U.S health care system -The Cottage Industry Crumbles, Or Does It?

This is for your information, and is not intended to be inflammatory.


In Prescriptions for Excellence in Health Care, a collaboration between Jefferson Medical College and Eli Lilly, and Co, Michael Millenson – a respected physician critic and widely-read author – argues our current health system is ” inefficient” and may even threaten our economic and national security. He says further IT adoption by doctors is a “high-visibility failure”, and the public is increasingly “intolerant of unsafe and unnecessary care.” Powerful economic, technological, and cultural forces. he believes, will inevitably cause the physician cottage industry, i.e, doctors practicing in small isolated, independent groups, without adequate oversight, to crumble.


In a new publication, Prescriptions for Excellence in Health Care, a collaboration between Jefferson Medical College and Eli Lilly, and Co, Michael Millenson – journalist, author, consultant, and scholar at the Kellogg School of Management at Northwestern – argues the “cottage industry,” i.e., physicians practicing in small groups with limited oversight, may be crumbling.


In “The Cottage Industry Crumbles: QI and the Foundation of Health Care,” Millenson says,


1) The current system is “inefficient” and may constitute a problem “affecting both our economic and national security.”


2) “The slow adoption of information (IT) by health providers” is “a high-visibility failing; is being tracked by employers, health plans, and government agencies.”


3) Zeitgeist, “ ‘the spirit of the times,’ is exemplified by increasing public intolerance for unsafe and unnecessary care.”


Millenson concludes,

“The evidence that the cottage industry model of medicine wastes money and kills and injures patients needlessly is decades old. But it is only because of powerful economic, technological, and cultural pressures that the traumatic process of change, uncomfortable yet irreversible, if finally under way.”

Millenson may be right, but his view may also represent idealistic wishful thinking for a better health system. It may be he hopes for what should be, rather than what will be. His views may represent a “paradigm shift” among critics in search for a more perfect world, but I doubt it represents a fundamental shift among patients and doctors.

• Scant evidence exists government, health plans, or big groups, deliver more efficient or safer care. Medicare in on track for bankruptcy by 2017, health plans siphon 20% to 30% of money out of the system, and large groups, supposedly the cottage industry’s antidote, have 5% fewer physicians than 10 years ago (source: Center for Studying Health System Change). No stampede for “efficiency” and “safety” is occurring, though some hospitals are installing patient safety systems. One thing is certain – a 50,000 physician shortage. As for health reform, his scenario may exaggerate efficiency problems in the form of overcrowded offices and ERs and long waiting times. As the governor of Massachusetts, Deval Patrick, has observed, “Universal coverage without access is meaningless.”


• I’m aware of the advocacy of pay-for-performance systems to reward “good” doctors, interoperable computer systems to foster “necessary” and control “unnecessary” care, and widespread electronic medical records to solve efficiency and safety problems. But these systems are in their infancy, underfinanced, and expensive for physicians to install and maintain. Evidence for their efficiency for the most part remains unproven. Physicians in their cottages, already overworked, in severe shortage, many struggling to make a living and pay back educational debts, are skeptical these systems are workable, desirable, or efficient. Many doctors find paper template systems more efficient in meeting quality indicators, and less disruptive and less costly in their practices. I know of one well-known physician who spends most of his time taking down and dismantling EHR systems that have failed to measure up to expectations. As for being a “threat to economic and national security,” applying that language to current physician activities is an overstatement.


• The “spirit of the times” – concern over safety and efficiency –isn’t common among physicians and the public, though it may prevail among critics. Public concern for their lives and safety may exist but not on a large scale. Physicians worry about limited autonomy, and rules that discourage physician-hospital collaboration and innovation, and constant criticism that casts a pall on their clinical judgments.

In ivory towers, bureaucratic or business and congressional office suites. it may seem government, health plans, employers, and the public at large are actively, purposefully, inevitably taking steps causing our current system’ foundation - independent small group practices – to crumble to assure quality and safety, and, it may be, these “powerful economic, technologic, and cultural” forces will dictate and restrict how doctors should practice, according to dictums from on high.

In the near future, however, I believe patients will continue to visit physicians in their cottages and will trust their independent clinical judgments over outside mandates. If government is serious about universal electronic documenting, engaging in surveillance, and coordinating care, it should pass a Hill-Burton like act to provide funds activating systems it believes assures efficiency and safety.

I agree with Millenson shifts in behavior and employment patterns are occurring among physicians – and economic, technological, cultural forces are at work. I am simply saying the forces are evolutionary, not revolutionary, and the cottage walls are likely to remain intact for some time.