I always look for regulations or unintended consequences of taxes or programs when I see things not working as they should. There's an old but interesting Forbes article that points out that house calls in the US by doctors didn't start dwindling until the 1960s, and it seems to coincide with the change from patients paying doctors directly, to payments being made by private health insurance, Medicare, Medicaid, and the Children's Health Insurance Program. The cost of waiting and travel time (and chocolate) shifted from doctors to patients because the customer was no longer able to signal how much they valued their time.
The timing you pinpoint makes sense. And the shift you describe -- from direct doctor-patient relationships to third-party reimbursement -- didn't just redistribute who bears the costs of time and travel. It also changed how power and information flowed...
Michael Lockshin has pointed out that the same bureaucratic shift also caused a sea change in doctors' diagnostic behaviors and attitudes: When doctors had to code illnesses to get reimbursement from these big standardizing bureaucracies, they stopped saying diagnoses were uncertain, because that wouldn't get reimbursed. The whole culture surrounding diagnostic uncertainty deteriorated.
That shift -- from "I'm not sure; keep talking to me" to "maybe you're just depressed" -- became structurally incentivized. Some AI diagnostic assistant tools have since compounded the problem by trying to make their accuracy numbers look better (decreasing false positives) at the expense of patients, including children, with milder versions of spectrum diseases like lupus. (I contributed a chapter about this dynamic for a book Michael co-edited on diagnostic uncertainty: "Shame, Name, Give Up the Game? Three Approaches to Uncertainty" that's online here if you're interested: https://verawil.de/shame-name-give-up-the-game-three-approaches-to-uncertainty.)
Another thing that often gets left out of partisan discussions about who pays is that patients who are the sickest (most fatigue, pain, difficulty traveling and waiting) may be the least likely to go in for help under this system. The most likely to have gone in and not gotten help (for difficult diagnoses and chronic problems) before. It again privatizes transaction costs on this type of patient especially when they go undiagnosed, suffer, possibly worsen, and pop up next in a worse state, still undiagnosed, now not expecting to be believed or helped... If the system "believed" uncertainty -- by paying for uncertain diagnoses and trial treatments -- it could help a lot of sick people function and live better.
But in the current third-party-payer system, the customer who lives the result isn't the entity that decides what payment is due for it.
I always look for regulations or unintended consequences of taxes or programs when I see things not working as they should. There's an old but interesting Forbes article that points out that house calls in the US by doctors didn't start dwindling until the 1960s, and it seems to coincide with the change from patients paying doctors directly, to payments being made by private health insurance, Medicare, Medicaid, and the Children's Health Insurance Program. The cost of waiting and travel time (and chocolate) shifted from doctors to patients because the customer was no longer able to signal how much they valued their time.
Thank you, Beth. This is such a smart and generous comment. I hadn't seen that Forbes piece. Looks like it's here: https://www.forbes.com/sites/theapothecary/2015/12/09/explaining-the-decline-fall-and-possible-rebirth-of-doctors-house-calls.
The timing you pinpoint makes sense. And the shift you describe -- from direct doctor-patient relationships to third-party reimbursement -- didn't just redistribute who bears the costs of time and travel. It also changed how power and information flowed...
Michael Lockshin has pointed out that the same bureaucratic shift also caused a sea change in doctors' diagnostic behaviors and attitudes: When doctors had to code illnesses to get reimbursement from these big standardizing bureaucracies, they stopped saying diagnoses were uncertain, because that wouldn't get reimbursed. The whole culture surrounding diagnostic uncertainty deteriorated.
That shift -- from "I'm not sure; keep talking to me" to "maybe you're just depressed" -- became structurally incentivized. Some AI diagnostic assistant tools have since compounded the problem by trying to make their accuracy numbers look better (decreasing false positives) at the expense of patients, including children, with milder versions of spectrum diseases like lupus. (I contributed a chapter about this dynamic for a book Michael co-edited on diagnostic uncertainty: "Shame, Name, Give Up the Game? Three Approaches to Uncertainty" that's online here if you're interested: https://verawil.de/shame-name-give-up-the-game-three-approaches-to-uncertainty.)
Another thing that often gets left out of partisan discussions about who pays is that patients who are the sickest (most fatigue, pain, difficulty traveling and waiting) may be the least likely to go in for help under this system. The most likely to have gone in and not gotten help (for difficult diagnoses and chronic problems) before. It again privatizes transaction costs on this type of patient especially when they go undiagnosed, suffer, possibly worsen, and pop up next in a worse state, still undiagnosed, now not expecting to be believed or helped... If the system "believed" uncertainty -- by paying for uncertain diagnoses and trial treatments -- it could help a lot of sick people function and live better.
But in the current third-party-payer system, the customer who lives the result isn't the entity that decides what payment is due for it.