Let’s not kid ourselves. Becoming a physician today requires more than altruism. It requires courage.
Thanks to the shift from fee-for-service care to third-party insurance, caring for patients has become a day-to-day battle with managed care companies. Committing an error in billing is now a federal offense. And following burdensome tomes of government regulations is all but impossible.
It should therefore come as no surprise that interest in medicine as a career may be on the decline. A study published in the September 2000 issue of the Journal of the American Medical Association (JAMA) finds the number of medical school applicants has dropped for the third year in a row.
The number of med school applications fell by 6 percent between 1998 and 1999, 4.6 percent between 1997 and 1998, and 8.4 percent between 1996 and 1997. Between 1996 and 1999, 8,439 fewer students applied to medical school: a nearly 20 percent drop from the 1996 high of 46,968 applicants.
Meanwhile, the U.S. population is increasing at almost 1 percent a year. According to the U.S. Census Bureau, nearly 7.5 million more people called America home during the same three years that over 8,400 fewer students applied to become their physicians.
Although the JAMA study found the number of applicants accepted into medical school was virtually unchanged since 1990, the continuing decline in applicant interest combined with persistent population growth may lead to future physician shortages and subsequent admission of less-qualified applicants–a situation that would negatively affect health care quality and access for all Americans.
Power Shift
The JAMA study does not offer an explanation for the sharp decline in medical school applications, but a shifting power base in the health care system may be reason enough to dissuade prospective students from joining the medical profession.
As a result of Medicare, federal tax deductions for employer-sponsored coverage, and the 1973 HMO Act, the medical bills of most Americans are now the responsibility of employers, government agencies, and health plans. As patients relinquished control of health care dollars, authority for treatment decisions moved from the medical profession to the insurance system.
Even the terminology changed. Physicians are now”providers” and their patients are the “covered lives” of insurance companies.
Because physicians depend on health plans for payments, patients are frequently caught between the medical decisions of physicians and the judgements of health plans. Managed care contracts, treatment codes, medical necessity reviews, prior authorization approvals, and proper paperwork severely limit the physician’s power to care for patients. As a result, today’s physicians can be found trading precious appointment time with patients for pleading sessions with health plans.
Treating recipients of government aid is no easier, and significantly more worrisome. Federal and state health care regulations totaling 132,000 pages must be scrupulously followed because small or unintentional health-care-coding billing errors can force physicians out of practice–or into jail.
The Health Insurance Portability and Accountability Act of 1996 classified health care fraud as a new federal offense, allowing federal agents to make felony charges against physicians, assess excessive fines for infractions, and seize a physician’s property. According to the American Medical Association, the fear of becoming subject to a federal investigation has caused physicians to undercode–charge less for–their services.
The decline in medical school applicants may also be attributed to 1997 changes in federal funding. Since then, Medicare has underwritten the cost of graduate medical education, the in-hospital residency training physicians receive after medical school. To cut Medicare costs, federal health officials have offered hospitals millions of dollars to decrease the number of physicians they trained each year, especially medical specialists.
Regaining Power
To maintain the practice of medicine as a viable and attractive career, sufficient medical training must be available, government regulations must be minimized, and patients and physicians must regain power over health care decisions.
Key to restoring patient and physician control is patient empowerment through more direct control of health care dollars. Inexpensive, high-deductible health insurance for the rare medical catastrophes, personal or medical savings accounts for routine and minor health care expenses, and federal tax incentives that encourage individual purchase of lifelong insurance policies will allow physicians to provide care and counsel to patients without third-party interference.
Once prospective medical students see the practice of medicine redirected from insurance and regulatory requirements to the care of hurting patients, applying to medical school will no longer require an act of courage. A heart of compassion will suffice.
Public health nurse Twila Brase is president of Citizens’ Council on Health Care.
For more information . . .
on how managed care arrangements can present a conflict of interest to physicians, see “Doctors as Accountants: The Ethics of Using HMO Referral for Cost Containment,” published in 1997 by the Nevada Policy Research Institute.
The full text of the 12-page document is available through PolicyBot. Request document #3252401.
Twila Brase is the president of the Citizens’ Council for Health Freedom.
