Is your doctor a frozen turkey?

What do eggs, roofing nails, men’s haircuts and plastic cups have in common? A bizarre fraternity ritual or my Saturday morning honey-do list?  Gasoline, copying paper and paperclips?  Shopping for a mobile accounting office?  Nope.  What these items share is that who ever makes them, wherever you buy them, they are essentially the same.  They are “commodities.”  They do not vary significantly in construction or quality.  The only way to tell them apart is cost.

In a consumer society, we chose between commodities by how much we want to spend.  Most of us have Apps on our phones that tell us the cheapest gas price.  None of those programs tells us which gasoline is better, just its cost. On the other hand travel websites may tell hotel prices, but also rate service, location and accommodations.  Not many of us go to an unfamiliar city and look only for the cheapest lodging.  Hotels are not commodities.

Is medicine a commodity?  Once you achieve a minimum of quality, is all healthcare the same?  Doctors all went to medical school, took the same classes and passed the same boards.  They do the same laparoscopic appendectomies, prescribe the same antibiotics and use identical CT scanners, which produce perfect pictures in Omaha or Oslo.  Cancer doctors use the same treatment protocols and achieve the same remission rates.  Does this make doctors more like gasoline than hotels?

The pressures to drive medicine into Henry Ford’s assembly line world (“you can have any color, as long as it is black”) are immense.  Patients and payers demand safety and uniform outcomes, which result in academically derived guidelines, which are enforced by the medical profession, regulators and malpractice courts.  Realizing the increasingly uniform nature of medical treatment, employers, industry, the government and insurers suck money from healthcare and demand usurious savings.

An identical product differentiated only by rate is the very definition of a commodity market. Patients shop online for the cheapest joint replacement, buy drugs from the least expensive vendor and through medical tourism visit cities and countries where they would not consider walking down the street, just to get a cheaper heart valve.

Frankly, what is wrong with converting the delivery of healthcare to a cheap-cookie-cutter product, if that results in widely available good treatment?  Should we conclude that just as we depend on gasoline to be the same wherever we drive, it would be a victory to have the same reassurance regarding our health, our very lives?

Allowing medicine to become a commodity would be a disaster. While we must have standards, guidelines, quality and efficiency, the next step, canned-tuna-medicine, will have multiple untoward effects.

First, as a commodity is differentiated only in price, this means that the cost of medical care, whether doctors, hospitals or nursing homes, will plummet.  Spending will be so low that the best comparison will be that ultimate commodity experience, the McDonalds drive-thru.  Yes, you can get the same burger anywhere in the world, but accept for the most senior corporate executives, everyone else is making minimum wage.  If salaries for doctors and other skilled medical providers are driven down that far, it will not be possible to spend 14 years in post-high school education, nor commit to 80-hour-work-weeks at the bedside.

There will be no money for teaching, outreach or basic research.   Healthcare is not just about individual treatments; it is about education of patients and communities, and the nurturing of future health professionals.  It is about developing technologies and science.  Medical innovation is dependent on academia for the development of cures.  The cash-for-profit pharmaceutical and device industry has failed to develop breakthrough innovations. In a commodity driven market anything that does not drop cost or increase short-term profit will vanish.

However, this is not the major problem.

If healthcare is a commodity, always the same, than health is always the same.  If the treatment is the same, the disease must be the same.  Illness becomes a sort of commodity.  Since people are the ones with identical disease, they themselves must be the same; patients therefore are commodities.  In a commodity medical market patients are not individuals, but clones on an assembly line.  The personal needs, dreams, beliefs and hopes of patients are sacrificed to a financially motivated, guideline structured, ultimate quality production model. We are all the same.

Physicians feel the threat of this transformation in their hearts.  While they support the concepts of data driven, quality guided and outcome weighed therapy, they also realize that real disease and real treatment happen to real people and real people are much more complex than defined by gross biology.  Each person’s struggles integrate with the patterns of their life.  What is important to them?  What do they believe?  What are their goals?  What alternatives are acceptable and which not?  How much do they understand and how much do they wish to know?  What do health, life and death mean to each?

In the 1970s, Frank Perdue had a problem.  He was a chicken producer and chicken was a commodity, all the same.  Perdue was being killed by price.  Therefore, he changed chicken.  It still needed to be fresh and of a certain quality, but he started selling it packaged as wings, breasts, fingers, spicy, plain, dark meat or white.  He gave people choice.  This is what must happen in health care.  We must be provide choice.

In the coming years responding to the commoditization of medicine, patients and doctors will seek ways to “humanize” care.  Personal service will improve.  Individual education will be vital.  Issues of family, career and spirituality will be emphasized as modifying factors in therapy.  Technology will allow patients access to data, treatment alternatives, communication and control. While we must standardize the physical practice of medicine, we must use that strengthened base to empower patients to choose care that suits individual lives.

Fail to achieve that goal and we will all be frozen turkeys.




