1. Countervailing Powers: The Changing Character of the Medical Profession in the U.S. James G. Anderson, Ph.D. Purdue University

2. Professional Dominance Clinical and institutional control exercised by the medical profession over health care.

3. Countervailing Powers  Interactions of powerful actors within health care. Dominance by one actor elicits countermoves by other actors to redress the imbalance of power

4. Deprofessionalization  Patients, government and corporate purchasers of health care are taking back the cultural, economic,, and technical authority long granted to the medical profession.

5. Reasons for Change  Concern over escalating costs  Unnecessary expensive procedures  Unexplained variation in practice patterns  Overspecialization  Failure of the medical profession to act in the best interests of society

6. Countervailing Power of Buyers  Large corporations, states and the federal government changed from passive paying bills to active control of costs  Payers organized markets for competitive contracts  The health insurance industry changed from passively paying providers to servicing the interests of payers  New organizational forms were created to deliver health care (e.g, HMOs, PPO,s)

7. Countervailing Strategies  When the federal government created the DRG system to control hospital costs, providers moved many services outside of the hospitals, invested heavily in new technology, began to provide services that would generate more income.  The federal government countered with a fee schedule for physician fees based on costs.

8. Countervailing Strategies  In response, specialists joined together in a political effort to reinstitute fees that were cut. Physician groups sponsored their own HMOs, threatened not to participate in Medicare/Medicaid.  Corporate purchasers of health care responded with an array of utilization management efforts.

9. Countervailing Strategies  States and the federal government attempted to move the Medicare and Medicaid enrollees into managed care plans.  The public began to lobby for Patient Rights legislation at the state and federal level.  Managed care providers began to withdraw from covering Medicare and Medicaid enrollees.

10. Change in the U.S. Health Care System  Trust in doctors  Cross subsidization of teaching, research, charity care  Extensive power to define professional work and to shape the organization and economics of services  Mistrust of doctors  Elimination of cost- shifting  Minimal power to shape the organization and economics of services

11. Change in the U.S. Health Care System  Exclusive control of clinical decision making  Emphasis on specialization and state of the art interventions  Incentives to develop new technology  Close monitoring of clinical decisions  Emphasis on primary care, prevention, minimal intervention  Disincentives to develop new technology

12. Change in the U.S. Health Care System  Cottage industry  Over treatment, high costs, fragmentation of services  Corporate industry  Under treatment, cost control, obstructed access, integrated delivery systems, reduced quality

13. National Survey of Physicians: Doctors’ Opinions about their Profession  Kaiser Family Foundation  March 2002  Random sample of 1,426 physicians

14. Would you recommend the practice of medicine today?

15. What is the main reason for not recommending the practice of medicine? Reason % Paperwork/Admin hassles 57% Loss of Autonomy 46% Excessive professional Demands 31% Less Respect for Medical Profession 31% Inadequate Financial Rewards 31% Difficult to Start/Operate a Practice 22% Ed. Process too Long/Difficult 16% Not personally Satisfying 15% Liability/ too Many Lawsuits 1% Other Reasons8%

16. The majority of physicians are satisfied with Satisfaction with% Continuity of their relationship with patients 84% Professional challenges79% Current income57%

17. The majority of physicians are dissatisfied with Dissatisfied with% Work hours spent on administrative activities compared to patient care 74% Time that it allows them to devote to nonprofessional interests, family and friends, 56% Having enough professional autonomy in the clinical decisions they make for patients 54% Their potential income over the next 5 years 53%

18. The majority of doctors tend to feel negatively about the effects of managed care Effect of Managed Care onIncreasedDecreasedNo Effect Amount of paperwork for providers and patients 95%2% Overhead costs for physicians’ practices 83%5%11% Amount of time doctors spend with patients 3%88%8% Ability of patients to see medical specialists 4%83%13% Ability of patients to get specific prescription drugs 6%78%14% Quality of healthcare for sick people 7%73%18%

19. During the past 5 years, do you think HMOs and managed care have had effects on Effect onIncreasedDecreasedNo Effect Overall health care costs 41%23%34% Amount of inappropriate care provided 26%29%44% Use of practice guidelines and disease management protocols 63%11%24% Likelihood patients will receive preventative services 42%26%31%