A Caste System Among Physicians

caste system

In historical Hindu society, a complex hierarchy of socioeconomic groups arose that can be oversimplified by the graphic to the left. Priests held the highest place in society, followed by the warriors using swords, then merchants trading goods, followed by laborers doing the most manual work.  Each group’s social and material wealth was preserved by limiting the financial and social opportunities of the group lower.

greek warrior

Did the era of fee-for-service healthcare (FFS) over the last several decades unintentionally create such a caste system among physicians? Perhaps our Priest Class is represented by cardiologists, radiologists, and orthopedic surgeons; our Warrior Class represented by gastroenterology, dermatology, and most surgeons; our Merchant Class represented by primary care and cognitive specialties; and our Laborer Class represented by associate practitioners.

Before you scoff, consider this. In most hospital systems in the US (whether for-profit or non-profit), members of the highest paid specialties control more of the resource allocation (investments in equipment, space, and personnel). Think of the surgeon who gets a robot (which might not improve outcomes in 80% of the patients who receive surgery using it), along with a dedicated operating room and team of specialized personnel, whereas a cognitive specialist or primary care physician doesn’t get a cross-functional process-improvement or patient-engagement program to reduce hospital readmissions or improve self-care of chronic disease.  There’s more immediate income for hospital, surgeon and device manufacturer in robotic surgery; there’s more long-term cost for America in suboptimally managed chronic disease.  American healthcare will be forced to reconcile that math within the next few years.

robotic surgery At the dawn of the Specialization Era (1950s), the highest paid specialties received an income 2-fold (200%) more than the median income for primary care physicians (source – Department of Commerce, published in Time 30July1951:70). Today, the highest paid specialties receive an income four-fold (400%) more than the median income of primary care (multiple sources). Moreover, those higher paid specialties have more discretionary income from clinical care to buy buildings, imaging equipment, faux-research programs, and other infrastructure designed to generate non-clinical income, which in many cases eclipses clinical income.

patient as ATM machine

I see a day in America’s future when …

(1) resource allocation within health systems is based upon “doing the most good” for a community of people, rather than generating the most income for hospitals, physicians or device manufacturers,

(2) the highest paid specialties earn no more than 3-times primary care, and

(3) governance of the delivery system is distributed among physicians, staff and patients, based upon criteria other than magnitude of revenue generation.

healthcare teamThat’s the way it’s been at Kaiser Permanente for 70 years.

For those of you in non-KP integrated delivery systems, it’s in your interest to dispatch the physician caste system prior to the widespread use of bundled payments from payors.  Well, unless you are a Priest.

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