Not What the Doctor Ordered

Liberating Caregivers and Empowering Consumers for Successful Health Reform

Jeffrey C. Bauer

• Publisher: Productivity Press
• Year: 2019
• eBook ISBN: 9781351686570
• Topic: Business
• Subtopic: Business General
• Index: Business

This 25th Anniversary edition completely updates the powerful insights and policy recommendations of Not What the Doctor Ordered, first published in 1993 by renowned healthcare futurist and medical economist the author. It presents specific solutions to serious problems of cost, quality, access, and outcomes by allowing all Americans to purchase services directly from caregivers who provide an expanding array of medical services at least as well as physicians—at lower cost.

Focusing on new realities of the 21st century, the authorshows not only why giving consumers the right to choose advanced practitioners is the top priority for improving our overpriced, underperforming medical care delivery system, but also how to make the necessary changes. As he clearly and concisely explains from medical and economic perspectives, the key is eliminating physicians' monopoly powers over advanced practice nurses, clinical pharmacists, physical therapists, clinical psychologists, and other advanced practice (AP) health professionals who now rival physicians in scientific knowledge and caregiving skills within well-defined scopes of practice regulated by state governments.

Chapter 1

Introduction and Background: 25 Years Later

This book updates two earlier works that explained why Americans must be allowed to purchase health care directly from caregivers who provide an expanding array of medical services at least as well as physicians—at lower cost. It shows why giving consumers the right to choose advanced practitioners is the top priority for improving our overpriced, underperforming medical care delivery system. Health reform’s traditional focus on expanding insurance coverage is doomed to ongoing failure until state governments eliminate antiquated laws that allow doctors to control other comparably qualified health professionals.

Our nation’s medical monopoly, created early in the twentieth century, was justifiable back then in the name of consumer protection. University-trained medical doctors (MDs) methodically studied human health and treatment of disease. Physicians’ competitors did not; they were charlatans with no science to validate or improve their practices. This book shows how much the situation has improved in recent decades, providing ample evidence that today’s advanced practitioners (APs) now rival physicians in scientific knowledge and caregiving skills within well-defined scopes of practice. Therefore, a very large number of Americans suffer physically and fiscally from licensure laws and reimbursement policies that give physicians unfair competitive advantage in the medical marketplace.

My proposal to end the medical monopoly was a revolutionary challenge to conventional wisdom when Not What the Doctor Ordered first appeared in 1993. One of the nation’s best-known radio reporters terminated a studio interview with me at the time, declaring that further discussion of the new book would hurt her journalistic credibility because “no American would ever trust a nurse to diagnose a disease or a pharmacist to change a medication.” Well, there’s been a lot of progress since then. Tens of thousands of Americans disprove the reporter’s mistaken view every day in choosing to be treated by advanced practitioners in hospitals, clinics, workplaces, and drug stores all across the country. Data not only show that these consumers are happy with the savings and convenience of direct access, but that they are satisfied with the quality of care provided by highly trained health professionals who are not traditional doctors.

In spite of improvement in consumer choice since the 1993 edition, a relatively small group of change-resistant doctors still fights to prevent competition from qualified non-physicians—competition proven to improve efficiency and effectiveness in the medical marketplace. I am therefore updating Not What the Doctor Ordered because there’s still much progress to be made and more reform needed to give all Americans a choice they deserve, especially as they are being asked to pay more for health care out of pocket. This third edition is a guide for Americans who want to get a better deal in the medical marketplace by ending outdated restrictions on competition among qualified health professionals. It is full of information and ideas to educate not only consumers and their employers, but also elected officials and policy-makers who are still under the influence of doctors fighting to preserve an outdated monopoly. It is written to promote informed public discussion of the imperative for change, sooner rather than later.

Key Issue: Regulation vs. Competition in Health Reform

A contentious national debate over health reform was at its peak when the first edition appeared about 25 years ago. The book directly challenged the Democrats’ push to expand government control over how health care was reimbursed when the real problem was how it was provided. Contrary to the widely prevalent view in 1993–1994 that the Clinton health reform was inevitable—a question of when, not whether—I predicted early on that Hillary and the hundreds of experts on her task force (including several personal friends and professional acquaintances) would fail to cap medical spending by reinventing health insurance. Fail they did, but my alternative focus on competition between providers and changing how they deliver care did not prevail, either.

