The changes in managed health care are not only affecting patients, but physicians and aspiring doctors as well. According to a recent Association of American Medical Colleges survey, the number of applicants for medical school in the United States has decline for a third straight year, dropping 6 percent to 38,534. Enrollment hit its peak in 1996 when the number of applicants reached nearly 47,000.
The association cited several contributing factors for the decline, including “the perceived loss of physician autonomy due to recent changes in the health care market place.”
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Robert Calise, a Rhode Island Medical Society Insurance Brokerage Court vice president agreed.
”I think that in general people in college don’t view being a physician as highly as they used to,” he said. “More students are seeing that physicians are being told what they can and can’t do by a health insurance plan, instead of seeing how it used to be when a doctor’s primary role was to treat the patient.”
Stephen Smith, associate dean for Medical Education at Brown University believes the decrease in applicants is because “many students feel there are probably easier ways to make money these days, and medicine may not be a secure route to making a good living.”
Smith said while applications are down, enrollment is constant.
Meanwhile, Smith said, medical schools have been responding to the changing environment, adding courses in health care management. Smith has been teaching the class at Brown since 1985.
”A lot of students have said the course really opens their eyes to the business aspect of medicine,” he said. “Most of the students say though they are still idealistic, they believe the knowledge will make them a better doctor.”
In fact, Smith said, there has been a 10 percent increase among students who choose to study the business management side of medicine, earning a Master’s of Public Health.
But as insurers retreat, Calise says confidence among physicians decreases. The recent decision by Tufts Health Plan of New England to pull out of Rhode Island and other areas, and a similar decision by Harvard Pilgrim Health Care of New England reinforce the physicians’ belief of the instability of the health care profession. Many doctors, he said, remain concerned about large outstanding balances owed them by Harvard Pilgrim.
”I definitely think it’s having an effect on the way physicians feel about health care in general,” he said. “A number of physicians have outstanding balances due to them. These large outstanding balances can have a serious effect on the overhead of running a practice. It has become a risky business to be a physician.”
Though Calise said there are different types of health care, none of them give doctors 100 percent control over their patients. He said even the recent statement by United Health that they will allow doctors to make the decisions, doesn’t mean they have complete control.
”Physicians need to have the final say,” he said. “The physician and patient have a private relationship and most patients don’t want health care companies to make the decision. They want their doctor to make the decision.”
Smith applied the term “benevolent despotism” to describe the present situation in Rhode Island, but said given the public backlash there probably will be a loosening up in the market place. He is hopeful the changes will bring more professionalism to the field, while at the same time giving more control to doctors.
”I think the question is whether we have had enough of predatory competition,” he said. “After all the blood that has been spilled people are coming to their senses and realizing that this isn’t the best way to bring health care to Rhode Islanders.”
Smith said in the future, the state could play the role as a broker of cooperative planning for the health agencies in the state. But according to Calise, many doctors don’t want the state government to step in and take control of the current situation.
”I think their opinion is that the state getting involved in trying to run a health insurance plan is not a good move for doctors, for hospitals, or for the people of the state,” he said.
