Healthcare mirrors every other industry in that it's a business enterprise. Acknowledging this fact is the first step towards creating true value-based care, according to Richard Kube, MD, of Prairie Spine & Pain Institute and Prairie SurgiCare in Peoria, Ill.
"As we continue to think of medicine as entitlement, it will continue to skyrocket in price," says Dr. Kube. "When people think of it as a 
bottomless pit of money that they feel entitled to dip into, there's no accountability."
In addition to a culture of privilege and instant gratification encompassing the healthcare industry, Dr. Kube believes employed physicians can also step up their roles by assuring patients receive the best possible care.
Everyone must have skin in the game and shoulder some of the responsibility of pushing costs down and quality up in the healthcare industry.
Being a businessman and physician
As an independent physician, Dr. Kube experiences the business aspect of healthcare daily. Running his own business means he's reliant on the number of patients walking through his practice's door.
"When our model is going toward value, I really need to be able to provide more for less," says Dr. Kube. "If I can control my time, efficiency and freedom to try new products, I can drive that value needle."
Employed physicians don't experience this same stress of running a business, or the same liberties of serving as their own bosses. Dr. Kube sees this instilled ideology as damaging to quality of care.
Because employed physicians aren't directly responsible for a hospital's business, Dr. Kube suggests they don't have the same "sense of urgency to go the extra mile."
"You become much more a technician as an employed physician and less a professional," says Dr. Kube. "As a professional, you are a doctor 24 hours a day and that's part of your identity."
The mindset of punching the clock creates a schism between physician and patient, lowering care quality. According to Dr. Kube, employed physicians don't feel the direct impact of losing a patient to another provider — they don't bear the same responsibility in helping the business of healthcare thrive.
"I consider my practice disruptive, because I continue to raise the bar," says Dr. Kube. "When I'm independent, I tend to compete against myself instead of some calculated broad metric. That changes my limits from such metrics to my imagination, and I can imagine quite a lot."
Granting young physicians a choice
Medical schools don't focus on exposing future physicians to the independent physician environment. Although many fellowships are in private practices, medical students receive significant academic and hospital experiences while in school and during their residencies. The natural next step funnels many young physicians into the hospital setting.
Dr. Kube believes young physicians are often robbed of their free will to choose between employed and independent settings, as they don't receive a balanced exposure to both options during their medical training. During his fellowship, Dr. Kube learned the ins-and-outs of spine surgery and building up a facility.
"I think there is a role for fellowship directors to mentor all aspects," says Dr. Kube, who doesn't currently have the resources to take on a fellow. "People who have access to those young people really need to voice that."
With limited access to independent settings, young physicians may be more inclined to grab the better salary and greater stability hospitals offer. Trading in the flexible work environment for the less risky work setting probably doesn't phase too many physicians fresh in the field.
"Hospitals will continue to hire doctors as long as they're making money off those doctors," says Dr. Kube. "And doctors, as long as they feel the safety of the hospital, will seek hospital employment."
With more employed physicians at the forefront, Dr. Kube believes patients will experience a decreased quality of care.
Reuniting healthcare with its business roots
With a presidential election around the corner, healthcare is sure to be rattled up once again. Dr. Kube hopes the future of the industry holds Americans' shifting attitudes toward healthcare. An ideological change occurred in the last few decades when patients expected treatment for every ailment. Dr. Kube describes this thinking as 'can I do this?' or 'can I do that?' as opposed to asking 'should I do this?'
"Doctors want to please patients, so we also got drawn into that slippery slope," says Dr. Kube. Physicians feel pressured to order tests or prescribe medication for any medical issue.
With consumers reacquainting themselves with their healthcare bills, however, the industry will be able to embrace value-based care. As a specialist, Dr. Kube no longer sees patients with one week of back pain and a MRI image in tow. Americans are becoming more frugal again as deductibles increase.
"If we want to tackle medicine, the cost, creating value, we have to be honest with the fact that [healthcare] is a business enterprise," says Dr. Kube.
A value-based system will be achieved if physicians are allowed to provide the best treatment plans for patients, not if they feel pressured to answer patients' demands for costly and unnecessary tests and medication.
And like everyone else with a stake in a business, physicians expect compensations that reflect their skill sets.
"We're in medicine because we like what we do and we like to impact lives," says Dr. Kube. "But I also didn't go through the 26th grade, excelling at every level, to not earn a good income."