Why has the ratio of administrators to doctors increased so much?
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Becaus of the [Iron Law of Bureaucracy](https://en.wikipedia.org/wiki/Jerry_Pournelle#Pournelle’s_iron_law_of_bureaucracy):
> Pournelle’s Iron Law of Bureaucracy states that in any bureaucratic organization there will be two kinds of people: First, there will be those who are devoted to the goals of the organization. Examples are dedicated classroom teachers in an educational bureaucracy, many of the engineers and launch technicians and scientists at NASA, even some agricultural scientists and advisors in the former Soviet Union collective farming administration. Secondly, there will be those dedicated to the organization itself. Examples are many of the administrators in the education system, many professors of education, many teachers union officials, much of the NASA headquarters staff, etc. The Iron Law states that in every case the second group will gain and keep control of the organization. It will write the rules, and control promotions within the organization.
Assuming you’re talking about the US, the short version is: the American health insurance system.
Billing-and-insurance related costs (also known as BIR costs) are the source of most of this administrative expenses. That includes things like hospitals/practices filing claims with the insurance companies, negotiating or contesting payment of such claims, processing payments from the variety of insurance companies and applying them to the right doctors/practices/budgets, plus all of the kind of record-keeping, financial tracking, fraud monitoring, legal services, etc. that go along with each individual practice tracking hundreds (or thousands or tens of thousands in the case of hospitals) of patients across potentially dozens of different insurance providers and hundreds of different plans.
All in all, the administrative costs of private health insurance is *conservatively* about 5-8 times that of government-administered programs like Medicare or Medicaid. [[Source](https://www.healthaffairs.org/do/10.1377/forefront.20110920.013390/#:~:text=Medicare%20Has%20Lower%20Administrative%20Costs,as%2017%20percent%20of%20revenue.)]
Compliance. For every doctor providing healthcare services, you need an army of people to ensure everything being done is in compliance with regulations.
An overlooked thought is that Administration is a specialised skillset, and previously doctors had lots of admin to do, that they did badly. And more administrators frees up doctors time… Well, ideally anyway.
I would challenge your position here and offer up that at least at my healthcare organization, the amount of administrative leaders (managers, directors, executives) are actually not increasing faster than the number of clinicians and front line staff. There is an increase in support staff such as call center, referral and authorization, EMR experts, etc. The reason for increases in those groups include, a growing patient population, growing requirements of insurance companies, and a growing use of technology to automate healthcare processes.
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