Whatever Happened to My Doctor?

I’ve had health on my mind lately. I’ve been thinking about how the internet and now AI makes health knowledge more accessible to consumers. And about our health data is locked up in walled gardens and that is kind of fked up.

That’s led me down a rabbit hole of inquiring about our health system (in the USA, forgive my geographic bias) and trying to make sense of a vague feeling that something just isn’t right.

“Healthcare in America is broken.” This statement is so broadly felt and so oft repeated that the comment is itself banal to the point of having become a trope for pointless discourse. What’s really broken is our social fabric, if you ask me, for so broadly agreeing on such an important problem and yet failing to do anything meaningful about it for decades.

But I didn’t realize just how broken it all is until these last few weeks. And just how much worse it is going to get.

Let me begin by delineating between two sectors of health very roughly defined: the healthcare system and the commercial health industry.

By the healthcare system I mean the professionals who are licensed providers and the infrastructure of services and facilities and staff that exist around them to deliver health care in the traditional, “this is scientific medicine administered and either it is or should be covered by insurance because it’s related to a health concern, strictly defined.” Think hospitals, urgent care, doctor’s offices, skilled nursing facilities, rehabilitation centers, and nursing homes. Within healthcare I’m also including the privately health clinics - privately owned local businesses owned by one or a few medical providers who operate under a limited partnership model and service their communities and who make good money for themselves in return for taking on person financial risk.

By commercialized health I generally mean the privately owned businesses and services which were born of an innovative idea which was intended to grow and scale. These commercialized services have shareholders and they are nominally intended to do good health things for people (this is capitalism, after all) but, at their core, their raison d’être is to return financial value to shareholders. Commercialized health is the corporations that have a brand and they carve a niche for themselves in the marketplace and to some extent they scale. Coming from the world of tech, I think of the 23andMes and the at-home biometric labs and the sleep aid devices and the continuous glucose monitor interpretation software, but I suppose you would also include the insurance companies and the healthcare consultants and the revenue cycle management providers and all the rest of them, as well.

For the purpose of this post I will strictly focus on the healthcare system. “Healthcare in America is broken,” and at least some commercial ventures used this sentiment as a launching point to sprout and grow and twine themselves into our social fabric. Despite their purported corporate missions it is not clear to me the commercialized ventures have made a meaningful contribution to the problem - we continue to grumble that healthcare is broken - and I have my fair share of gripes with the commercial innovators. But here I’ll be focusing on traditional healthcare because that’s usually what we mean when we say “health” and, heck, we expect more of our professional health sector and it’s also where a lot of the problems with health in America begin.

Finally, let me preface and clearly caveat: I am in no way intending any of this criticism to be an indictment of the individuals working in the healthcare sector. I genuinely believe that most people who work in health do so incurring significant personal cost to themselves and that they do it with the intent to improve the lives of the people and the communities around them. I believe the people who make up healthcare are good people.

But I also believe health is, on the whole, broken. I have come to believe that we are on a slow and gradual path to ending generalized healthcare in America.

Beginning with a personal anecdote

A couple of years ago I noticed an unusual symptom. Not thinking much of it I messaged my health provider. Come in immediately, they said. I obliged, they asked their questions, and they immediately ordered a series of tests. They seemed concerned. “Are you sure,” I asked, “because I feel fine otherwise.” “Yes. This is not good. This is serious,” they said.

What followed was a series of tests and procedures and negative results followed by more rounds of tests and on and on and on. This went on for months. Close to a year.

Order the labs. Another round of labs, just to double check the first wasn’t an error. Let’s run labs one more time but, in the meanwhile, an ultrasound. Then the specialist consult. Then an MRI with differential. Then another specialist. Now let’s do some different labs. On to another specialist. A rather intrusive (if I may remark) camera exam, just to be safe. Another specialist. Some jump scares along the way as I independently reviewed my test results while waiting to see whichever relevant specialist.

In the end, thankfully, I’m fine. Probably. I just can’t take certain types of vaccines anymore, and it’s all in the past for now.

But through my experience I had a realization: this is all just a giant game of hot potato, and I’m the potato.

Every stop on my journey would go the same way. Receive a referral to a specialist, some insurance tediousness, scheduling issues, some paperwork, make an appointment, do some paperwork, see the specialist. “Hello, I’m this-type-of-specialist, why don’t you tell me what’s going on.” Recount my story from the top, specialist patiently listens and scribbles some notes. “Let’s order some tests and come back to see me when they come in.” Time passes, results happen, I ChatGPT the test results until I can get back in with the doctor.