The good news is that the first edition sold well in spite of its contrarian views on the Clintons’ paternalistic approach to reform, euphemistically called managed competition. The bad news is that few political leaders were interested in pursuing other changes once Hillary’s grand scheme collapsed. A Republican landslide in the 1994 mid-term elections diverted attention from any significant health reform efforts for another decade; the party’s leaders argued that American medical care was the best in the world and did not need fixing. Sensing reform fatigue at the national level, I refocused on teaching statistics and research at a medical school and studying how information technology and telemedicine could improve the delivery of medical services.

Government intervention to manage competition by restructuring reimbursement clearly fell “off the radar.” In its place, a new concept rooted in the private insurance sector, managed care, was widely expected to solve the health care crisis all by itself. With Republicans in control of the House and the Senate, the government’s role was to get out of the way and let private enterprise develop its own mechanisms to reduce demand. Even if its publisher (Probus) had stayed in business, the first edition (1993) of Not What the Doctor Ordered probably would have been the last one, too, because it did not explicitly address managed care. McGraw-Hill picked up the rights and asked me to publish a second edition (1998) in collaboration with the Healthcare Financial Management Association (HFMA) on the condition that I update it to encompass this new trend. The subtitle was changed to How to End the Medical Monopoly in Pursuit of Managed Care.

Managed care ultimately turned out not to be a panacea. It did not make medical services less expensive or more accessible, and it certainly did not produce any savings for consumers. As shown in Chapter 2, the only people who benefited monetarily from managed care were financial managers and venture capitalists who restructured the capitalization of health systems and health plans—without improving the overall performance of either in the process. Consumers (patients) and purchasers (governments and employers) did not get a better deal, just a different deal where “gatekeepers” restricted patient access to traditional services and health spending continued to increase at a disturbing rate.

Americans continued to be disenchanted with the deficiencies of their health care system. They remembered the astronomical costs and other scary features of the Clinton plan, especially the bureaucracy and taxes it would have created, but they did not clamor for Congress to try reform again any time soon. They wanted competition and choice, but not at the expense of quality and access. Consumer choice in competitive markets was addressed in depth in both previous editions of Not What the Doctor Ordered, but it did not yet have the transformative power of “an idea whose time had come” (in the celebrated words of Victor Hugo) because medical societies were fulminating about long waits for textbook care, no choice of doctors, rationing, and other alleged horrors of socialized medicine. Hopefully, this third edition is the good luck charm that finally defuses sensationalists’ scare tactics and creates public access to an efficient, effective, fair, and competitive health care delivery system.

The Making of a Contrarian Health Economist

Having proudly earned a reputation as the health industry’s constructive contrarian, I digress here to explain the origins of my unconventional perspective. Readers who are eager to get to economic analysis and policy recommendations can skip this section’s summary of 50 years of experience in the medical marketplace, but it explains why I unabashedly “think different” about American health care. It’s fine with me if you proceed directly to the next section (page 7), but please come back to read this one if you subsequently find yourself asking how I could possibly reach the conclusions embodied in this book. There are good reasons.

Unlike many conservative economists who oppose all government intervention in principle, I believe governments should protect public health, regulate safety of goods and services, and promote fair competition. I have never seen any evidence that the so-called “free market” accomplishes these goals in our medical marketplace. And, unlike liberal economists who want public entities to finance and even deliver medical services (e.g. Medicare for All, or other single-payer insurance, or public hospitals), I strongly believe that American health care is best when delivered in truly competitive markets by private sector organizations, both for-profit and not-for-profit.

I am extremely grateful to several very special people who helped me avoid the dogmatic views of either political extreme. They taught me new ways to look at things, giving me courage to buck conventional wisdom and be creative. My fundamental self-image—being a teacher—was shaped at an early age by my father and grandfather. Both were university engineering professors. They purposefully stressed the art of problem-solving when teaching me how to fish, repair a car, play baseball, or build a bookshelf. They also involved me in their academic work; as a kid, I spent many hours helping them in their university offices and research laboratories. I was raised to be a professor. The only major career dilemma I ever remember facing was what I would teach, not whether I would teach. Even thoughts about going into politics were based on the assumption I would be doing it on leave from an academic position.

My father and grandfather exposed me to many careers, but not the one I ultimately pursued. The thought of becoming a medical economist hadn’t even crossed my mind when I began college, planning to major in physics. Four years and four majors later, I found myself graduating from Colorado College with a bachelor’s degree in economics and a Fulbright Scholarship to study economic development planning in Switzerland. I had also been accepted to graduate programs in international economics and atmospheric physics. (OK, I was unfocused, but it was the sixties … and I did inhale.)

