Medicine

The “McDonaldization” of the health care industry.

By Chris Rangel MD ⋅ May 29, 2006 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

A recent AP poll found that Americans are amazingly impatient. The poll found that we can’t stand waiting in line more than 15 minutes or being put on hold more than 5 minutes. Why are we so spoiled (for lack of a better term)? This has to be a direct result of what sociologist George Ritzer described as the “McDonaldization” of society. I.e. the modern rationalization of how we conduct business using the fast food industry as the model. When we go to a fast food restaurant we expect standardization (all McDonalds look alike), predictability (all Big Macs taste alike), and efficiency (your meal in minutes). With ever increasing efficiency the increasingly rare “long line” becomes intolerable.

But Americans would never expect the same kind of “McDonaldization” of service from the medical care industry where the inherent complexity of patient care makes predictability and efficiency very difficult to come by. Right? WRONG! Welcome to my personal hell.

As a relative new comer to outpatient/office practice I was astounded to realize that patients are increasingly becoming intolerant of “long” wait times and yet when they did get in to see me they wanted to spend as much time as possible discussing every possible health concern no matter how trivial. Either that or they were unsympathetic to my explanation that some patients were sicker/more complex then they and so required more attention and time which is very difficult to predict and plan for. How did it come to this?

Though “McDonaldization” is not necessarily a bad thing, most Americans are unaware that they must sacrifice quality in return for efficiency, predictability, and lower prices. Certainly if you want to eat the best hamburger in the world then you should expect to pay more and wait longer for it to be properly prepared. The problem is that in the health care industry, price no longer becomes a factor by virtue of insurance and 100% top quality services are automatically expected by virtue of the importance involved!

To use the same fast food analogy, imagine a situation where price was no longer an issue (because of insurance) and the hungry masses started demanding the best burgers in the world . . . . but they wanted to wait no longer than they did for the regular “McDonaldized” burger. The problem is that the amount of money that the restaurant gets from the “burger insurance company” is little more than what they got from the customer when the meal was paid for directly. So the burger guys are stuck.

Unlike the gourmet burger place across the street that accepts only cash (or plastic), the “fast food” burger guys (who only take burger insurance) can’t increase their prices. If they could then they could serve fewer customers and concentrate on quality while trying to hold down wait times. What to do? There are only two choices. 1. Close up shop or 2. Serve the crappiest burgers as possible so that wait times can be as short as possible, cash flow is kept stable to maintain profitability and cover overhead, and hope that nobody notices.

“Oh, but Dr. Rangel, you’re not suggesting that the quality of American health care is being kept low by the current physician reimbursement rates, are you?”

YES. You bet your ass I am.

How many minutes do we schedule the average patient for? 15 minutes? Maybe? And this is supposed to be enough time to review charts, lab results, radiology results, biopsy results, referral notes from specialists, and perform a decent physical and review of systems, medication review, charting, other paperwork, perform in-office procedures and tests like EKGs, review health maintenance like vaccinations, mammograms, endoscopies, “pap” smears, and screening for depression, alcohol abuse, drug abuse, dementia, domestic abuse, sleep apnea, diabetes, high cholesterol, and counseling for diet and weight loss, smoking cessation, substance abuse rehab, exercise, etc. etc. etc. etc. etc. Yea, right. BULLSHIT!

The ironic thing is that most patients don’t really realize that the current system is short changing them! Many Medicaid and Medicare populations in particular still do not have a full appreciation of the benefits and complexities of preventative care. For many of these patients a short wait time to get in and out with medication refills, test results, or a minor acute illness is more important than keeping track of their last cancer screening or their doctor asking peculiar questions about their sleeping habits, appetite, or sex life.

So in some aspects the “McDonaldization” of medical care has been beneficial, i.e. patients will keep coming back if wait times are short and they get the prescriptions they want with few questions or hassle from the doctor. But efficiency does not mean good care and many patients have no idea how to tell the two apart. So they keep going back to the same doctor who pretends to fully review their 7 major medical conditions in a scant few minutes because they don’t have to wait long and they get their prescription refills quickly.

Maybe this explains why an ever growing number of physicians are changing over to the so-called “concierge medicine” model of practice. This is the gourmet burger place of doctor offices. The physician charges more but in return the patients get shorter wait times AND longer and more detailed physician visits! Imagine that; Getting what you pay for.

But lets not kid ourselves any more. Falling physician reimbursement rates are only going to continue to negatively impact the quality of patient care in this country. Americans have become so used to getting cheap and crappy burgers that they no longer know what a really good burger tastes like anymore! And they don’t care as long as they don’t have to wait more than 15 minutes to get it. The same appears to be happening with their health care, as well.