“Good news! I’m happy to tell you that your problem is not the specific type of problem I specialize in.” Cool, I say, now what. “Now you go on to see this next type of specialist.” And so the cycle continues until I’ve exhausted and invalidated every symptomatically-related option that modern science knows of.

I’m not saying any of these specialists were bad people. They did their jobs. This is what our health system is designed to do.

But. Throughout this whole process no one was meaningfully present to own the issue and to centralize and coordinate and make a measured, informed, holistic, balanced assessment. It might seem obvious to a layperson like you and me that we should have some such expert individual and advocate through such a logistically and scientifically confusing process. But, just think from the healthcare system’s perspective! Can you imagine the legal liability! And how would the system cover the cost for such a squishy and unquantifiable and unmeasurable service?

So instead we have this alternative. A labyrinth of specialists and standard operating procedures and decision trees according to every possible combination of symptomatic presentations. Escalating procedures and prior authorization pathways that, conditional on having previously checked the right formulaic boxes, green light increasingly expensive workups. It’s all a complex matrix of minimizing liability while also minimizing the summation of probability-weighted cost of the procedures born and paid by the ultimate payer - the insurance company.

Never mind that in totality this process imposes far more cost, in both time and money, on the overall system than what might be the case otherwise. Thankfully, by the grace of insurance, I didn’t have to incur the financial cost of this labyrinth myself. And by this exact token so the cycle of insanity continues; near term financial incentive structures leading to long term careening big picture nonsense.

The gravitron that is our healthcare system keeps spinning faster and pushing harder and going nowhere.

The fiction of the doctor

There’s a myth that we tell our young children. It goes something like this.

“This is a fireman. When there is a fire they come in a big red truck and they put out the fire and they keep us safe.”

“This is a teacher. They are a friendly adult who helps you learn new things and grow up to be smart.”

And then we turn to the next page of our picture book.

“This is a doctor. They are special helpers who check that we’re healthy, and when we have an ouchie they help us make it right.”

Real doctors - the type that exist out here in the real world, not the type we tell our children about - are good people and they serve an essential role in society.

But that romanticized abstraction of a doctor, the one that we grew up believing in - an essential individual; an authority for health, who has the trust of their local community members, with whom they have a relationship over time; a person who makes a minimum standard of health accessible and attainable to all, regardless of socioeconomic birthright or social connection and privilege - that doctor simply does not exist. It did once, I think. They were called family doctors, at least at one point.

That notion of a doctor is a rapidly dying breed in our society. The profession is a victim of the economic structure we have built around our health system.

By the way, that mythical notion of a doctor - the one that we tell our children about - it has a name. They do actually exist, in principle.

They’re called Primary Care Providers.

Context - sorry, but it’s important

Doctors are good individuals and they have good intentions. But individuals exist in a context. That context can be generalized and further generalized. Eventually “context” becomes society in the broadest sense. Each layer of context also sets incentives.

And individuals, even the best intending ones, respond to incentives.

If you want to skip this entire section, just take this next statement at face value: the incentives to be a primary care provider (PCP) suck.

If you want to understand why being a PCP sucks, you have to begin by understanding the economic incentives that our societal context has set. And that, of course, requires a brief detour into the wonderful world of health insurance.

When you receive care in our healthcare system you are generally not the payer for that care. In some indirect sense you are, because either you or your employer pays for your health insurance and so ultimately it’s your dollar that round trips its way back to the provider. But you don’t pay for any specific service which you receive - you are shielded from the economics of your care by your insurance policy - and so we as consumers of healthcare in the aggregate have no role in setting a market clearing price for the care that we receive. The specific price for any given service is set by the actual payer, which is the insurance company. (Insurance companies are literally called “Payers” in the coded language of health sciences.)

Now let’s look at the economic context of healthcare from the perspective of the providers who delivered your care - the doctor and the staff and the healthcare system which exists around them.

Insurance companies pay for care but it would be very difficult for them to assign individual dollar values to every geography and specialty and procedure and service and provider. So instead they negotiate contracts with provider groups (the hospitals, clinics, etc.) whereby they will pay a fixed dollar amount for any given unit of work. That unit of work is called an RVU - a relative value unit. The determination for how provider groups will be compensated goes something like the [RVU of any individual service] multiplied by the [dollars paid by insurance per RVU], and that in turn determines how the individual provider (doctor) is paid.

The financial value delivered by doctors is not measured in effort made but in services rendered. And not all effort has a value assigned to it, even if it’s exactly the part of your care that you, as the consumer of that care, would say that you value the most.

