Doctors should be paid on their skill and expertise in maintaining life and restoring health - not in keeping people healthy. To argue that Doctors responsibility is to keep people healthy is to shift the onus of personal choice and dumb luck of an individual onto the physician and to dis-incentivize the mere creation of a physician-patient relationship and penalizing the provider who does choose to intervene.

However, linking physician compensation to the restoration of health, maintenance of quality of life, and the preservation of life and bodily function and patients should pay for access to that expertise. The removal of direct pay for care by insurance has shielded much of the patients from the true cost of their care which has inevitably led to increased consumerism of the 'health care' product and turned the health care industry from a profession and more towards a drive-through service industry where all menu items are "free" or drastically reduced and so the patient demands or the physician offers it all.

The intervention of CMS (medicare/medicaid) and third party insurers in this equation over the last few decades has been to sour the physician/patient relationship while creating monopsony power in the market. This allows them to not only determine what premiums they will charge to a patient with their co-pays and deductibles, but also to negotiate, in heavy handed ways, the reimbursement schedules and fees a physician may charge. Yes; physicians do not set prices and it is illegal for physicians to discuss the prices they 'charge' with other physicians or hospitals in the market for fear of anti-trust lawsuits and fraud (true for individual providers or for large groups). Couple this with the constant year-over-year reductions in fees and insurers and CMS decrease the amount reimbursed to physicians for their work with near impunity (full impunity in the case of CMS, and near impunity for 3rd party insurers for they do have state boards to answer to - but the state boards power is really minimal), and it is easy to understand how physicians feel as though they are victims here, too, leaving the debate about the cost to attend medical school in time/money and continually compounding interest to another day.

In response to the power of the insurers, many physicians will innovate to protect their revenue as per-patient revenue declines each year. These innovations often include new tests and procedures, the refusal to accept new patients under particularly poor-paying plans, or the refusal to accept insurance payments outright and return to fee-for-service "cash pay" programs where they are free to negotiate prices directly with patients. Another response is great amounts of consolidation in the health care market as many private practices are being bought by larger hospital conglomerates and corporations. Though costs of care can be shared, potentially reducing overhead for a practice and increasing revenue, this often comes at increased cost, too, as these entities tend to order more test, charge more to the insurance companies for services and durable products, and reduce the intimacy of the physician patient relationship.

Lastly, the drug prices debacle is killing the fixed incomes of many patients who rely on these medications for their health and quality of living. One of a patients greatest anxieties is paying for their maintenance medications each month, going to re-fill their prescriptions, and not knowing what the cost is going to be. Add to that any new, branded or generic, medications prescribed by their physician, and a very large part of their fixed income is lost on pharmacy co-pays. This may be one of the biggest barriers to compliance and health on the side of the patient who cite the cost of medications as reason for not taking them even in the face of declining health. Both branded and generic medications are subject to large changes in price without warning as manufacturers or patent holders restrict access and reduce manufacture of meds to justify increased per-pill prices.

The end result? A massive blame-game where physicians, once the heroes of the health care world, are seen as villains because patients can put a face on who is directing the care; where patients are seen not as individuals, but as animals glutting themselves at the feedlot and demanding more free care and better services as though they were at McDonalds; insurance companies and hospital corporations seen as blood enemies and greedy behemoth corporations fighting over the carcass of healthcare dollars and leaving mere scraps for the patients and physicians. All the while, the government, who through this whole mess is seen as a potential savior, is responsible for this mess with constant threat of prosecution, regulation, reduction, law and tax.

I blame politicians, mostly, for this mess.