Commentary : Solo Doctors to Become Fewer

Within 10 years, individual doctors practicing solo will have become an endangered species. Under competitive pressure from large Health Maintenance Organizations (HMOs) and other organized practice groups, themselves competing fiercely for corporate contracts, practitioners that cannot beat them will have to join them.

By 1995, as much as 50% of the U.S. population will be enrolled in HMOs, compared to less than 10% today. The transformation taking place has been described as “corporatization” or “industrialization” of health care and is only one of numerous sweeping changes anticipated for the years to come.

These predictions come from experts in delivery of medical services who have studied health care in America. Although crystal ball gazing has never qualified as an exact science, based on current trends and educated projections forecasters envision a drastically different system for medical services than what we know today. The main disagreement among the forecasters is not what will happen, but when it will happen.

By 1990, the United States will experience a surplus of physicians. This surplus of health care professionals will intensify competition for patients and make membership in large health organizations virtually mandatory for all but the few practitioners catering to affluent or rural populations.

The world of the 1990s will contain 30% more Americans over the age of 75, many of them elderly women living alone, many with serious health problems. Coping with the health care needs of persons over 75, today the fastest-growing segment of the population, already has become an issue. Long past their peak earning years and no longer enrolled in employer-supported health insurance, many elderly find that Medicare is not sufficient to take care of all their health and social needs and must rely on relatives or turn to publicly supported clinics for medical attention.

Existing trends indicate that in the future health care “haves” and “have nots” will receive treatment at markedly different levels.

For the “haves,” people with adequate incomes or health insurance, the availability of advancing medical technology will raise the level of care and with it, the price. By 1990, the total expenditure on medical services is expected to total $660 billion, or 12% of the gross national product. Today, Americans spend about 11%. In 1960 that figure was only 6%.

Health care of the “have nots,” those without either money or insurance, presents one of the most difficult problems future society will face. Government at all levels is expected to further restrict spending on medical care for indigent patients in response to changing public attitudes. Government policies are now directed to putting caps on health care costs, not toward expanding health care coverage.

Even segments of the population now considered capable of affording traditional types of medical treatment may find themselves newly classified as “have nots.” Although 85% of today’s population has some form of health insurance, these policies do not cover expensive organ transplants and new technologies that now are funded with grants for experimental research. It seems unlikely that an insurance company that paid for very expensive procedures could keep its rates competitive with its “no frills” competitors.

In nature, a change in environment requires that organisms must adapt to survive. Similarly, the coming changes in the way health care is provided require that academic health centers like the UC Irvine Medical Center take a hard look at this new competitive and changing environment.

Unlike non-academic institutions, teaching hospitals are burdened with the significant additional responsibility of educational and research functions along with providing medical service to the community. This responsibility is vital in ensuring a supply of well-trained physicians and for progress in medical science that comes from a clinical research environment. The basic functions of teaching and research will always remain a major responsibility of our state institution.

In one sense, the pressure of change will create a competitive environment and will favor the survival of only the efficiently managed health care providers. Yet the task of providing top-rate care to the community while also conducting education and research has begun to prove a handicap that cannot be overcome by belt-tightening and efficiencies alone.

Some state universities have transferred ownership of their hospitals to nonprofit organizations that must then compete for patients, while some private universities have sold or leased their teaching hospitals to a for-profit hospital chain. Professionals in academic hospitals have debated about the quality of educational programs and the availability of indigent care in a for-profit environment.

If UC Irvine Medical Center and many other academic medical centers are to survive, it may only be as a result of recognizing them as a protected species. Public policy must not ignore the issues of teaching responsibilities and care for the indigent. These two issues are very often connected in the academic health center. Without increased public support in the form of subsidies or a “public utility” status shielding them from the leaner, corporate competition, teaching hospitals may go the way of the lone physician.