Medicine and health care is always changing, and the pace of
change seems to be accelerating. Some of this change is good for people -- some
of the new drugs that come out actually help, either a lot of people, or more
commonly a few people. Sometimes new treatments are more effective, less
painful, shorter, or less debilitating than older ones. And, sometimes, they
are not. One thing we can be sure of, though, when we see a new treatment
advertised, whether on TV or in a magazine or on a billboard, is that someone
is making a lot of money on it.
There has been a great deal of coverage of two of the most
important and egregious industries in which large corporations make lots of
money at the expense of our health: pharmaceuticals and insurance. They deserve
it, and I have written about them often. But another extremely important area
where corporatism and corporate culture has taken hold and is expanding is in
the ownership and management of hospitals. The most important thing about this increasing
corporatism is that it is about making money (even in “non-profit” hospitals), not
primarily about providing the health care that people need; of course, if what
you need (or can be persuaded to buy) is profitable for the hospital, they’re
all about it. For example, new surgical techniques and imaging, and
particularly high-margin, low risk procedures like joint repair and replacement
in otherwise relatively young healthy people (let’s go for that high school
quarterback or 40-something weekend warrior). Not so much problems that occur
in people who have multisystem disease, are old, are high risk, or are poor and
uninsured. And some stuff – like psychiatric treatment for the most needy, or
trauma care, are big money losers. Hate that if you’re a CEO, although might be
good if you are a person who needs it.
This trend has been going on for a long time, particularly
in large metropolitan areas, where most big hospitals are, and most of them are
now part of hospital systems. Of course, big hospitals were always big, but the
overemphasis on making decisions based upon money rather than people’s health
has been accelerating. And more recently the process has taken over hospitals
in smaller communities, including Critical Access Hospitals in rural areas. The
Critical Access designation is meant to reflect the geographic isolation of a
community, such that travel to the next-closest hospital creates real health
risks for the population, and so even if operating it is inefficient, it
receives federal support.
This is discussed in an outstanding editorial by Andrea
Wendling in the October 2018 issue of Family
Medicine, “Times
Are Changing”. Dr. Wendling focuses on two major areas, the
reinterpretation of the “value” of physicians and the role of family
physicians. Family physicians are the most common specialists in rural areas,
in part because they can have such a wide scope of practice. They can care for
the medical problems of adults and children, deliver babies, provide care for
many musculoskeletal problems, mental health, women’s health care, and provide
many procedures. At least as important to patients, they can see them in all the
venues where they need to be seen – the office, the hospital, the nursing home,
and even the patient’s home. Dr. Wendling notes that this is threatened by the
corporate perception of physicians’ value, which is their value to the system, measured financially, rather
than their value to the health of the community. Yes, you might find it
beneficial to have a doctor who knows you, who has cared for you and your
family for years, be able to see you in whatever setting you find yourself in,
but the system has decided it is more
efficient (read “more profitable”) to have your doctor be only an ambulatory
care provider, or only a hospitalist.
It is not only family physicians who are affected, although
they predominate in rural areas. While some specialists – those that provide care
that is not necessarily the most important, but is the most profitable – have
always been more highly paid and more sought after by health systems, even they
are seeing decreases in their pay and status. It is hard for the family
physician to cry for slight cuts in the income and power of doctors (like
orthopedists and radiologists) who are making many times what they do, and in
fact it is hard for most Americans to cry for the plight of even the
lowest-paid doctors. Perhaps it feels like crying for the white men who bemoan
their loss of privileges (real and desired) because women and minorities are
finally moving the playing field to being, at least a little, more equal. But
the corporate influence is far more malignant.
Family doctors believe that their contribution to people’s
health is relatively greater than their income. Doctors believe that, whatever
their income, they are working to improve people’s health. CEOs and
corporations believe that health is a good thing to try to sell, provided we
sell the kind that makes money. They do not put the health of the community
first; they put the financial well-being of the corporation first. And, not
surprisingly, this affects both poor and rural communities the most, because of
the limited access to services they had in the first place; an arrogant and
self-serving corporation taking over the only hospital in a community does not
bode well for the overall health of the people who live there.
And, adding insult to injury, it is not only the
dollar-centered approach that is a problem, it is the egos of the local leaders
who, emulating their corporate bosses and our political class, think that they
as individuals are important and deserve respect and obeisance. I have a friend
who led the physician group at a rural hospital when it was taken over by a
larger system, and helped negotiate the criteria for bonuses for the medical
staff. Soon after, that physician was fired by the local CEO for “embarrassing
them”! The doctor got their job back with the help of lawyers, but imagine the
gall of that CEO! If what they were doing was right and good, they had no
reason to be embarrassed; if they had reason to be embarrassed because what they
were doing was corrupt, self-centered, not good for the physicians or for the
community’s health, what they were doing was wrong and should have been
exposed. I have no doubt that if the people in that town were asked who they
valued more, the physician who had cared for them for years or the new CEO put
in by a corporation, which one would get more votes. Maybe the CEO would get
that of their spouse.
So we have a health care system that is structured to be
corrupt, from the insurance companies, to the drug and device makers, to the
big health systems, all geared to profit. We have many physicians, in all
specialties from the rich and powerful subspecialists to the family physician,
who are trying to figure out how to stay on the “good side” of these corporate
systems and of the local martinets. We have physician leaders, in hospitals and
medical societies and academic departments who often are looking mostly at
themselves and how to show that they as individuals are important (like that
rural CEO), maybe believing that what is good for them is somehow good for
people. Sadly, this is even true in family medicine, no longer the
‘counterculture’[1]
its founders, like Gayle Stephens, wrote about, but now often simply other
supplicants for corporate largesse.
All of this is at worst immaterial and at best subsidiary.
The criteria for whether a healthcare system or aspects of it are good is
whether it improves the health of people and the community. We have a long way
to go in our healthcare system. And it’s long since time to get started.
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