A critique of clinical economy: reassessing value and care during covid-19—an essay by Eric Reinhart and Daniel Brauner

ABSTRACT

For decades, American medical practice has been organised around billing codes, with severe consequences for patient care and physician morale. The interruption of routine clinic visits owing to covid-19 presents an opportunity to reconsider the guiding principles of clinical care, write Eric Reinhart and Daniel Brauner The United States is host to more documented covid-19 cases and deaths than any other country. Under pandemic conditions, deficiencies in the organisation of the American healthcare system have become more visible and their consequences—particularly racial and class disparities in care—intensified. The routine clinic visit is one feature of this system that has attracted attention by its sudden obsolescence. As is the case across broad swathes of the US, the clinics in which we work and train have been closed or drastically curtailed because of infection risks. Concerns about face-to-face interactions have led some states to prohibit non-urgent appointments in physical clinics during covid-19, provoking a surge in telemedicine. Such interruptions to standard practices are now prompting critical questions How necessary is the clinic? What functions does it serve? Could its essential medical roles be fulfilled otherwise? This ongoing disruption has led many to argue that the high volume of clinic visits in the US has been neither medically necessary nor beneficial. Such observations alone, however, are not sufficient to allow us to change and improve our existing practice standards. To do so effectively, we must also re-examine the structural economic pressures by which clinical care has been shaped over the last half century. In American healthcare, the organisation of care remains determined by disconnected institutions that bill private and government sponsored insurance on a fee-for-service basis. This system is conditioned by mundane, taken-for-granted billing codes that supply the overarching economic incentives for the delivery of care. This essay traces the rise of the …