Countervailing Powers: The Changing Character of the Medical Profession in the U.S.

1. Countervailing Powers: The Changing Character of the Medical Profession in the U.S. James G. Anderson, Ph.D. Purdue University

2. Clinical and institutional control exercised by the medical profession over health care. Professional Dominance

3. Countervailing Powers • Interactions of powerful actors within health care. Dominance by one actor elicits countermoves by other actors to redress the imbalance of power

4. Deprofessionalization • Patients, government and corporate purchasers of health care are taking back the cultural, economic,, and technical authority long granted to the medical profession.

5. Reasons for Change • Concern over escalating costs • Unnecessary expensive procedures • Unexplained variation in practice patterns • Overspecialization • Failure of the medical profession to act in the best interests of society

6. Countervailing Power of Buyers • Large corporations, states and the federal government changed from passive paying bills to active control of costs • Payers organized markets for competitive contracts • The health insurance industry changed from passively paying providers to servicing the interests of payers • New organizational forms were created to deliver health care (e.g, HMOs, PPO,s)

7. Countervailing Strategies • When the federal government created the DRG system to control hospital costs, providers moved many services outside of the hospitals, invested heavily in new technology, began to provide services that would generate more income. • The federal government countered with a fee schedule for physician fees based on costs.

8. Countervailing Strategies • In response, specialists joined together in a political effort to reinstitute fees that were cut. Physician groups sponsored their own HMOs, threatened not to participate in Medicare/Medicaid. • Corporate purchasers of health care responded with an array of utilization management efforts.

9. Countervailing Strategies • States and the federal government attempted to move the Medicare and Medicaid enrollees into managed care plans. • The public began to lobby for Patient Rights legislation at the state and federal level. • Managed care providers began to withdraw from covering Medicare and Medicaid enrollees.

10. Trust in doctors Cross subsidization of teaching, research, charity care Extensive power to define professional work and to shape the organization and economics of services Mistrust of doctors Elimination of cost-shifting Minimal power to shape the organization and economics of services Change in the U.S. Health Care System

11. Exclusive control of clinical decision making Emphasis on specialization and state of the art interventions Incentives to develop new technology Close monitoring of clinical decisions Emphasis on primary care, prevention, minimal intervention Disincentives to develop new technology Change in the U.S. Health Care System

12. Cottage industry Over treatment, high costs, fragmentation of services Corporate industry Under treatment, cost control, obstructed access, integrated delivery systems, reduced quality Change in the U.S. Health Care System

13. National Survey of Physicians:Doctors’ Opinions about their Profession • Kaiser Family Foundation • March 2002 • Random sample of 1,426 physicians

14. Would you recommend the practice of medicine today?

15. What is the main reason for not recommending the practice of medicine?

16. The majority of physicians are satisfied with

17. The majority of physicians are dissatisfied with

18. The majority of doctors tend to feel negatively about the effects of managed care

19. During the past 5 years, do you think HMOs and managed care have had effects on