A medical procedure will be worth more RVUs than a typical consultation. This might directionally make sense, generally. The devil is in the details: how much more valuable should the procedure be and also what about everything that isn’t the procedure or the consultation itself.

Surgeries, coronary stents, colonoscopies, critical care, and the like are all assigned high RVUs. This makes sense! They address the worst and most advanced diseases and require the most specialized knowledge and skills.

Consultations, on the other hand - cross-sectionally examining your lifestyle, triaging your concerns, answering questions - are generally not very valued in the RVU system. Within the framework that RVUs measure (services rendered) a consultation is for the most part just that, a consultation. Office visit RVUs can scale a bit with time and complexity, but even a long primary care visit is worth a fraction of what a quick procedure brings in and it’s not much different to a cursory alternative. In addition, the invisible work that exists around any one given consultation isn’t captured at all.

Here’s a laundry list of items you might think should be valued by healthcare payers but in reality they are not:

• responding to patient messages in MyChart (You know those helpful questions you’re getting answered, your prescriptions refilled, clarifications requested after a consult, those things you do all from the convenience of not having to take time out of your life for a doctor visit? They’re useless in the eyes of the medical system);
• PCPs independently coordinating and clarifying with specialists in support of your overall care;
• arguing and making your case to insurance so as to secure prior authorization and have your care appropriately financially covered;
• reviewing additional outside health records to double click, further investigate, and arrive at a non-obvious diagnosis;
• reviewing lab results, titrating dosage, refilling prescriptions, de-prescribing unnecessary medications.

Most of this work has historically had an effective RVU of ~zero: either there was literally no code for it to bill or the codes are so poorly paid and administratively painful that they don’t get used. From a PCP’s point of view, all of this is effectively unpaid labor from their part.

Now you see how the healthcare experience that we actually receive begins to make sense. I don’t know about you, but the way I ascribe value to the component parts of my healthcare is very different than what’s described by this RVU structure.

This begs the obvious question: who sets these RVUs anyway? And this brings us, inevitably, onto the topic of regulatory cartels.

Any insurance company could, in theory, set their own RVU schedule. In practice they do not. Doing so would be complicated and difficult and it would add significant obstacles to negotiating contracts with the broad and diverse ecosystem of medical provider groups. So instead private insurance companies adopt the RVU schedule that is used by Medicare, which is by the far largest single insurance group in the United States. And where does Medicare get its RVU schedule from? The American Medical Association.

Within the AMA sits the RUC: the RVS Update Committee. The RUC is composed of 32 doctors. The majority of them are nominated by each respective medical subspecialty’s society: cardiology, dermatology, psychiatry, neurosurgery, and on and on.

The RUC has 4 or 5 seats that could be said to represent “generalist” doctors: pediatrics, geriatrics, internal medicine, family medicine, and one additional primary care specific representative.

The RUC is tasked with evaluating the complexity, effort, risk and value of physician work across the healthcare system and this is translated into practice when they set RVUs for the healthcare industry and they set RVUs by committee vote. Most of the voters are very specialized doctors who have spent their lifetimes dedicated to studying and addressing very specific, very narrow, very advanced conditions. 15% of the voters (5 of 32) come from the perspective of how to keep you and your family generally healthy, generally speaking.

The death of the PCP

Individuals exist in a context and context sets incentives and incentives motivate individuals.

I am not a doctor and I do not fully appreciate the nuances of the life of a doctor. The RUC sets RVUs and the RUC is made up of doctors - doctors who understand the nuances of being a doctor. I believe doctors are good people and I believe that the members of the RUC have good intentions when they set the RVUs which go on to drive the economic incentives of our entire healthcare system.

But those RVUs have effects which reverberate through our economic system, so let’s talk about those realities as they narrowly impact the life of a primary care provider.

PCPs are financially compensated less, overall, than their specialist counterparts.

PCPs shoulder a huge amount of additional work that isn’t shareable with a billable technical team, unlike specialists operating in procedure-heavy hospital settings.

PCPs are compensated by unit of work performed - whereby a unit of work is an individual consultation with an individual patient - largely irrespective of the effort surrounding or quality of work delivered within that consultation.

PCPs are uncompensated for managing ongoing care, refilling prescriptions, coordinating care across the medical system, and advocating on behalf of their patients to insurance companies - all of which are parts of the job which patients reasonably and intuitively expect their doctor to be providing as their PCP is nominally their gateway to the medical system.

It is an open secret in medicine that the students who are the doctors of tomorrow are quietly but persistently steered away from primary care: it’s too much work, too little pay, too high a risk of burnout. Choosing primary care despite these warnings will mean trading money, status, and an easier life for the noble but thankless work of being the patient’s first and most trusted port of call when something is wrong.

