"Did you hear that there are 10 administrators for every physician in the United States?"
"Wow - I just read an article online that said that the number of health care administrators in the U.S. has increased by almost 2300% since the 1970's."
And then someone else pulls up a graphic on their cell phone and just says, "This."
As it turns out, investigators at Harvard reviewed data from both the Bureau of Labor Statistics and the American Medical Association and found that the number of health care workers in the United States increased by 75% from 1990 to 2012. In other words, if you are talking with one of your kids about careers with a lot of job security, look no further than the U.S. health care industry. In this study, most (almost 95%) of the growth in health care jobs occurred in non-physicians. The ratio of physicians to non-physicians changed from 1:14 to 1:16. Moreover, only six of the 16 non-physicians were actual front-line clinicians (nurses, allied health professionals, pharmacists, medical assistants). So back to the statement I heard earlier - there are roughly 10 administrators (loosely defined as administrative and management professionals) for every physician in the United States!
Whenever I hear some of my colleagues talk about these statistics, I start asking them questions about what they think is going on - the usual reply is something like, "Well, this only proves my point that health care has gone too corporate." I also hear comments like, "Health care is being run by the suits!" I don't necessarily disagree with these comments, but I do think there is a clear "Chicken and Egg" problem here ("Which came first, health care became 'Big Business' because of all the glut of health care administrators or alternatively, we had to hire so many health care administrators because health care has gone too corporate?").
Let's be careful here. There is no question that health care is a big business. How could you say anything differently about an industry that accounts for nearly 18% of the U.S. gross domestic product (GDP)? I don't think it is necessarily a bad thing to call health care a business - indeed, there are a lot of things we can learn (and have learned) from the business world to make health care better for our patients. And it is important to call out that the concept of health care as a business is nothing new. Socrates, in Plato's Republic, asked, "But tell me, this physician of whom you were just speaking, is he a moneymaker, an earner of fees, or a healer of the sick?" In its heyday, the American Medical Association (AMA) did everything it could do to protect the business interests of physicians. The AMA originally attached the stigma of "socialized medicine"" to then President Harry Truman's attempts at health care reform (recall that socialism was a four-letter word during that time of the rapid rise of communism). Only fairly recently has the AMA been supportive of the kinds of health care reform to move closer towards universal health care (the AMA supported passage of the Affordable Care Act and has been vocal in its opposition to the more recent health care bills before Congress).
Regardless of how you feel about it, the simple fact is that medicine is a profession (and always will be - a topic for another time) and health care is a business. Deal with it. However, I do think that the rapid and unprecedented increase in the number of health care regulations and requirements that touch virtually every aspect of the patient encounter is really the key driver of the increase in the number of health care administrators in the United States. We have created such a complex system that there is no choice but to shift the burden of documentation (as far as documentation outside the patient-physician encounter, and in many places we have shifted this burden on administrators as well - see the growth in the number of medical scribes), billing and coding, regulatory compliance, and at times complex negotiations around reimbursement to non-clinical professionals. Our patients are sicker and more complex than ever before - it takes an army of clinical coordinators to work with the number of different providers that care for the modern patient. And if anything, all we have done with all these additional layers of bureaucracy (though absolutely necessary in the current system) is to increase the cost of care. None of these non-clinical administrators work for free. The U.S. has the most expensive health care system in the world, and in large measure, a significant driver of health care expenses stems from administrative costs.
So, what can we do? First, we can't blame the administrative burden and associated costs that currently exist in the U.S. health care system on the number of administrators. Just ask the next administrator you see why they joined the health care profession. The odds are that he or she wanted to make a difference, just like you and me. Health care administrators are just as dedicated to patients as we are, even though their job is different from ours. And in many cases, they want to help us do what we do so that together we can make the patient better. Second, we have to be part of the solution. Part of the blame lies with us - many of the regulatory requirements were imposed on us, because we weren't doing what we needed to do to cut out waste and make health care delivery more efficient. We have more control over what we do than we sometimes think. There are a lot of things that we can do to cut out waste. Third, we have to continue to advocate for real health care reform - the kind that will make our system simpler and more efficient. Regardless of what side of the political aisle that you fall on, there are things that we can agree on that will cut out some of the administrative burden and eliminate the hassle factor. Fourth, we need to encourage leaders in our field to join the fray. For too long, we left health care administration to the so-called "business types" ("the suits"). We need physician leaders who can cross over "to the other side" and become administrators (while at the same time continuing to practice medicine, if possible). Rather than poking fun at our colleagues who move into administrative positions, we need to celebrate them and thank them. They have work to do - for us. There is no mystery why some of the best hospitals and health care organizations are led by executives with a clinical background.
So which came first, the chicken or the egg? As it turns out, that's not an easy question to answer. The reality is that health care has always been a business, at least to some extent. If we are going to get a handle on the rising costs and growing number of administrators, we are going to have to make health care delivery simpler and more efficient.
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