Unhealthy Trends: The Future of Physician Services

Hoangmai H. Pham; Paul B. Ginsburg

Health Affairs. 2007;26(6):1586-1598. 

In This Article


Health Affairs came into the world just a few months before Paul Starr's The Social Transformation of American Medicine, published in 1982. Starr's influence was profound, even when he overstated his case. In the 1990s many analysts and experts assumed on Starr's authority that the medical profession was on the brink of corporatization. The empirical signals were mixed. But for managed care and managed competition to transform the delivery system, medicine would have to emerge from its cottage-industry cocoon. So people believed. When it didn't happen, the wheels came off the decade's preeminent policy bandwagon.

Instead, the organization of medical practice has evolved according to its own script, more slowly than Starr and others expected, in different directions, and in an environment quite unlike what the apostles of managed competition had in mind. As Starr himself cautioned, "A trend is not necessarily fate. Images of the future are usually only caricatures of the present." To the extent that it has occurred, the corporatization of medicine has been primarily small-scale and local, into single-rather than multispecialty groups, and under fee-for-service rather than capitated reimbursement. One-and two-physician practices seem finally to be evanescing. But the following review by Hoangmai Pham and Paul Ginsburg, based on more than a decade of painstaking local surveys and interviews, suggests that the changes that have finally begun to occur in physician organization are not necessarily focused on achieving a more rational allocation of resources or more efficient and effective care. Although some of the changes have the potential to unlock health system improvements, others may be leading toward further growth of excess spending and overuse of services.

Pham ( mpham@hschange.org ) is a senior health researcher and Ginsburg, president, at the Washington, D.C.-based Center for Studying Health System Change. This paper draws on research from the center's long-running Community Tracking Study. Both authors have written extensively on physician issues, and Ginsburg is the former executive director of the Physician Payment Review Commission, forerunner of today's Medicare Payment Advisory Commission.


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