This sentiment is borne out in the data. After medical school, graduates enter the residency match where they’re slotted into specialties. Every year the system struggles to recruit enough trainees into true primary care roles: family medicine leaves hundreds of slots unfilled after the main match and a shrinking share of US medical grads choose primary care tracks, even as the need for primary care providers in the market keeps rising. The market is failing to normalize supply and demand in the marketplace.

Because the pipeline from trainee to practicing doctor is so long we have good visibility on the trend. The context of healthcare today has already defined the workforce of our healthcare system a decade from now. The number of PCPs per American has been decreasing and it will continue to decrease for as far as we have projections.

But it gets worse.

As the number of practicing PCPs decreases, the overall patient burden loaded on each individual PCP increases. Individual consults have to be shorter, there are more prescriptions to refill, there is more care to coordinate, it takes longer to respond to patient messages. Administrative burden grows and doctors have less time to provide the individual care which they were signing up for when they chose their profession. The cycle feeds on itself and the problem gets worse.

Primary care providers should be the first line of defense of our healthcare system, along with emergency medicine. PCPs are who we go to for help when our health concerns present at their earliest and least advanced stages. PCPs are the layer of our healthcare system tasked with preventing and delaying advanced adverse outcomes. And they are the layer that our economic system has left behind.

Some closing thoughts

One unique quirk of our American healthcare system is that, unlike most other advanced economies, we do not offer a universal, publicly administered healthcare option. I will not express an opinion on the tradeoffs between a primarily market based, distributed health system like the US vs a universally available national health system like in Europe. I think capitalism is generally good and I do not wish to wade into an ideological debate about the virtues of capitalism vs socialized medicine.

However through this process of thought and research, one question on the back of my mind has been “What are we looking for when we as consumers of health say ‘we want to be healthy’?” And I have come to realize that one unexpected consequence of our market based healthcare system is that we don’t have an authority to define health.

I’ve heard the phrase “standard of care” bandied about in the context of health, but let’s be real: there is no standard of care for Americans. There is a legal standard of care, one which we use in the case of litigation, but this standard is a legal question which is specifically applied in individual situations when interrogating legal malpractice. We have no overall standard to benchmark ourselves against as individuals in the search for health; no defined standard that we can point to and grapple with and challenge and apply to ourselves and our lives.

In America, it is uniquely the responsibility of the individual to answer for themselves the questions: “What is health? What does it mean to ‘be healthy’? How do I attain healthy?”

I find it perverse that our discourse hand waves the virtue of preventative medicine as obvious common sense, as if it should be self-evident that a healthy lifestyle and proactively understanding and managing our personal health is the best way to care for ourselves; that no less obvious than preventative medicine’s virtues are how to access and practice it; and that our society treats those who fail to practice preventative medicine as moral lepers and the deserved reapers for the life they sowed. “Preventative medicine is the best medicine” has become nearly as trite as “healthcare is broken.” Isn’t it great that the two tropes are complementary and that they make a third trope between them: “preventative medicine is the key to fixing our healthcare system.”

Curiously, almost nothing about how we spend money or design incentive structures suggests that we believe what we say.

If you define our societal values as what we do rather than what we say, then what we value is things like heart transplant surgery for advanced cardiac conditions. We value highly advanced technical procedures which require teams of highly trained and highly specialized doctors who operate in high risk situations and perform medicine which exposes them to great legal liability.

And valuing such types of advanced procedures comes at the cost of us not valuing, on a relative basis, the statin medications which went off patent decades ago. Medications which are commonly available at roughly zero cost. Medications which, however, do require generalists to meet and evaluate patients early and often; require consulting with those patients about their conditions and intervening with first-line treatments early; which require monitoring patient progression and titrating dosage and refilling prescription over a long period of time. All functions which are either uncompensated or minimally compensated by the economic context of our health system.

It’s absolutely wild.

I wrote this because I have thought and I have inquired and I have researched and I have challenged and this is the place I’ve come to. It’s so broken - so much more broken than I thought it was when I was naive and felt like surely it couldn’t possibly make sense but I didn’t understand why. And now that I’m starting to have a sense for why, I don’t know what can possibly be done about it. Everyone is doing their best and responding rationally and ethically within the context of the healthcare system but the machine is so dispersed and so complex and so entrenched as to being incapable of making the sweeping changes to rightsize its direction from the inside. I don’t want to sound dramatic but at this exact moment it all feels rather hopeless.

In the meanwhile, we can all at least do one good thing.

The next time you see your doctor: thank them.