The reason, IMO, why all the normal triggers have come and gone without effect is painfully simple: We do nothing because to fix the problem requires systemic, far-reaching and disruptive change and pain to the groups that have lived off the fat of this system.

The reason systemic change is required (and far more radical that even the most radical Democratic party proposals is that medicine has labor-limited scaling, that is, it’s a knowledge worker business model, which have only very limited means to scale up to keep pace with economic “growth” expectations and inflation. It is an unscalable business model given the role it plays to the general public.

All revenue in such a business model is either billable labor or materials. In general, labor swamps materials. So you have, simplistically, R = F * t: revenue = fee rate x hours. Human are limited to 2000 (in the US) hours per year of deliverable work time. That puts a hard limit on t for raising R to keep up with either growth or inflation. That leaves F, the billable rate. This can be raised until it hurts, and then people stop using the service (supply and demand). Billable rates for doctors more or less peaked pre-WWII and pre-Great-Depression. What happened since? Post-war business was flush with cash (we had no competitors as we were the only industrial power not bombed to oblivion) so business started offering health insurance. This worked fine because they had deeper pockets that individuals ever did, employees were happy for it and it wasn’t a big deal for business. But to keep up, the billable rates needed to continue rising and they did.

The medical community has gone through all the same tricks that other labor-limited scaling business models have also used. The first was incorporation. Corporations have different tax model from individuals: income taxes are based on net profit rather than net revenue. This helped the squeeze.

The next trick is tiered hierarchy used by accountants and consultants: you charge at a senior partner rate but pass the work down to a lower paid subordinate and pocket the difference. This is what delegating medical activities to nurses really is. The need for tiers of price/performance is why nursing has some many different categories now compared to 100 years ago. The problem is hierarchies have performance limits (as Arrow pointed out) so the growth scaling slows with size logarithmically.

An additional trick is to skimp on the quality of product delivered per unit time. This occurs in the hierarchy scaling anyway as a matter of course, but you can extend it by adding more patients per hour and bill for full hours on each. Sound familiar? The current statistics on medically-caused (iatrogenic) deaths make it clear we’ve already gone too far down that path: you are more likely to be killed by iatrogenic death than by a terrorist, or even an automobile accident (which is 10x more likely than terrorist already)! Any *one* form of iatrogenic death (prescription errors, medical procedures, hospital infections) is greater than either risk!! There is absolutely no more room for decreased quality of service - any worse and you’d be statistically safer never seeing a doctor at all, ever. That may already be true.

Finally, recently, even business has started to squawk at the cost loudly. They’ve asked government to take the unprofitable parts (elderly care such as Medicare). They still want to skim the profitable cream from that group so you have MediGap insurance from private providers. And government can’t really cover it either, but especially now with the interminable financial crisis. If you think things will turn around in less than a decade, you’re on drugs.

The real issue is the framing of the problem: if you actually listen to every debate about the health care crisis, left or right, Democrat or Republican, it’s always about “which sucker can we pawn off the tab to next” rather than “what are we doing wrong and how do we fix it”. I was struck by this listening to a KQED Forum talk show - you’d think “new ideas” would abound in San Francisco, but I was sickened by what I was hearing.

The problem is that the role of doctors in health care has never been questioned. Having people in every loop and every step, no matter what, assures that meaningful efficiency will never be added to the processes that create cost and deliver care. The current system *can never scale* in any serious or meaningful way.

It gotten to this point because of one simple reason: moral hazard created by separating cost payer from benefit recipient. The economic signal for creating efficiency is completely messing and it’s a unscalable business model and we live in an economic system with incipient (but unnecessary) inflation. The growth-by-fee-rate-increase should have never been allowed to occur in the post-war period - efficiency would have been forced upon the medical community early on. This late will be harder to swallow.

This failure-to-scale is why the service/knowledge economy business model is doomed to failure in the US - bad failure. The world had service/knowledge economy once before: pre-Industrial Revolution crafts industries. Industrialization and machination replaced it because machines scale, but people do not scale. We have the same “throughput”, the same scaling, that we did 10,000 years ago. We only have better tools for leverage. Leverage by means of technology is the only way people scale - but it’s really the technology that is scaling and not the people. And when it comes to medicine, the human is in the critical path too often to allow scaling through efficient use of the tools of industrialization. When we don’t improve those tools yet need to raise revenues, this kind of price/performance crisis is the inevitable result. The service/knowledge economy was always a step backward rather than a step forwards - it’s self-denial of more fundamental problems.