  • Liz
    1) it is not possible to shop for all your medical care by price. Much of the time you can't even GET a price for anything beyond the advertised price (not insurance adjusted price) for an office visit, and at times you don't have the time to shop by price even if that information were available… With a commodity price is the only thing that matters because… see #2 2) Commodities are only commodities if and only if (as you mentioned) (1) all products sold are absolutely, completely, identical (and we know this is not true due to individual differences with humans as opposed to identical quality nails - and not all nails are identical quality so you'd have different markets for high quality nails, junk walmart nails, etc.) from the point of view of what is important to the consumer. You need that for price to be all that matters (which of course you are pointing out). BUT ALSO (2) there needs to be free choice to buy any version of the item in a free market (this is not true thank you insurance, no easy way to ship some services - for example surgery to distant locations, closed practices...), (3) there are large numbers of the product (also not true for most specialities, in some areas there area not enough of even primary care doctors let alone specialities to meet the demand) and (4) there is pretty close to complete information what you are buying (also not true - in fact even when you have purchased use of the doctor multiple times you typically don't have complete information or there wouldn't be surprises about problems later in the game - and then you have almost no information to very insufficient information about doctors you don't use). So using the definition of a commodity - medicine is not it. It fails to meet most of the criteria as defined by economists. -------- What you appear to be talking about is standardization processes that don't take into consideration "exceptions" and perhaps even fails to recognize "exceptions" without a time consuming battle. Loss of autonomy appears to also be an underlying issue in what you are discussing as well. Medicine already standardizes treatment of some things - we use antibiotics with strep throat because science has demonstrated over and over again that science works and if the antibiotic isn't working something, in addition to the strep, must be going on (antibiotic resistance, a secondary infection, wrong diagnosis…). Not many doctors seem to have a problem with that "accepted" practice. You choose chemo for your patients from amongst the "accepted" collection of treatments that have been shown, on average, to do some good. If your patient falls outside of that 95% confidence interval of the patients it works for, you then go looking for alternatives. You may or may not agree with the FDA or the insurance company on what you can get your hands on for the patient, and that would seem to be behind some of your objections (eg the argument would be over what is used to create the standards/rules of what you can use and what you can not without following even more rules). You are not giving them purified urine (or at least I am assuming you are not LOL) which has no science base. So it seems to me that you are upset with the exclusion of treatments you know has some evidence that work or the loss of freedom to choose amongst all the choices (eg insurance limits). If you wanted to include purified urine woo (or other snake oil with no scientific evidence that they work) in your choice set then the governing bodies have the right to censor you and prohibit the choice because because it does not do what it says it does. If you do not like science based medicine restrictions, and don't want to listen to and follow that, you have the right stop offering science based products, not treat that associated customer base and join the snake oil product segment and treat that target group of customers who prefer products that have no scientific evidence that they work. Or join that new group who offer both. It would also appear that you are unhappy with cost containment processes that are imposed on you by insurance companies, the government (medicaid and medicare) and other regulations that impact your income to a level below what you believe you should be earning because for you the cost/benefit analysis only comes out positive if you have a certain, presumably relatively high, income level in return for work hours and working conditions (along with education, etc. required). If doctors don't join forces to fight that, go on strike if necessary, etc. then you have the choice to change professions (yes there are sunk costs involved and the cost of changing may be seen as too high…). I am an academic and I get paid far LESS than what many of what my students will be paid, who have less education than I have. I could bail and do something else. And I sometimes question if it was worth the time and added student loan debt to make less than many of the students I teach will make, in some cases starting out and in most cases, when they have been working for 10 or so years. I also hate some aspects of my job - pressure to pass students and given them enough second, third, forth, etc, chances, pressure to dumb down classes because enough students don't want to do the work...One could argue if you don't like something, don't want to try to change it (and it may not be changeable without significant effort and cost) then make a different choice. Of course presumably most doctors go into medicine for reasons that include financial but are not exclusively financial. Same with academics. So like in any other profession we accept tradeoffs and make our choices based on whether the tradeoffs are worth it. It sounds like they are not worth it for you if outside forces drives your income down low enough. And I don't apply for some academic jobs that pay really low either - at least not while there are others out there that pay closer to the national average. Fortunately for you doctors are also subjected to the supply and demand forces. Consolidation of the medical profession (eg away from small practices into large group practices or hospital affiliated practices - where I live 99% of the physicians of all specalties are in one of 3 large groups, each affiliated with one of the three hospitals around here - some speciality groups are affiliated with 2 hospitals as the population base here is small enough that if they only had access to the patients who used one hospital they would not have enough patients. There is some wage competition between these three groups. Fewer doctors and wages go up. I have read that the wages to be a family practice doctor have been rising as the supply