The U.S. health care system, once admired for innovation, is increasingly failing to meet the basic needs of patients, generating $5 trillion in annual revenue primarily for hospitals, pharmaceutical companies, and administrative staff.
If you’re searching for solutions to these deep-seated problems, you won’t find them here. This isn’t about answers; it’s about acknowledging the issues. As a physician retired from clinical practice, now navigating the system as a patient and caregiver, I see firsthand the growing disconnect between what healthcare should be—high-quality, accessible, and affordable—and what it is.
My personal experience underscores this reality. My wife, Becky, 80, has severe vascular Parkinsonism and cognitive impairment, requiring constant care. She lives in an assisted living facility and frequently needs medical attention. The delays—months to see specialists, five-to-six-hour emergency room visits—are unacceptable, and access to her primary care physician is often frustratingly slow.
The Shift to Non-Physician Primary Care
Recently, Becky developed leg cellulitis. I immediately contacted her hospital-employed internist’s office, requesting an urgent appointment. The response was blunt: a week’s wait. Knowing the infection could quickly worsen, I pressed for sooner, only to be offered an appointment with a nurse practitioner (NP) that same day. Despite reservations, I accepted. Any port in a storm, as they say.
The NP’s care was a stark contrast to many of our physician visits. Becky was seen promptly, treated with professionalism and genuine concern, and given ample time to discuss her condition without being rushed. She prescribed an appropriate antibiotic and ensured follow-up care was readily available. Becky improved quickly, a testament to the value of timely access. This experience highlights the need for physicians to utilize RNs, NPs, or physician assistants to triage urgent cases and ensure same-day or next-day appointments when appropriate.
For 23 years, I practiced with a physician-owned ophthalmology group that prioritized timely access for patients with urgent concerns. That changed after a private equity (PE) firm acquired the practice, implementing a for-profit model. Allegedly, things have worsened since then.
The inevitable consequence of limited physician access is an expanding scope of practice for non-physicians. Patients, frustrated by delays, will increasingly turn to NPs, PAs, podiatrists, optometrists, and other healthcare professionals for primary care. Many are already referring to their nurse practitioner as “Doctor Nurse.”
Addressing the projected shortage of 37,800 to 124,000 physicians within the next 12 years remains a significant challenge. I don’t have the answers.
The Profit-Driven System
For-profit hospitals openly prioritize financial gain. Paradoxically, even “nonprofit” hospitals often operate with the same profit-driven mindset. Healthcare dollars flow to shareholders and highly compensated administrators. Your health concerns are, quite literally, their financial gain.
The U.S. spends significantly more on healthcare administration than other wealthy nations. Hospitals, like universities, are burdened by large, unnecessary administrative bureaucracies. There are now 10 healthcare administrators for every physician in the United States—a ratio that simply isn’t sustainable.
Despite this massive spending, the U.S. lags behind other developed countries in key health indicators. We have the highest rates of obesity, autism, substance abuse, type 2 diabetes, maternal and child mortality, violent deaths, and suicide, coupled with a declining life expectancy. We’re paying a premium for substandard results.
The situation is further complicated by the influx of private equity firms acquiring physician practices. In Kansas City, most major ophthalmology groups have already been sold to PE firms. I’ve witnessed the resulting changes: staff reductions, time limits on patient encounters (often 15 minutes), mandatory referrals within the group, increased fees, and pressure to prioritize high-profit procedures. Physicians are assigned monthly billing quotas and face repercussions for failing to meet them.
PE firms often shunt routine primary care to non-physicians, allowing physicians and surgeons to focus on more profitable procedures. In ophthalmology, this means diverting primary eye care to optometrists. These measures prioritize financial returns over patient well-being, and studies consistently demonstrate lower quality and higher costs when PE firms acquire practices.
Then there’s the pharmaceutical industry. Drug prices are often exorbitant. Lenmeldy costs $4.25 million and Beqvez $3.5 million for a single treatment. How can these prices be justified? New drug development costs are intentionally obscured, allowing pharmaceutical companies to inflate prices and maximize profits. And, crucially, they wield significant influence in Congress, spending $150 million in 2024 to lobby for favorable legislation.
I’ve personally experienced this greed. The Migliazzo-Hagan-Kosa treatment for acute migraine—using liquid timolol 0.5 percent—is effective, safe, and inexpensive. We’ve been pitching this treatment to pharmaceutical companies for over a decade, only to be repeatedly rejected. They acknowledge its potential but deem the potential profit insufficient. They disregard the fact that an estimated one billion people worldwide suffer from migraines, and hundreds of millions could benefit from this treatment.
Addressing the Access Crisis
Proposed solutions include expanding medical school enrollment, shortening medical school, importing international medical graduates, and increasing residency positions. The default solution in Jefferson City is often to expand the scope of practice for non-physicians.
“Minute Clinics,” staffed by nurses, offer accessibility but variable quality. “Be your own doctor” kits, advertised on television, promote self-diagnosis and treatment, often including prescription medications. The implication is that practicing medicine is easy. What happens when things go wrong? Perhaps patients can sue themselves for malpractice.
Medical tourism, traveling abroad for treatment, is an option for some, primarily for cosmetic or extremely expensive procedures. Telemedicine, expanded during COVID-19, offers some relief, but many visits require physical exams.
And then there’s artificial intelligence (AI), touted as both a panacea and an existential threat. While AI holds promise in areas like pathology, radiology, and dermatology, it lacks the empathy and compassion that are essential to patient care. Compassion, I believe, cannot be digitized.
Securing a timely physician appointment through conventional means is often difficult. I confess to leveraging my status as a physician to expedite appointments, a privilege not available to most patients.
As a nation and as a profession, we must do better. Lives depend on it.
John C. Hagan III is an ophthalmologist.
