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Medicare is to blame, and Medicare for All would only worsen it.
There are many reasons for the physician shortage, but burnout and early exits from clinical medicine are major drivers. These physicians who leave their practice blame administrative hassle as a leading reason.
Medicare for All advocates claim that removing private insurance would alleviate this burden, allowing doctors to practice medicine again. This is a dangerous misconception, and I warn my fellow physicians not to be taken in by this siren’s song. Most of the micromanagement in the working life of physicians comes not from private insurance, but from Medicare.
Like most physicians, I deal with the administrative hassle imposed by private insurance: the prior authorizations, the claims denials. But those are just a minuscule part of the problem. I spend more hours of my day glued to a computer to satisfy Medicare’s rules.
Medicare sets the “conditions of participation” for hospitals and payment rules for doctors. These regulations give administrators sovereignty over the practice of medicine. When Medicare is the major source of revenue, it is the primary customer, and its preferences must be given priority. For example, doctors’ concerns over non-working operating room equipment are ignored while administrators threaten them for not copy-pasting the correct checklist into their computerized notes. Medicare prioritizes the checklists more than the working operating room equipment. Administrators take up hours of clinicians’ time hounding them about documenting quality scores. Medicare prioritizes computerized data input over face-to-face patient care.
When Medicare pays a hospital, it relies on very specific documentation from the doctor. Does the patient meet inpatient criteria? What diagnosis category are they in? Do they have a “major complication or comorbidity”? This all relies on whether certain words were in the physician notes. So hospitals hire teams of consultants to comb through patient charts, then harass the doctors to edit their notes, making sure the hospital maximizes billing.
Medicare’s quality metrics add even more demands. These schemes, intended to reward hospitals with the best outcomes, have become exercises in metric manipulation and coding games, again largely falling on the doctors. A 2016 study found physicians spent 2.6 hours a week on quality reporting. A study of heart-failure patients even linked a readmission-reduction program to increased mortality. MedPAC, which advises Congress on Medicare policy, recommended replacing many of the programs. Yet Medicare continues them.
Physicians have also seen their independence vanish due to Medicare rules. In 2024, 57.5% of physicians were employees of large hospital systems, up from 41.8% in 2012. Adjusted for inflation in practice costs, Medicare physician payment has fallen 33% from 2001 to 2026, while the cost of operating a practice has gone up. Meanwhile, federal policy gives hospitals financial advantages, such as facility fees and 340B benefits, that are unavailable to independent practices. Thus, many doctors, unable to sustain their overhead costs, sell to hospitals that have these financial arbitrage opportunities.
Medicare also restricts physicians from building alternatives. Section 6001 of the Affordable Care Act bars new physician-owned hospitals from billing Medicare. The Stark Law restricts physicians from referring Medicare patients to ancillary services they own, such as an MRI or physical therapy clinic. Medicare favors large, consolidated hospital systems over independent practices, steadily eroding physician autonomy.
So why would physicians want MORE of Medicare?
I can see the allure. After a particularly frustrating experience with private insurance, doctors might be excused for wanting to eliminate those complex middlemen with their utilization management rules. Indeed, Medicare for All supporters promise simpler billing. They promise they will get rid of the quality metrics, the declining reimbursement, and the complexity.
But this is not realistic. Healthcare utilization would increase under Medicare for All. The CBO predicts this. We have multiple randomized studies that show utilization goes up as patients’ out-of-pocket costs go down, and the increased utilization is in both less-effective and more-effective care. So, to reduce the use of that low-value care and keep from overwhelming the system, there must be some sort of utilization management.
We ran this experiment in the early days of Medicare. The original rules for doctors had no modern quality metrics and far simpler coding and utilization controls. Doctors could bill Medicare based on their “customary” charges. Costs rose rapidly. Over the years, Medicare slowly added all the utilization control schemes outlined above. They implemented price controls. They cut reimbursement. They restricted doctors from self-referral. They added quality metrics.
Medicare for All might promise simplification and high reimbursement for doctors. It won’t deliver. Not without blowing an even bigger hole in the federal deficit. It’s an economic impossibility.
The answer for physician burnout and the resulting shortage is not going to be an expansion of Medicare. It’s going to be deregulation, allowing physician ownership and autonomy to once again flourish. Doctors are doing this outside the system right now, offering low-price and high-quality alternatives. Physician-owned hospitals have high patient-experience scores. Direct primary care doctors report high practice satisfaction. Cash-pay surgery centers are thriving.
