HJNO Jul/Aug 2025

WHAT’S WRONG WITH HEALTHCARE 54 JUL / AUG 2025 I  HEALTHCARE JOURNAL OF NEW ORLEANS   cal students, residents, and faculty access to the most state-of-the-art technology and facilities. However, these partnerships also shed light on the tension that arises in medi- cal practice patterns as the evidence-driven academic world collides with the more eco- nomically oriented world of private practice. To Bridge a Chasm Public versus private arguments also permeate viewpoints about healthcare as a human right. Some might argue that health is largely a matter of person- al choices (diet, exercise, smoking, etc.). Those viewpoints might hold that if preven- tive care were a right, it may reduce personal accountability and encourage dependence on the state. Others might argue that healthcare as a human right might lead to a slippery slope to expanded entitlements, thereby declaring that healthcare as a right may open the door to government guarantees of many other social services. Some worry this could lead to unsus- tainable fiscal obligations or a bloated welfare state. Critics may compare it to a “right to hous- ing” or “right to food,” arguing these are not enforceable without massive state intervention. Others might assert that government should have a very limited role in private markets, tout- ing that healthcare, including preventive care, is a service best regulated by market forces. These individuals might argue that government-run healthcare would inevitably lead to inefficien- cies, reduced innovation, or rationing of care. And yet still others might argue that declar- ing preventive healthcare as a right would imply a legal obligation to fund healthcare for all, at enormous cost that would be unaf- fordable. Such an argument would main- tain that private markets enable the most efficient use of limited resource allocation. But is that the case? One can derive les- sons from looking in the mirror at ourselves as a profession to try to determine if the private practice of medicine is efficiently, effectively, and affordably delivering the best possible healthcare for as many people as possible. The majority of healthcare in this country remains funded via commercial health insur- ance through the private marketplace, while a smaller but still significant percentage of healthcare is financed by public insurance through Medicare and Medicaid. And as outlined in the previous two articles, pub- lic insurance options came to bear in this country as a result of private market failures. However, most American families do not un- derstand the nuances of public versus private hospitalsorhealth insurance.They justknowthat they feel the impact of dysfunctional healthcare in their pocketbooks. According to the 2025 Milliman Medical Index, the annual healthcare cost for a typical American family of four now exceeds $35,000, a three-fold increase from their first report in 2005 — for a 188% increase in costs — compared to wage growth of just 84% over that same period, thereby creating a chasm between affordability and care delivery.1 And a chasmexists not only in affordability, but in quality as well. Indeed, the 2003 Institute of Medicine report, Crossing the Quality Chasm, describednot justagap inthequalityofcarethat potentially could be delivered, but a chasm.2 And although the policymakers and payers play a role in the creation and persistence of this chasm, we providers need to look in the mirror and attempt to understand our part as well. From the provider perspective, clinically unwarranted practice pattern variation plays a huge role in healthcare’s affordability and quality problems, and is a major barrier to be- ing able to provide health insurance to all — affordably — such that healthcare might one day come to be regarded as a human right. Three Types of Physicians I recall in my first year of medical school being told a joke by one of our profes- sors that, like many good jokes, had an ele- ment of truth to it. The professor told us the story of a first-year medical student who was quite eager to learn their grade for their first-ever medical exam, to which the pro- fessor told the student the following story: “Son, there are three types of doctors in this world. There are doctors who make mostly A’s. These are the doctors who en- ter academic medicine and advance the scientific frontiers of medical knowledge. “There are doctors who make mostly B’s. These are the best doctors and the ones to seek out preferentially when in need of medical care. “And then there are the doctors who make mostly C’s and barely scrape by to earn their medical degrees. These are the doctors who make the most money … and son, one day you are going to make a whole lot of money.” There is probably more than just a kernel of truth to this joke, and many fellow physicians who might be reading this article will quietly acknowledge that they have made financial sacrifices for themselves and their families in the name of doing what is in the best inter- ests of their patients. These quality-driven and outcome-oriented physicians realize that tak- ing their time to ask the right questions and perform a comprehensive (but appropriate) physical exam will often provide them the in- sights needed for correct diagnosis and treat- ment, often without the need for expensive tests or unnecessary referrals to specialists, which can often result in clinically inappropri- ate and unnecessary testing or procedures. One of the best internists and primary care physicians I know was a few years ahead of me in training. He achieved the distinction of being elected to Alpha Omega Alpha, the medical honor society for those medi- cal students who finish at the tops of their classes. He went on to become chief resi- dent of the internal medicine residency pro- gram where he trained, an honor usually be- stowed on the highest-performing residents. Truth be told, I believe he would have derived immenseprofessional satisfaction fromentering the world of academic medicine, which is often where the best and brightest physicians end up. But here is where the financial realities of our profession conflict with the fiscal responsibilities to one’s family. At the time we finished our train- ing, the compensation from a career in academ- ic medicine could be less than half — or even a third — of what was possible in private practice. This physician is not even remotely materialis- tic. He drives an old pickup truck and devoted most of his financial resources to ensuring that his children had every opportunity to succeed in life. He also probably never sees more than around 22 patients per day, opting instead to spend time with them, build relationships, and ensure that they receive the very best care. And even then, he often spends a few hours in the evening — long after many of his col- leagues have gone home — completing his documentation to be certain he delivered the very best and most medically appropriate care. He is well compensated for his efforts and does better financially than if he had entered into academic medicine. However, he does not make nearly as much money as some of his colleagues who spend significantly less time with their patients (thus seeing more