Lessons From The Abyss

As a primary-care internist in Seattle for almost 30 years, I’ve loved every day and most of the patients I’ve cared for. I have also watched medical care descend into a deep abyss—one in which quality, access, and cost have all been severely compromised. I think I may know the way back, and I want to share that with you.
Although I had no patients in 1980 when I opened my practice, I had bright, energetic partners and was privileged to find staff members who understood how to care for patients and for me. I dreamed of practicing until I retired, without distraction or interruption. How wrong I was. As doctors and as patients, we were victims of a number of well-intentioned but catastrophic decisions, some made by us and some by others. Together we have nearly destroyed medical care.

The first error was our approach to health insurance. I have always been a supporter of health insurance. The idea that people should have access to the best medical care, even if they are of modest means, is captivating. When health insurance began to flourish in the 1960s, I was in favor. Medicare and Medicaid—the pinnacle of the Great Society of President Lyndon Johnson—held great promise. It seemed to be the beginning of an era in which we would finally overcome our class discrimination and care for the elderly and the poor.

What happened to medical care as insurance grew widespread? It got expensive. For the first time, doctors were sending their bills to third-party payers, not to patients. The enormous restraint inherent in a doctor-patient transaction was gone. As prices went up, so did insurance reimbursement—and insurance premiums. Employers were paying those premiums, and since American industry was strong, wealthy, and competitive, costs continued to rise. The era of medical inflation had begun. It has not ended yet. Doctors were not the only or even the major beneficiaries of this money grab. Medical technology, pharmaceutical companies, and hospitals all dived in. The health-care gold rush was launched. With cost-plus health insurance we invented an inflation machine, one powered by government and employer money, one without any brakes. Doctors and patients could order what they wanted. Insurers would pay. As the money flow expanded, so did insurance-company profits. It’s no wonder that health care got expensive.

The next well-intentioned development in the devolution of medical care was the mechanism by which medical fees were set, a system called Resource-Based Relative Value Scale (RBRVS). This was the invention of Professor William Hsiao, an actuary at the Harvard School of Public Health. RBRVS attempted to price every item in medical care based on the resources required to create it. Procedures or devices that were expensive to make were priced higher. Physicians who required more training and preparation were paid more. What a dream for insurance companies—pricing without negotiation. In any industry but medicine, this would be called “price fixing” and probably be illegal. Instead, RBRVS was immediately adopted by Medicare in 1988. It has been a fixture in insurance reimbursement ever since.

Unfortunately, there was a problem with RBRVS—it killed primary care. Just as bad, it caused a natural migration to more and more expensive treatments. The primary-care doctors didn’t have expensive procedures, and they didn’t spend as many years in training as the specialists. In the RBRVS world, they were nearly worthless. In real markets, prices are determined by what customers value and are willing to pay: Too high a price, no sale. In health care, if it is expensive to produce, we pay more. If you want to understand why American medical care is dominated by specialists doing expensive procedures, you need look no further than this. Despite growing mountains of data showing that medical systems dominated by primary-care physicians produce better health outcomes at lower cost, we persist with an insurance system programmed to annihilate primary care and encourage expensive procedures. We spend the lion’s share of our waning national wealth on expensive, overpriced, and often-dangerous alternatives.

As the battle between providers and insurers grew, medical culture took a turn for the worse. Doctors organized themselves as large financial units with professional management. We moved further and further from our role as healers, further and further from our patients. We were thinking about reimbursement, not medical care. The now-well-paid proceduralists began to dominate clinics financially. The primary-care doctors became the ugly stepchildren, allowed to stay mostly as a source of referrals to the specialists, but vastly underpaid relative to their high-flying colleagues.

There is one more key element that has moved us toward the brink. We have come to equate medical insurance with medical care. Insurance companies do not see you when you are ill. They don’t take out your appendix. Every politician and health strategist in this country talks about ways to enlarge health insurance when we should be talking about ways to promote health care. Health insurance is a mammoth middleman. It is a key part of a health-care system, but it cannot and should not enclose and manage that system. It is not the answer. In the case of the least expensive and most critical aspect of health care—primary care—it is the prime barrier to care.

What should you take away from my journey?

It matters if your doctor works for you or for your government, employer, or insurance company. If you want better medical care, then make sure that the money for your care goes throughyou—whether it comes from your wallet, a health savings account, your insurance company, or the government. You need to be the customer, and you should be making the decisions.

If you are a doctor, don’t sign contracts that hand over medical care and pricing decisions to any third party.

Medical costs need to be appropriate for patients, not for insurance companies. Physicians need to rediscover what “reasonable” prices look like.

Technology is nice, but it is not a substitute for access to a doctor with the time to take care of you and a keen awareness that he or she works for you and only you.

If you don’t have a primary-care physician, you should get one. Consider decoupling that care from insurance. Pay with your own money (it won’t cost you much). Insist on access and service.

The new administration has pledged to reform our broken health-care system, and it has built an excellent team to complete this important task. I hope it will listen to some of us old-timers. recommended


Dr. Garrison Bliss is a Seattle-based board-certified internist. In 1997, he led the  second-ever conversion of a medical practice in the United States to a direct-practice model, in which physicians are paid a low monthly fee directly by patients instead of seeking and accepting payment from insurance companies. He is now chief medical officer of Qliance Medical Group and continues to see patients. Dr. Bliss can be reached at thestranger@qliance.com.