By Sean McLinden, M.D.

Sean McLinden, M.D., a licensed neurologist, is executive director of the Pittsburgh Health Research Institute.

Published October 1996

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This quote appeared in Getting There: The Epic Struggle Between Road and Rail in the American Century by Stephen B. Goddard. It was used in the context of the decline of the American railroad throughout the 20th century, when America’s once largest industry faced ruination. It could as easily have referred to hospitals or insurers as to railroads. The story so closely parallels the history of American medicine that many a physician would liken reading it to a near-death experience. It is the quintessential story of that great American comeuppance; a riches to rags twist on Horatio Alger.

Near the turn of the century, roughly one in every ten working people was employed by the railroads, while one out of every three working people was affected by railroad commerce (contrast that with one in every seven people working in health care in Western Pennsylvania). The railroads had brought prosperity and economic growth to many. Chicago (railroad) eclipsed Galena (riverboat), where the two cities had once been equal in size. America had the most sophisticated system of commercial transportation in the world. Before long it would unravel.

What doomed the railroads was not competition from the automobile, rather, they were undone from within. In the shift from customer focus to shareholder focus, the shareholder became the "customer", and when ignored customers became technologically empowered they went elsewhere, taking the laws as well as the spirit of the nation with them.

The United States has the highest standard of care in the world (morbidity and mortality being measures of implementation rather than standards of care). In spite of this (or perhaps because of it), the opportunities for customer dissatisfaction are high, and it was just those dissatisfactions that led to the establishment of health care reform as a key element of the Clinton platform. A great debate has raged about the causes of the health reform movement and whether it was needed, but the fact remains that the patient felt ill whether there was evidence of disease or not.

Ironically, at a time when naysayers are predicting the elimination of 4000 regional physician jobs, there has never been a greater demand for patient care services. Our ability to extend the length as well as the quality of life has increased the demand for these and other health care services, though there has been a shift in the types of service requested. There remains a large segment of the population that does not have access to affordable health care, which is itself an opportunity for both technical and financial innovation.

So, why are physicians concerned about the future? Simple. We’ve lost sight of who is the customer. In our panic to secure the best managed care contracts and the best hospital affiliations we have forgotten that the demand is coming from the patients themselves. It is the patients who are asking for greater access to more affordable services. It is the patients who are attempting to reconcile the often conflicting goals of cost and quality. And if we are too blind to recognize this, our competitors (yes, competitors!) are not. Witness the affrontery of a large regional insurer claiming that they’ll restore patient care to where it should be. What drove it from that point in the first place? In this century where the brand name has replaced the craftsman as the symbol of a quality product, why have we not responded to this demand instead of letting businesspeople and accountants do it?

The answer, I suspect, is that we have plenty of leaders and no leadership. We take no risks, instead allowing billion dollar corporations to replace our time honored profession as the symbol of quality care whilst we fight amongst ourselves for the gleanings. "Who is your provider?" has been replaced by "What is your provider?" Or, as Hillary might put it, "It takes a village to care for a patient." "Not-for-profits", many of which have forsaken their mission statements (remember those?) of community service and public accountability in favor of unbridled and unjustified imperialism, continue to argue that these steps are "necessary for survival" or to "preserve the type of care that we deliver", but who has answered the question, "Is this what the patients want?" With all of the media attention to networks, IPAs and MSOs, when was the last time that higher quality patient care was mentioned as the objective?

The American Medical Association recently asked, "Should the physician be the patient advocate?" and there were a number of sound and convincing philosophical arguments on both sides of the issue. But the problem is that this issue is not philosophical. It is purely pragmatic. In this age of ever increasing costs and options for care, the patients are seeking advocates for their interests and if not us—who know more about care than anyone—who then? Be assured, someone will rise to the task.

The story goes that in the early 70’s, Swiss watchmakers were introduced to the quartz crystal which could be made to oscillate so as to keep time. Legend has it that the Swiss, with more than 90 percent of the world market, laughed at the idea that time could be kept without a mainspring. Is the idea that patient care can be delivered without physicians as humorous?

We have but one option: to retake control of patient care before it is lost for good. The answer lies not in partnerships with hospitals or payers, for neither in its current form is essential to the health care process and both have identified themselves as competitors. Moreover, each has a cost structure that renders it noncompetitive (I received a $1000 bill for a routine physical with testing at one of our local hospitals; the cost to actually deliver the services was but a fraction of the charge). Nor does it make sense for a hospital to invest in an MSO any more than for a commercial laboratory or pharmacy to be an investor. For-profits risk that the directors will become accountable to the shareholders, not the customers (patients), though for-profit models are becoming increasingly popular.

Instead, our likely partners are the businesses, who act in the interest of their patient employees to purchase care, and the patients themselves. In this network we can be a collective purchaser of the services required to provide care, rather than a bidder for involvement of a care process directed by others. Other potential partners are the manufacturers of pharmaceuticals, who are working on disease management models in which seemingly costly care can be justified in light of its expected utility. Although this relationship has in the past been suspect, the realization than many individuals with preventable risk can have significantly improved outcomes on therapy has suggested a new ground for collaboration that establishes patient care as the overriding goal.

A little more than a century ago we created our hospital-based system of care and watched it become the most advanced in the world. And when it became necessary to finance that system in order to guarantee that it be available for all, we created the forerunner of today’s health insurers. Our loyalty is neither to an organization nor a building. We created those artifacts to service our primary objective of patient care. Ultimately, our common bond is with those who share our philosophy of care and our belief in the system of medicine that filters science through the lens of human compassion: our fellow clinicians.

When necessity dictated it, we have responded with innovation and creativity. Are we now like the flightless kiwi with only vestiges what were once wings? Or can we collaborate, once again, to create a system of care for the next century, one in which the physician continues to occupy the primary role in the management of health care delivery? When asked recently why physicians don’t simply regain control of patient care, a physician essentially responded that we were happy just to be invited to sit at the table. To my way of thinking, the invitations should be extended by those who can cook, not by those who are to be fed.