is well below the need (demand). Academics is subjected to that too. Medical school, legal and business faculty make far more than English faculty. Why? Because under most circumstances the choices outside of academia pay far more than academia and so the wages for that group needed to rise in order to even get enough people to agree to be academics (although they are still less than what people could make, on average, outside of academia but academia has other perks that some people feel make up for the lower wages) and many people do not therefore go into academia for wage (or other) reasons. Where as English PhD's are a dime a dozen, jobs outside of academia often pay the same or less and there is an over supply. Someone bails from an english prof job and 100 others will apply for their job so they are the third lowest paying "specialty" in high education. Medicine is NOT even close to being a commodity (doesn't meet most of the tests to be one) - importantly there isn't anything even close to complete information (or even enough information) about the providers for customers to make intelligent choices based on product quality to then make price driven choices within a quality grouping (eg not enough information about what doctors offer outside of "standard" medicine, doctors doing the things you talk about - while some advertise most don't). There are limits on choosing a doctor (eg who is in-network - so insurance is limiting choices) so the market is not open or free. Free choice is also seriously limited because of "large numbers" problems - as in there isn't that most of the time (which is needed in a commodity market) because there is a shortage of physicians in some areas and in some specialities. As a result of all these things economic models of free market behavior don't fit and I don't think the market forces out there will drive the kinds of changes you are predicting. Be nice if they did though.
  • meyati
    When I had my biopsy, I checked with the HMO about the price. If a person owes anything anywhere in this HMO, they can't get further treatment. I was told the price was either $35 or $495. I couldn't believe that. I made several calls in the next few days, and this was true-either $35 or $495. I made arrangements with billing that if there was anything outstanding, that billing would allow me to get care if needed-it takes 2-3 weeks for me to get the bill. I took my son and his wallet with me when I had the 2 biopsies. They were $35 each. I think that the pricing game is with your coverage: premiums,co-pays, what's covered-seems not very much-. I don't know how to judge a new doctor. It seems the worst doctors have the highest ratings, so I try to go to doctors with average to low ratings. A person used to be able to get a feel for the practice by how the staff acted-were they happy? Could they answer questions? That's pretty hard to do when a phone bank answers the phone. I try to look for cleanliness. I don't know what else to look for at this point--Oh, yes-do I end up having them be rude to me or obviously lying? .
  • Honestly, there should be a reasonable level of standardization among providers as this does improve patient outcomes. Providers should be using the most up to date information to treat patients. With that said, it is the appropriate delivery of high quality care that is the real point of discussion. Support for those who strive to provide high quality compassionate care should be our emphasis. Sensationalist news stories and insurance company CEOs concerned about their pay packages interfere with this process. Medical professionals are bright, articulate and care about the patients they treat. Providers are faced with intimidation tactics, outright bullying and data collection demands that interfere with patient care. We need to return to the sane delivery of care and support providers.
  • Penny H.
    You're a specialist and, when it comes to shopping for the one you want, that's a whole other ball-game than a primary care physician. That's true for me; others' mileage may vary. When our family's primary care doctor decided to change from a hospital affiliated practice to doing contract ER work (after some 30 years) ... it was a pretty traumatic thing for us. We had a working relationship with this man, considered him a friend as well as a doctor, had been through thick & thin including deaths with him in charge of a loved one, and trusted him completely. As I asked him, "Now what do we do for a doctor?", he said to me, "Penny, M.D.'s are like grains of sand on the beach. We're pretty much all so much alike, you can't tell the difference." He was wrong on that. Just as wrong as he could be. It took me many years to find another doctor that was even close to living up to the quality of care our old doctor had exhibited from day one. A commodity? I don't think so. Thank God the new guy has sense enough to send me to the right oncologist right off the bat. We're building our relationship through the years, and if I live long enough ... who knows. He might just fill Dr. S's big shoes one day.
  • Kathleen
    For most patients this ship sailed decades ago. Despite the best intentions of some fine doctors and health practitioners, to most medical organizations and insurance companies we are interchangeable profit units, and have been so for a very very long time. In the late 1970s I was shocked when an old friend beginning her medical residency told me that she opposed a universal national health plan. Private insurance was much better, she said. "Because it's efficient." Efficient? Perhaps for profits. She went on to treat the rich and famous. Many times over the years I've thought of her statement. When I spent most of my non-sleeping hours off work waiting on hold with insurance companies that had denied medically necessary claims yet again. When my brother's main staff person tells me that she could run his medical office alone (instead of that staff of 5) if they didn't have to deal with all the insurance companies. When my HMO discharges me from from post-op PT as soon as I can feed myself - no matter that I need a much higher level of functioning. When I deal with doctors who are so trained to stick to the well-worn path that they really do think that "That would be rare." is a valid argument against a diagnosis that turns out to be right, only after many miserable years later. Well, those years were miserable for me; the docs were just fine. No wonder so many of us do our own research. When we have to deal with cookie-cutter docs, and way too many of them are just that, time after time that research saves our lives.

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