In the 1960’s, the Federal government entered the health care industry with the development of Medicare (insurance for the elderly and disabled) and Medicaid, a federal-state collaboration to help insure the needy. Initially rejected by physicians, the steady revenue stream from the federally insured patients helped support the rise of American physician incomes to the elevated levels (in comparison to peers globally) where they are today. And, since then, we have lived in an unstable era. For physicians, they see themselves -speaking in the broadest generalization-as solely engaged in a professional relationship with their patients. The patients, on the other hand, face enormous costs for health care (both the insurance premiums, partly covered by the employee, and increasingly large out of pocket expenses such as deductibles and copayments for services). Neither of these parties is especially sympathetic to the payors (either federal or private insurance) responsible for distributing money -Medicare is often criticized in spite of its great efficiency, and the private insurance companies have, in some instances, reaped enormous profits, because, in a sense, no one wants to say “no” to health care. This has led the US to a health care crisis. We are spending about 17% of our gross domestic product on health care, and our outcomes–the health of our population–are not particularly good.

This crisis has led to some action by the government and some shifts in the health care industry. As the major payor for health care services, the government is exerting its power through a variety of regulatory changes in the ways in which it will pay doctors and hospitals, all of which might be generally described as new demands for accountability for payment. In the prior system, fees generated by hospitals and physicians were paid by the government, with limited scrutiny, the honor and the professionalism of the physician’s actions were taken as a given. Now, in a number of different ways, the government is exerting more demands in exchange for payment -through a variety of review processes designed to ensure that the government (and, by extension, the patients) are receiving value for what they are paying for. The payors are no longer willing to pay a high price tag for a system that is not delivering quality. One component of this change on the part of the federal government is the requirement (for full reimbursement) that physicians and hospitals (or, integrated health systems) adopt electronic medical records. Paper medical records were quite common in the United States as recently as five or ten years ago, even amidst an industry that has benefitted from technological innovation. The isolation of important medical information in individual paper charts was identified as a reason for poor coordination of care, duplication of services, errors in patient care, and poor performance of the system, as a whole, in providing care for patients. Listening to physician responses to the widespread adoption of electronic medical record, or EMR, one is brought back to the reaction of factory workers to the introduction of machines in 18th century England, so well documented in the famous chapter 15 of Marx’s Capital. While the EMR will undoubtedly lead to increased productivity and efficiency of health care in the long run, it has indeed prolonged the working day for physicians, now working later hours or working at home documenting their care; changed the system of compensation due to the intricate relationship of documentation and reimbursement; changed the character of the workplace, with workers parked at stations in front of their machines; displaced some physicians from jobs (as well as plenty of transcriptionists); and, also led to the development of Luddite physicians, angry about those changes (and, even, led to isolated instances of physician vandalism of computers -at least one health system was forced to implement physician behavior codes for the first time due to these problems). Physicians are very frustrated about the ways in which the EMR, the machines, have disrupted their professional lives and, from their standpoint, been forced on them, placed between them and their patients.

So, we are at a point where the world of the American physician has been turned upside down and physician morale is at an all time low.

To be continued…