The answer is to 1) determine when and where having a billing human in the loop is really delivering value and is doing so in a way that helps the system scale with added care-receivers and revenue pressures, 2) finding ways to replace doctors (yes, this has already really been the sticking point) with machines and thereby empowering individual care-receivers themselves to be the primary triage for all medical care, and 3) dismantle and remove the current “moral hazard”-creating structure of insurance companies and business-payers.

This is the only scalable path. This is the only path that will ever fix health care in the US. It will get worse, far, far worse - like dysfunctional 3rd-world level worse. Ironically, much of the 3rd-world is actually better at delivering health care than what more Americans receive.

I have doubts that the US has the cahones to fix it, just as I have doubts the US has the cahones to fix its economic mess and its education mess and its energy mess. These are all tied, of course. The nation is too full of itself with cocksure jingoism and delusional self-surety, but also compounded with being too fat, dumb and happy for too long to know how to start. This is how all empires in history declined.

Mr. Gruszynski’s rambling comments are interesting, but I believe un-insightful. While there have been temporary excesses in billing, most commonly by proceedure dominated physicians such as ENT, Ophthalmology, etc., the “billings” of primary care physicians has barely kept up with inflation over the past decades. When Clinton era health reform went down in flames at the hands of the insurance industry we were saddled with “managed care”, which basically beacme managed pricing and denied care by the insurance companies. Throughout the US most physician’s practices are defined by closed contracts with insurance companies that strictly limit fees paid to doctors. Operational costs (employee salaries, benefits, malpractice insurance, office expenses, etc.) have steadily increased, but doctor’s fees have not. In such a system it makes no difference what a doctor charges, as his/her payment is limited by the insurance company (including Medicare and Medicaid). Federal law encourages colusion by insurance companies by their exemption from the Sherman antitrust act, while physicians are prohibited from any form of joint negotiations with insurers. Physicians - and their patients have suffered. Mr. Gruszynski is correct in his simple assumption that to maintain income doctors are forced by these pressures to see more patients/hr. That is a dangerous situation which physicians would rather avoid, as it increases risk for all concerned.

For better or worse the person to person contact between caregiver and patient is inherently necessary in medicine. “Machines”, by which I assume he means computers are wonderfully competent at processing data, but notoriously unable to make “judgements”, or understand the nauances of verbal inflection, body language and cultural/verbal context. Simply put a computer can only answer the question it is asked and deal with the data with which it is programed You can’t take the human programmer or data entry out of the equation. I don’t believe that Mr. Gruszynski would actually want to consult a machine to discuss his erectile dysfunction, his depression, or his chest pain. The complexities of human dysfunction cannot be neatly converted into a series of “yes or no” questions. On the other hand computers can and have provided valuable help in reducing medication errors and bringing to the doctors fingertips the most up to date scientific information. The internet provides an excellent example of the limitations of this model. It contains an overwhelming mass of information, much of which is in conflict and is not edited or verified. The public becomes progressively more confused - and eventually must consult someone they trust with sufficient training and experience to sort the real from the nonsencical - usually their healthcare professional. The machine can perform a function, but it cannot discreminate or make judgements. My surgery professor once stated that, given 6 months time, he could teach a chimpanzee of average inteligence to perform an appendectomy - but he could never teach him how to make the decision WHETHER to operate.

Our healthcare system is the irrational result of a random process of coverage by the government, and businesses, which leaves millions of Americans with no insurance. When they become ill they are forced by access issues to seek care from the system’s most expensive, least efficient provider - the emergency room, where costs are ten times that of primary care. Those expenses are then shifted to the backs - and premiums - of the insured, and the cost spirals up and out of control. We already ration care, but do so in an irrational manner. Until all americans have coverage, the cost/shift spiral will continue. This will only occur when we have a public insurance option, not controled by the insurance industry.

Trying to make physicians the “whipping boys” for the increased cost of healthcare is simplistic. Since WW II medical technology has exploded. We have the highest technological level of care in the world, which hasn’t improved our health as a nation! Technology increases costs when we have no rational mechanism to determine where the technology is applied. Our healthcare system is broken, and terribly expensive. We need system wide reform, which will only come through citazen activism and involvement. We will all have to compromise to get where we need to go. Primary care physicians support that project.