Doctors working in these environments, outside Medicare, report huge reductions in compliance costs and office staff. They aren’t micromanaged by administrators. Instead of sitting glued to a computer, they are taking care of patients.
They’re just practicing medicine again.
Doctors need that to stay committed to clinical medicine. More Medicare would only make the doctor shortage worse.
Discussion (11)
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Good stuff, Doc. Government is always the problem.
Sometimes I'm surprised there are people still pursuing practicing medicine.
God bless Y'all.
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Nothing ever gets taken away. Just added to. Even when things are no longer useful, nurses and doctors still have to chart it. Ask TPTB to have them removed from charting and you get "well, somebody might still use this information". It doesn't bother them that you spend more time clicking through 5 pages of crap on the computer than taking care of your patient.
I wish people would understand the problems you address here. Instead, they'd rather blame you greedy docs.
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Over the last forty years, this has been a surreal story of the insurance companies-government in a game with the hospitals.
My second child was born in 1979. I had a caesarian section, and I was, as I was with my first child, also a caesarian section, in the hospital for a full seven days. Flipping forward 1985, just six years later, when my third child was born, also a caesarian section, I was discharged two and a half days after the surgery. A caesarian section used to be considered "major surgery," and it was standard care to keep patients a full week afterward.
What happened in those six intervening years? The insurance companies didn't want to pay for inpatient care anymore if they could possibly avoid it. As a homeowner, I can understand that. The overhead alone of keep someone in the hospital has to be staggering. This accompanied the push to outpatient surgeries that are so commonplace now. These were the years those facilities expanded tremendously.
The other thing that happened at that time was that the insurance companies decided to reimburse cities and towns for ambulance services. The idea was that the hospitals would release as many patients as possible with EMTs and ambulances standing by should a small percentage need readmission for complications. These patients were not being readmitted because of medical errors. They were being readmitted because of unforeseeable complications, complications that have always arisen with surgery and that have been handled in the hospital setting where there is trained staff, equipment, and needed pharmaceuticals. But this overly optimistic early-discharge policy became the norm during those years.
Cities and towns invested heavily in new ambulances. and they hired lots more highly trained EMTs. They also expanded home nursing care. It was quite an elaborate infrastructure that people constructed for this purpose at that time. The insurance companies-government saved a bundle in getting people back into their own homes.
But once this became the norm in medicine, it also became very hard to keep patients in a hospital setting.
There were many far-flung effects (to borrow a term from the environmentalists) from these shifts in policies. One was that painkillers ended up in people's homes more than ever before. When the patients stayed a week in the hospital, by the time they were discharged, they were pretty much on benign painkillers. Naturally, being released the day of surgery or a mere two or three days later, not having access to all-night drugstores or doctors or even able to get in a car should the need arise, doctors compassionately prescribed enough painkillers to get patients through the night. Later on doctors were accused of "overprescribing," so now that has stopped, leaving postsurgery patients at home in pain. Nice going, regulator agencies.
Needless to say, the cost of all these adjustments started adding up, and the insurance companies' assurances to doctors and patients that they would happily pay for any readmissions for complications turned into a billing battleground. Insurance companies were apparently far more generous with their assurances and promises than they were with their actual cash.
When ObamaCare passed and hospital "quality control" measures were implemented as a result, I saw that hospitals were now being penalized for "readmissions" because why? The doctors and hospitals were doing everything the insurance companies demanded of them: getting patients out of the hospital. Of course many complications arose. By readmitting those patients who needed additional care, the hospital administrators and doctors were acting as the humanitarians they are. Now, as the bitter end of this story, hospitals are hesitating to readmit because of these penalties. The government strikes again. More suffering.
This has been an absolutely absurd chain of events, and I can't help thinking that people in medicine are not wired well to argue with government and insurance companies. Their brains and personalities are very much in the present. Vague academic policy discussions must be hard for them. This "readmission penalty" was a no-brainer to get tossed out.
I don't mean that as negatively as it sounds. I am fascinated by personalities and how different professional fields attract people with similar personalities, interests, curiosities, and strengths. Lawyers would not make good doctors. They are simply wired differently.
