In 1967, the Bonzo Dog Band from England released their debut album with an opening track (which you have likely never heard but should listen to) called “The Intro and the Outro.” The song introduces an endless cast of characters that each play their respective instruments or contribute their voices and whose sounds are layered upon one another in a cyclical, repetitive fashion.1 Eric Clapton even plays ukulele! The result is entertaining, confusing, and somewhat mind-numbing—and yet, you want to stick around to hear what comes next.
It is an apt metaphor for the US healthcare system. Our system has a seemingly endless cast of characters that have taken the stage over time. We started with some apothecaries, physicians and quasi-physicians (bone setters, herbalists), and quasi-hospitals (almshouses) in the 18th century. In the mid to late 19th century, we added more professionally trained physicians and nurses, hospitals, pharmacies, and pharmaceutical companies. In the 20th century, we then added a succession of other players (in roughly chronological order): private insurers, nursing homes, employers offering health insurance benefits, group purchasing organizations, hospital outpatient departments, public insurers (Medicare and Medicaid), long-term care hospitals, emergency rooms, drug wholesalers, pharmacy benefit managers, hospices, medical device firms, ambulatory surgery centers, biotechnology firms, managed care organizations, home healthcare agencies, information technology firms, and retail clinics.
This proliferation in healthcare occupations and organizations has been going on for over 70 years and perhaps for a century.2 Decades ago, Milton Roemer documented that the ratio of nonphysician healthcare professionals (eg, nurses, dentists, technologists) to physicians rose from 0.58:1 (in 1900) to 3.35:1 (in 1950) and then to 12:1 (in 1973).3 More recently, David Lawrence, former chief executive officer of Kaiser Foundation Health Plan and Hospitals, noted that the number of categories of healthcare professionals mushroomed from 10 to 12 in the 1950s to more than 220 by the early 2000s. Similarly, the number of specialties in medicine grew from six to eight following World War II to more than 100.4 Such proliferation has been interpreted in a variety of ways.5 First, some view the growing sprawl as evidence of “Taylorism” in healthcare: an increasing specialization and division of labor that leaves professionals in ever narrow, bureaucratically confined roles. Some extrapolate further and suggest that these professionals have been “proletarianized.” Second, some view this as a major contributor to the growing “fragmentation” of healthcare, where no one professional or organization takes account of the “whole person” in the delivery of healthcare. Third, some view this as contests among competing professional groups—“turf battles”—for control over healthcare work that used to be dominated by physicians. None of these interpretations sounds good. However, they may all be accurate (see Chapters 9 and 10).
Each year I teach and conduct research, I discover yet another “nook and cranny” in the US healthcare system’s “cast of characters” that ...