If the Selective Service had not sent me a draft notice the same month I graduated from college, I might today be one of the world’s leading authorities on some arcane subject like economic development planning in Pakistan (the topic of my master’s thesis) or the formation of hailstones in cumulonimbus clouds (the topic of my first scientific paper, published by the Journal of Atmospheric Physics in 1967). But because I am a pacifist, my draft board denied a request to travel to Switzerland for the Fulbright on the grounds that I might not return to the United States afterward. Instead, I was drafted and assigned to perform two years of alternative service at Penrose Hospital in Colorado Springs as a medical records clerk on the “graveyard” shift.

The punitive drudgery of working nights quickly ended when the hospital’s Director of Medical Laboratories recognized me as a freelance photographer whose pictures had appeared in the local newspapers when I was a local college student. I already had the advanced camera and darkroom skills he was seeking in someone to run a division of medical photography, and the salary dictated by my draft board was a fraction of the going wage for a clinical photographer. Thus, for almost two years, I worked alongside practicing physicians and medical residents who asked me as many questions about photography as I asked them about medical science and health care delivery.

One physician in particular, Dr. Morgan Berthrong, taught me an incredible amount about the theory and practice of medicine and strongly urged me to become a physician. Doctor Berthrong, also a professor at the University of Colorado School of Medicine, took pride in giving me many clinical experiences taught in the third and fourth years of medical school. However, I did not have the basic sciences of the first and second years. The thought of learning this material and cramming for the dreaded Medical College Admission Test (MCAT) deterred me, so I applied for graduate programs in meteorology and economic development instead.

Becoming a medical economist still was not part of my plan. That path was set unexpectedly by Sister Myra James Bradley, Penrose Hospital’s CEO. She was extremely kind to me from the day I began working there, occasionally inviting me to her office for chats about weather forecasting and economics (my final major at Colorado College). The curious reason for her interest in economics was not clear until the day she summoned me to attend a meeting with her and Dr. Berthrong. The topic was a new piece of diagnostic equipment installed in the medical laboratory that morning. Tests had already been run on the machine, but the fees had not been determined.

I prepared a mini-lecture on price theory to help Sister Myra James and Dr. Berthrong decide how much to charge for the tests, but she never gave me the opportunity to deliver it. Rather, she reported that the very same diagnostic device was already in use at two other Catholic hospitals in Colorado, with a $10 charge 40 miles to the south in Pueblo and a $15 charge 60 miles to the north in Denver. She proposed charging $12 at Penrose because Colorado Springs was between Pueblo and Denver, but closer to Pueblo. Dr. Berthrong quickly agreed, and the meeting was over.

I was chagrined by the lost opportunity to explain economic factors that should have been used to set the price, but Sister Myra James casually told me as we walked out the door, “Health care really needs medical economists. I want you to become one.” Like Jake and Elwood in The Blues Brothers, I felt life’s calling at that very moment—I’m not even Catholic, much less religious—and began contacting the graduate schools that had accepted me in their economic development programs to see if I could specialize in medical economics instead. (For the record, I dedicated the first edition of this book to Sister Myra James.)

A private university back East denied the requested change on grounds that medical economics was not a recognized field of study in its economics department—which was generally the case across the country back in 1971. A state university in the upper Midwest was receptive because a professor there had begun to apply economic analysis to the allocation of health resources, but the admissions office said my financial aid was tied to studying economic development. (Ironically, I subsequently spent seven years as a part-time professor at the university’s medical school, where I wrote a textbook used to teach physicians how to do research and evaluate data.)

Fortunately, financial aid at my home state university was not tied to the course of study, so I entered the PhD program in economics at the University of Colorado at Boulder after completing the Fulbright Scholarship in Switzerland at the University of Geneva. The lack of a medical economics track at the University of Colorado was disappointing at first, but it turned out to be a blessing in disguise. Four professors deserve special recognition for customizing my development as a medical economist. Their intellectual guidance gave me the courage to become an in...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• About the Author
• Acknowledgements
• 1 Introduction and Background: 25 Years Later
• 2 Medical Monopoly: What the Doctor Ordered
• 3 The Medical Marketplace: Learning Lessons of History
• 4 Captain of the Ship: Legal Foundations of Independent Practice
• 5 Advanced Practitioners: Health Professionals Whose Time Has Come
• 6 Case Studies
• Additional Reading
• Index