I don't know if the medical field as a whole just needs better lawyers or what. This early=discharge situation is just one example of thousands of situations I've observed over the years in which a really good Daniel Webster-type lawyer could get these ridiculous policies removed. We need someone to say, "Okay, but last year you told us thus-and-such."
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My GP (solo practice with occasional PA added) has as many as three people at desks to answer phones and do paperwork. Virtually all providers hand me paper forms that ask for information that should already be in a database (whatever happened to my single favorite provision in Obamacare about uniformly digitizing all medical records?).
If I have a co-pay for a prescription or a procedure (pretty rare for me as a boomer sponging off Medicare w/supplemental plan) it often seems like some random number that could not have been predicted in advance.
I sometimes wonder if all the inefficiencies are mandated.
In a legal practice, there are usually not separate rates for separate procedures (research, drafting, depositions). One hourly rate, maybe a different one for trial work, reimbursement for out-of-pocket expenses (no markup allowed per ethics rules). Or even the whole thing covered by a fixed fee or a contingency percentage.
In contrast doctors and hospitals appear to be compelled to record every Mickey Mouse detail in every category the government and/or insurance companies have thought up.
Maybe blanket subsidies for some facilities and providers with a some general review/accountability on overall service and outcomes on a reasonably long-term basis in lieu of micro-reporting--and since the entire medically relevant record should be digitized for easy aggregate examination and review, could something like that eliminate the costly mickey mouse reporting burdens?
Politically, we probably can't do medical savings accounts or anything else bring market pressures and competition to bear. At least not until a crisis accrues.
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EMRs do not communicate with each other. EPIC doesn't interface with eCLinicalworks, or Express Scripts, or MEdical Manager (does that even exit any more?) or Cerner, or Athena.
A number of years ago I worked for a hospital in New Braunfels, TX (Resolute Hospital) that had a paperless hospital EMR system. The hospital business plan was to integrate all of the office EMRs ofthe physicians directly with the hospital so that there was complete data sharing. Unfortunately, that could not be done at that time (that was 12 years ago). THe hospital worked mightily but simply could not intergrate the EMRs. THe physician referral base disappeared because of that failure, no one referred patients to the hospital, and it folded. THe hospital was a newly constructed hospital that cost a quarter of a billion dollars. It was purchased for pennies on the dollar by the Baptist Health System in San Antonion and became a conventional community hospital.
For the record, all physician reimbursement is based on the RBRVS system initiated to control Medicare costs under the Reagan administration. The prices are fixed, except for regional adjustments based on costs in different areas of the country. Further, all private insurance contracts for physicians are based on the same Medicare payment schedule. For all medical services. This is completely price fixed system. Physicians and hospitals can charge whatever they want. They get paid based on a Medicare payment schedule,either directly via Medicare, or indirectly by a private insurance reimbursement tied to the Medicare payment schedule. .There is no such thing as any free market fee for service system, nothing remotely like what you describe for attorneys. The system is locked in.
Even further, when a physician is hired by a hospital or insurance company or any entity, the payment system for that physician services is either a salary, or based on RBV Units that are priced according to Medicare scheduled (which is essentially a system of fixed payment, on a per unit basis, for services rendered), or a capitated system of a specified amount per patient on your list (which systems are extensively gamed by padding diagnoses to increase the appearance ofmorbidity for which higher capitated payments are allowed.. So this is a price and wage control system. Results of any such system are queuing, shortages, lack of access, and increasing costs. The entire system is insane.
Physician payment adjustments are completely dependent on yearly acts of Congress. This is a centrally run, essentially a single-payor system disguised as something of a market system. It is nothing of the sort. The best alternative is a system in which individuals control their own resources to pay for their own healthcare. That places more of a burden on the individual and Americans no longer want to chart their own destiny or arrange their own care. They want someone else to do that for them, by and large. The result is that something like obesity, the most prevalent chronic disease in the world, is not allowed to be called a chronic disease, lest currently available treatments have to be covered, which would enormously increase costs. So the sclerotic system actually raises barriers to improved treatments and improved care. IF a cure for all cancers were miraculously developed, it would be banned to limited so severely by this system that patients would be unable to access it. Americans, like Britons and Canadians, seem happy to have the care limited and constrained, as long as they don't have to think about it too much.
Medicare for all would be lethal for a lot of seniors. Sort of like getting sent to a Nursing home with COVID during the pandemic.
ALl in favor of letting the government continue to run health, standup and say Hallelujah!
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