accepted is that true health care reform is outmoded.

A quarter of a century ago, health care began experiencing its latest revolution, evolution and reformation, and has by now shifted into a phase of social legislation. The underpinnings of this legislation are found in the economic and political approaches to issues believed to be ripe for reform.

All of these issues--quality of care and outcomes, malpractice and tort reform, health care insurance and managed care--may be valid, but they are not adequate by themselves. Based on the older order, each has been treated as an individually self-contained matter that has crippled the scope of any legislation proposed thus far and any that will be proposed.

What has been missing is a diagnosis of the condition of health care as the result of a withering away of its traditional structures and its move to pluralism. This broad disconnect makes health care different today than during any other century and that makes it entirely different from the type of health care most people expect.

As the majority of the population moves through mid-life and into elder years, health care will assume the proportions of every social, political, and economic decision because health is a most basic need of every person.

But almost every scholar, politician, practitioner, public advocate, and member of the press who has proposed a "reform" has overlooked this simplicity. This makes the prescriptions of reform disappointing if for no other reason than partisan politics and economics cannot resolve what is actually an issue about the advancement of change in the institutions conserved in our free society.

And, just as important, the proposed programs mistakenly deal only with surface social phenomena and dismiss social analysis.

Below the surface is the fact that the practice of medicine--and the doctor/patient relationship from which all health care provision in our society emanates--has already begun to bifurcate into a profession that is not only female-determined, but one that is also age-determined.

It is significant that one extreme social transformation has proceeded with a minimum of attention from anyone who is involved with or utilizes health care: the physician workforce that existed in the United States before the last quarter or third of the 20th century had been male-determined from the start; it is now becoming female-determined.

The incitement of this latest revolution in American health care is evidenced by the fact that females now account for half of all medical school applicants where 35 years ago they comprised less than one-tenth of the applicant pool.

Socially and psychologically, this shift will alter every timeworn impression of the physician. Nothing like this has happened since females began replacing male teachers during the 19th century. Economically, the increasing number of females in the workforce has already changed things in momentous ways. Chief among them has been the growth in the number of females who join the physician workforce and who also continue to involve themselves in traditional roles at home that has been the driving force behind flexible work schedules.

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Female physicians born during the time between the early 1960s and as late as 1980 were among the first band of physicians to demand flexibility and variety in their schedules. When these requests were accommodated, male physicians of the same generation requested similar elasticity in their schedules and then so too did physicians en masse.

This is another factor of something to which not even a handful of people are even beginning to pay attention: the older population of physicians assert different expectations about their work compared to the younger generation of physicians.

Physicians of the Baby Boomer generation--those 45 years old and older--experienced dramatic, almost 180-degree, practice management changes throughout their careers. They most likely began and spent most of their careers in private practice as solo practitioners or in small groups, but are now likely employed by or similarly associated with a large health care organization.

These physicians convey satisfaction in their jobs because they are entrenched at a point in their careers where they are given opportunities to voice their opinions and make high-level decisions.

Practicing medicine has also provided a respectable level of affluence for most members of this generation because of less-stringent economic constraints on medicine during the early and middle years of their careers. But younger physicians have been largely deployed into the field during a time when medical practice management has been relatively static, having been run by an organization of some form or another.

In the not-too-distant future, every working physician will for the first time in the United States have been enveloped in a career-long bureaucratic system that systematically leads to a more impersonal, less satisfying work experience.

Like professionals in other industries who do not find satisfaction in their jobs, physicians will increasingly turn to activities outside the work-place in order to balance out their dissatisfaction. Such sentiment, though largely shrouded by more pressing surface concerns, has already made dealing with physicians who view their work as a "job" rather than a "calling" the central management issue of every health care organization and every health care consumer over the past 20 years.

Respectively problematic, these wholesale professional changes are the result of changes in values, expectations and objectives that have already occurred but that have not yet been negotiated, which makes health care delivery regulations remain based on relic assumptions.

Medicine today is defined by the reality that health care continues to operate on old world sensibilities and the persistence of nostalgic beliefs.

Among the factors impacting health care are:

* The overall growth of the United States population

* An increased demand for physicians' services due to economic expansion

* An increased demand for more medical care by an aging population

* Increases in malpractice insurance premiums and concomitant legal issues

* Insurance carriers that dictate practice methods and income

* Physicians' salaries that lag behind the rising rate of inflation

* The retirement of practicing physicians

* The fact that physicians spend long hours--an average of nearly 60 hours per week--involved in professional activities

* A general decline in productivity

* Geographically dependent lifestyle effects

These are broad strokes that make today's medicine structurally divergent from the historically personal form of health care with which most of the middle-age and older population is familiar.

Within five or seven years, as the physician workforce experiences the zenith of the natural progression of younger workers coming in and older workers going out, medicine may completely evolve from the historically very personal form of health care delivery to a mostly impersonal form.

