7

　　.

　　This is particularly in relation to hospital care. The physician must give evidence of the

　　9

　　for hospitalization, determine what procedures will be performed, and announce when the patient may be allowed to leave. The patient may be consulted about some of these decisions, but in the main it is the doctor’s judgments that are

　　10

　　. Little wonder then that in the eye of the hospital it is the physician who is the real “consumer.” As a consequence, the

　　11

　　represents the “power center” in hospital policy and decision-making, not the administration.

　　Although usually there are in this situation four recognizable participants — the physician, the hospital, the patient, and the payer (generally an insurance carrier or government) — the physician makes the

　　12

　　for all of them. The hospital becomes an extension of the physician; the payer generally

　　13

　　most of the bills generated by the physician/hospital; and for the most part the patient plays a

　　14

　　role. We estimate that about 75-80 percent of health-care

　　15

　　are determined by physicians, not patients. For this reason, economy directed at patients or the general are relatively ineffective.

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