Health Affairs, 22, no. 1 (2003): 283-284 doi: 10.1377/hlthaff.22.1.283 © 2003 by Project HOPE	New Online   House Health Reform Bill   Paying for Reform   Vetting AHIP's Report   HIV/AIDS Costs   Brief: Insurance Reform   HA Blog Top 10

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Letters

Market Demand Matters

Grumbach discusses the analytic challenge of treating "the anticipated incidence of disease." This misrepresents what in today’s health care marketplace constitutes a sizable proportion, if not a majority, of providers’ work output. Today’s medical paradigm is not the treatment of established disease, but disease prevention and the counseling of those already afflicted. Screening studies for cervical, colorectal, and dermatological malignancies as well as coronary occlusive disease constitute huge segments of demand for providers time. Often, these studies are marginally compensated. Counseling for sexually transmitted diseases, chronic hepatitis, coronary occlusive disease, hypertension, and an almost innumerable array of other maladies has drastically altered and added to providers’ duties and, hence, demand.

The mere chronological computation of physician-to-population ratios provides almost no meaningful input in a market primarily characterized by an ever burgeoning demand. To portray such demand as provider-driven or inappropriate reflects, at best, misplaced hubris and, at worst, an ignorance of medicine’s history, which often reveals today’s medical fad to be tomorrow’s standard of care. Any attempt to impose Edmund Burke’s dictum that "society cannot exist unless a controlling power upon will and appetite be placed somewhere" ignores both political and market realities.

Barry Kisloff

University of Pittsburgh, Pittsburgh, Pennsylvania

I am sympathetic with Barry Kisloff’s observation that many factors have "added to providers’ duties" but find fault with his logic that more physicians are therefore needed to respond to this "ever burgeoning demand." A variety of factors—biomedical innovations, evidence about effective standards of care, patients’ expectations—add to physicians’ potential workload.¹ But to conclude that this added workload means that more physicians are required to meet the health needs of the public rests on three assumptions: All the work currently performed by physicians is clinically appropriate and improves patient outcomes; physicians are currently operating at maximal productivity; and none of the work performed by clinicians could be performed as effectively by less expensive personnel.

None of these three assumptions is met in the U.S. health care system. Although evidence suggests that physicians should be doing more of some things (such as screening patients for colon cancer, prescribing beta-blockers after heart attacks, and counseling patients about smoking cessation), evidence also suggests that physicians should be doing less of others (such as annual physical exams for adults, total body screening scans, and aggressive hospital interventions for patients preferring palliative end-of-life care). Productivity is far less than optimal because of ill-designed practice systems that are inefficient. Part of this inefficiency results from the lack of a suitable division of labor among clinical team members. Although physicians should have a hand in the counseling activities mentioned by Kisloff, much of this counseling could be more efficiently—and often more effectively—provided by nurses, health educators, and other team members.

Before jumping to the conclusion that more physicians per capita are required, physicians and policymakers need to critically assess the effectiveness of the work now being performed by physicians and think more creatively about reengineering practice organizations to enhance clinical performance and productivity.

Kevin Grumbach

University of California, San Francisco

NOTE

1. K. Grumbach and T. Bodheimer, "A Primary Care Home for Americans: Putting the House in Order," Journal of the American Medical Association 288, no. 7 (2002): 889–893.[Abstract/Free Full Text]

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