Conway McLean, DPM, Journal columnist

Times are hard for many Americans. Inflation is on the rise, and at a frightening rate. The increase in the cost of gas is even worse. The pandemic and supply chain issues have only exacerbated the problem.

But this is a constant for the costs of healthcare, which seem to be growing exponentially, and have been for years. The expenses incurred by our medical system have ruined many of those unfortunate enough to experience a significant illness. It is a common question; why is healthcare so expensive?

This is a complex, multi-faceted question, with many differing answers. Unlike our neighbors to the north and all the developed European countries, people here are profiting from the illness of others (they’re called shareholders). And the number of middle managers and administrators for all the varied plans and insurance companies is truly staggering. Also, to be factored in are the fee’s charged by hospitals for the most mundane of products and services.

Many Americans would assume the doctors are a primary contributor to our healthcare costs. Certainly, a physician’s income is higher than average….but not by as much as you might think. How physicians are paid has changed, reduced to the fine print on a 50 page employment contract. Consequently, physician satisfaction surveys have plummeted, in part because of the assembly line style of modern medicine, leaving doctors far less time for patient care, their time dominated by administrative and insurance-related duties.

Economies of scale, where bigger is better, explains the success of Wal-Mart and Costco, and assumes that bigger is better. This phenomenon has spilled over into medicine, as is completely predictable. Large corporate entities have gone into the business of medicine, speeding the shift towards medicine as a commodity. Too often, physicians employed by large groups feel like they are now working in a factory, with quotas to keep, reports to file. Individuals receiving their care in these ‘human repair factories’ also get a similar impression, becoming simply a number.

The number of doctors in solo practice has fallen fast. Those economies of scale aren’t working in their favor in the private practice environment. The costs of supplies, the required protective gear, medications especially, have grown tremendously during the pandemic. Although everyone is having supply chain issues, these issues are heightened in medicine. Imagine, if you will, a world without local anesthetics, where a trip to the dentist would be an excruciating experience.

The challenges faced in medical practice are unique. In no other setting does this unique triangle of participants exist. Patients are the consumer, while healthcare providers are the supplier. This makes the insurance companies the middleman, getting in the way of the process. But worse than that, they are dictating the process, deciding who gets what treatment. And the reason for many of these decisions seems arbitrary at best, even to educated consumers. To a physician in practice today, the private insurers are the enemy.

Prior Authorizations are a favorite tool of insurance companies. The frequency of these inane requirements has increased noticeably in recent years. The doctor must take time out of his schedule (since a nurse or physician’s assistant is not sufficient), to talk to a nurse working for the insurance company. But there is no debating the issues at hand, the treatments that would be best for this individual. It generally seems to be a mere formality…… and yet it limits care. Too often, the doctor is not able to stay on the line, waiting for the appropriate individual to take their call, or the line gets disconnected, a common occurrence. made all for the benefit of a patient.

Many Americans have massive deductibles (the amount they must pay out-of-pocket before their insurance will start paying for care), thus their insurance is primarily for catastrophic illness, like a heart attack. The care of these emergencies in the US is second to none, but for prevention, i.e. health maintenance and disease prevention, most other Western nations are far superior.

Many aspects of US healthcare are under the auspices of the health insurance industry. For example, and surprising to many, the fees charged by a physician are out of his control. All the insurance plans have a fee schedule. When a practice signs on to be providers (for those individuals who have purchased that plan), the practice must accept those fees.

Non-covered services are another matter. Every insurance plan has limitations. There is always some service, treatment, or medicine the plan won’t pay for. Certainly, some treatment that is highly experimental shouldn’t be paid for, but the list of exclusions is not so simple. Some appear to have little logic associated with the limitation. Well-researched technologies, utilized safely, with excellent results, continue to be excluded from the list of covered services. Often to make use of the optimal therapy, the patient will have to pay for the service. In this case, the medical practice does set the fees.

Between pressure from insurance companies, the unreasonable patient, the demands on time, and much more, the stress of practicing medicine in this era is driving many doctors out of practice. Burnout, an excessive workload, fear of infection, anxiety or depression (often because of COVID-19), all have been associated with an increasing number of doctors intending to leave medicine. Experts believe the shortage of doctors will worsen dramatically over the next decade as more retire or leave practice.

The United States spends nearly $4 trillion on health care, making it the most expensive system in the world. Yet, compared to other technological countries, it produces the worst outcomes in categories such as life expectancy, obesity rates, and chronic disease burdens. Many American physicians have been in practice long enough to see the dramatic changes that have occurred. A familiar refrain offered by many doctors “this isn’t what we signed up for!”

The US remains the only industrialized nation in the world without a national healthcare system for working people. Senior citizens have Medicare, which is healthcare provided by the government, true national healthcare. Inept, perhaps, but not motivated by profit. For the private insurance companies, put too simply, more income is generated when services are denied, an arrangement that seems improper. Should this be the case? Is healthcare a right of citizens or a simple commodity, going only to those who can afford it.

Even though it is your health and well-being, your medical care is a business and people are making a lot of money from it. It seems a relevant question if this is a fair and just system. Many doctors would say the difficulties of medicine make the practice ever more frustrating. For many Americans, finding a provider is likely to become ever more challenging as well.