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I agree about the diseconomies of scale. I got in some trouble many years ago in a college econ class by pointing that out for other businesses. I do not entirely agree about physician productivity. I work as a lean consultant in the medical area. The majority of a physican's time is NOT spent providing medical service. By focusing on maximizing value added service and process flow, I find we can generally increase productivity as much as 50%.

Efficiency is always welcome in any "business," but my medical care as an internist has always been about taking "enough time" for the patient. Who decides what is "enough?" About 90% of that is the patient's choice.
I am very "inefficient" and I will retire from medicine, rather than work hard to run people in and out. I see my days as numbered, maybe to the extent of 6 months to 24 months remaining of my professional life.
The MDs who didn't like practicing medicine and took the MBA course are the ones that I blame for this perversion of the profession.
I'm damn glad I am 68 now. I don't think we will recognize medicine in five years and it will be more "available" as the physician's time is spread over many and each gets less.

I agree that not all large medical organizations are doomed to fail, but groups that undergo expansion may lose sight of the fact that financial viability is dependent on physician productivity.


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