Physicians and Medicine in the Twenty-first Century

The changes in the overall health care scene that are taking place will have a profound impact on prospective medical students who will be the practitioners of the twenty-first century. These changes will be reflected in the three areas discussed separately below.

Physician Status

• In the twenty-first century most physicians will be salaried employees rather than fee-for-service practitioners. They will work in or for group practices, hospitals, insurance companies, medical schools, or health maintenance organizations (HMOs). Medical care will be provided to patients as a result of contractual agreements between business and governmental units and medical providing groups, with solo practitioners usually not having access to enrollees of such plans. As a result of this restructuring, competition will increase among individual health care providers.
• It is anticipated that there will be fewer specialists and a greater number of primary care physicians. Some subspecialists may have to retrain in order to also serve as primary care physicians.
• Practicing physicians will be held more accountable for their performance.
• Business managers will have more input into how medical services will be provided.
• On the positive side, there will be less paper work imposed on physicians and thus they will have more time to see patients. It is anticipated that primary care physicians will be reimbursed at a higher level while specialist remuneration will decrease. The working schedule of physicians will be more predictable. This will provide them with greater leisure time.
• Medical care in the next century will focus much more on prevention and patient education in order to both extend life and also reduce long-term medical costs. Physicians will experience reduced per-patient revenue, but with an increased number of patients having access to medical care, they will be forced to see more patients in order to maintain their income.

Physician-Patient Relationships

Today, the depersonalization of medical care due to the interference of administrative personnel has had a dehumanizing effect upon patients. The disease, rather than the patient, is being treated. A positive doctor-patient relationship can be restored by providing a more sympathetic and attentive attitude. Medical treatment is not always essential or even necessary, but the patient's psychological and emotional needs should always be addressed.

Physician Reimbursement

The focus in health care over the past several decades has changed from one aimed at increasing access to medical care to an emphasis on decreasing costs. Both public and private insurers have been seeking ways to significantly lower expenditures. Most current health care proposals have the following features in common. They would (1) insure access to health care of most, if not all, citizens, especially those in the central cities and rural areas (who are frequently uninsured); (2) establish cost controls; (3) establish defined criteria for quality; (4) require preventive care (such as immunizations, mammograms, etc.); and (5) introduce medical malpractice reform (see below).

Managed Care

Proposals for managed care fall into three major categories. The first is a national system (modeled on that in Canada) that is completely under government control. The second is diametrically opposite and is a “free market” approach, which allows the principle of supply and demand to control the health care system. The third, a middle of the road approach, is known as “play or pay.” This involves businesses either purchasing insurance for their employees or paying into a health insurance pool for use in governmental pools.

All managed care is not government sponsored. Managed care is in effect, in the private sector, run by businesses that contract to provide comprehensive health care for their employees with group providers for specified time periods and preestablished costs for each employee. As a result, physicians have, in increasing numbers, become part of corporate medicine. They have been engaged as salaried employees of Health Maintenance Organizations (HMOs), which sometimes own hospitals. These organizations hospitalize patients much less frequently, and therefore are less expensive than traditional fee-for-service practitioners. HMOs have become increasingly successful. They have stimulated the formation of Independent Practice Associations (IPAs), in which groups of physicians treat patients in their own offices, and Preferred Provider Organizations (PPOs), which contract with companies to provide health care to employees.

Group providers seek to offer internally as much needed medical care as possible. Highly specialized care that the group cannot offer is supplied by outside specialists, who are reimbursed by the group. If the cost to the group at the end of the contract period is less than that guaranteed in the contract, the group will turn a profit. If the cost is more, it will incur a loss. In managed care under private control, physicians must make critical medical and ethical judgments about providing patients with access to diagnostic and therapeutic medical services. In contrast, in a fee-for-service relationship, the physician is paid to provide the patient with services that also necessitate making professional judgments about what medical tests and procedures are medically mandated, for it passes over into the area of “defensive” medicine.

All of these developments clearly indicate that increasing numbers of physicians will elect to become salaried employees rather than traditional fee-for-service doctors. The prediction has been made that more than 75% of newly graduated physicians will eventually work this way.

There are concerns that too much time is being spent by physicians on the business aspects of conducting a medical practice, especially dealing with HMOs. A recent innovation is the formation of Practice Management Companies (PMCs), which purchase practices and then assume responsibility for running the business end of them.

Having the office managed by a professional company provides for greater leverage when negotiating contracts with third-party payers or managed-care firms. Physicians are then free to devote themselves to providing patient care and avoid the distractions of the business phase of a practice for which they usually lack training and skills.

Physicians are also taking courses in business administration. This provides them with a grounding in the fundamentals of running their practice like a business.