Principles of coming health care "reforms"

The most pervasive option to manage such change has thus far been found in the leitmotiv of providing better care more efficiently through sweeping quality improvements.

Quality, though, as a highly subjective abstraction, is only as good as a market dictates it to be. The consensus that promotes the supposition that quality must improve if the medical system is to perform "well" has not been identified. Nor is it clear exactly who will define the standards.

Without this designation, the popular link between quality of services provided and physician compensation is illusory. It also makes aligning physician compensation with the quality of services provided as unjustified and ridiculous as aligning teacher salaries with student test scores.

Nevertheless, merit-pay systems that are rooted in the belief that monetary incentives will motivate a service provider to produce at a higher level of quality than is the "norm" have been worked into the conversation for one purpose only: to reason that rising costs in health care should be handled no differently than rising costs in other industries.

Alas, the inherent lack of protection rendered by individual production-based compensation that has long been a risky-but-lucrative system for professionals across every other industry, is not likely to lead to increased productivity among most physicians because it distracts and disengages physicians from key priorities by focusing on quality over delivery of care.

Over the past quarter century, while the demanding modes of change experienced by physicians and patients have not radically altered the elements of health care, the clearest indication that health care--and medicine, in particular--is no longer composed of "mom-and-pop" type outfits is that what used to be a "physician" is now a "provider" and what used to be a "patient" is now a "consumer."

These are the most obvious expressions of a health care system that has bypassed the doctor/patient relationship in favor of a system almost totally defined by group practice relationships, health maintenance organizations and managed care.

These models, which can be traced to the prepaid health care programs conceived as far back as the early 19th century, deliberately wed delivery of care with cost of care. Such special-purpose, consolidated organization models inherently reduce the amount of independence that physicians and patients experienced in the past by the increasing concentration of power and decision making, remanding it to the executives and higher level custodians of the respective organizations.

To counteract any system-based dissatisfaction, the economist or politician turned "health care reformer" has dreamt up all sorts of regulatory designs. Neither together nor alone could any of these "answers" be optimally effective in redefining health care in the United States because not one of them fundamentally undercuts the devolvement of health care into its present jumble of individual and collective government, business and society interests.

Cowering to political bases, these tremendous and forceful attempts to restore order have postponed and evaded any solution and are provably nothing more than redactions of "safe think."

New medicine

We are now more than 15 centuries since the Greek physician Hippocrates "modernized" medicine, having discredited the Cnidian convention that favored diagnosis and classification of diseases over attention to the individual patient. Though a regard for the former remains a matter of disrepute in the practice of medicine, it is a concern for systems, not people, that has again become policy and practice throughout health care. A reliance on systems has ushered in the era of consolidated health care organizations--"health care blocs"--that are the integrated units of modern medicine. The goal of each bloc is to establish internal support and alliance, and to eliminate and protect against any internal and external barriers, limitations and obstacles by investing in the creation of institutions for the bloc to be effective. Within each is the oft-concealed belief that economic progress is the highest, most justifiable goal and the lingering question, "What is the return on investment?" This is, fundamentally, economic medicine. But now the urgent question is whether this institution is alert enough and engaged enough to handle the "new medicine."

That is, has economic medicine integrated the principles and philosophies of Hippocratic medicine? And by virtue, will the new medicine integrate these principles in a way that is socially, politically and economically meaningful today? From any given historical point, it is true that health care has existed primarily to preserve the well-being of human beings. It is equally true that health care has always entailed the prevention, treatment and management of illness if human well-being is to be preserved. What has changed--and what we can reasonably expect to continue to change--are the conditions and requirements of a health care system as it functions in society.

Presently, we can regard as certain two things: that the currently available programs have outlasted their usefulness, and that we do not and cannot yet know what the basic concepts of new medicine will be. Also of late, economic and political actions that supercede philosophical beliefs have wrested ownership function and status from the practitioner and the patient; they have conceivably forced any levels of decision making through layers of corporate and government apparat, and discounted the physicians and patients who are the actual users of the health care system. That truth is precisely why there are no absolute antidotes to cure the ills of the health care system.

In order to resolve the health care system issues in the United States, physicians, physician employers and health care organizations, politicians, the media and the public will press each other to invest in the creation of new institutions throughout health care and society. But they will all have to recognize that the primary task in the preparation of these new and viable aims is to think through basic problems and to understand basic issues, beginning with an examination of the physician at work. It is physicians who on a daily basis participate in health care more than any other stakeholder, which means they are the constant baseline--the touchpoint--from which to assess the thoughts and behaviors of the people, organizations, managements and systems that have an impact on health care.

Lee H. Igel, PhD, is a professor at the School of Continuing and Professional Studies at New York University in New York City. He can be reached at 212-998-7132 or [e-mail]

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By Lee H. Igel, PhD