Wednesday, March 1, 2023

Making people healthy or making money: What should be the goal of our health system?

In the February 16, 2023 issue of The Nation, epidemiologist Gregg Gonsalves writes about The Fight for the Soul of American Medicine. It is a particularly good and thorough review of the corruption of American medicine by the quest for profit, and the growing resistance of many physicians to its adverse effects on themselves and, more important, the health of their patients.

He cites several other recent articles that emphasize different aspects of this situation. Eric Reinhardt, writing in the New York Times about physician burnout, calls for increased unionization of physicians to counter the power of the corporate controllers of US medical care. Gonsalves also cites a JAMA Viewpoint by former CMS administrator Don Berwick calling out the many ways that greed perverts and destroys American healthcare, using the old Pompeiian phrase Salve lucrum, “Hail Profit”, and naming it an existential threat. Finally, he cites an article in the Journal of General Internal Medicine by Gondi, Kishore, and McWilliams called “Professional Backgrounds of Board Members at Top-Ranked US Hospitals” which identifies the fact that US hospitals are run by people with finance, not healthcare, backgrounds:

At top-ranked US hospitals, the most common professional background for board members is finance, far exceeding representation from physicians, nurses, and other health care workers. Over half (~56%) of board members are from finance or business, while a small minority (~15%) have clinical training or are from the health services sector.

Gonsalves notes how the perversion of healthcare, particularly medical care, by an explicit profit motive leads to the US having both the greatest cost and the worst health outcomes of the wealthy countries of the world, but then goes beyond that to further criticize our reliance on medical care as the avenue to people’s health. He cites the National Academy of Sciences estimate that medical care accounts for only 10-20% of health, with social determinants (and, one could convincingly argue, social determination) accounting for the other 80-90%. Social determination is found in the structure of our society, conceived perversely on democracy and plutocracy, rooted in the extermination of one set of peoples and the enslavement of another, and the racist roots that continue to poison our social structures today. Social determinants – including poverty, housing, food, education, childcare, and others -- are well documented, and are profoundly poorly addressed by us in the US.

This is more than coincidental. Gonsalves refers to a book by Bradley and Taylor, The American Health Paradox: Why spending more is getting us less (which I discussed, along with a NY Times op-ed they wrote, in a blog post To improve health the US must spend more on social services Dec 18, 2011). The essential point of that book is that, while the US spends far more than other wealthy countries on medical care (twice as much as a few and three times or more as much as most others), it spends far less on other social services and social supports. Furthermore, as Bradley and Taylor document, the US is unique in that of all its spending on social service and medical care, the vast majority is on medical, dwarfing expenditures on food, housing, childcare, job training, and social supports that are far more important in maintaining health and preventing disease, while medical care is focused on treating disease once it is there (for those who can access it, at enormous cost).

These are all true things. Our society spends most of its “social services” money on medical care, and it is directed at the most expensive types of care, those that generate the most profit for the big corporate and venture capital players in the hospital, nursing home, and ambulatory care fields as well as the better-documented profiteers in the pharmaceutical and insurance industries. The burnout of physicians from overwork is real and is simply what industrial workers used to call “speed-up”, the demand for more production in the same hours (and for the same pay). In industrial workers, speed-up was and is well known to increase the rate of accidents, both minor and major, and to destroy the psychological health of those workers, so that it is unsurprising that it does the same to doctors and other health workers. What is more surprising is that it has taken so long for them to realize it; over a few decades corporations have taken over almost all of health care delivery, with independent physicians and physician groups that own themselves almost disappearing.

Most hospitals, or “health systems”, are controlled by large corporations – or so they are called if they are for profit. The non-profit health systems, however, including academic health centers, behave scarcely less like corporations, chasing increased revenue (if not “profit” per se), and are, as Gondi et al., demonstrate, just as likely to be led by people with financial backgrounds, rarely medical ones. The good aspect of for profit relative to non-profit hospitals is that they, at least, pay taxes rather than be the recipients of government largesse through being tax-free in return for ostensible, and increasingly unrealized, community benefit. The bad side is that they provide even less community benefit, and generally have worse quality care, than non-profits. In addition, the positive side of the non-profit ledger is enhanced by inclusion of those hospitals in rural areas and inner cities that actually do care for the needy. These, however, are the very ones that are at greatest risk of going bankrupt, and closing because their patients are uninsured or are underinsured, including by Medicaid and even Medicare. A NY Times article recently addressed the increasing closure of rural hospitals, and an even more recent one documents how many rural hospitals are closing their maternity units, because it is a high-cost, low-revenue “service line”, causing rural women to have to travel dangerous distances for pregnancy care and delivery.

In terms of other healthcare operations, such as physician practice groups and nursing homes, “private equity”, venture capital groups, are playing a larger and larger role. Nursing homes have long been primarily private, and of generally poor quality, but they are increasing being acquired by such private equity or health corporations. Those physician practice groups that are not already owned by hospital systems (including academic ones) are often being acquired by the same groups. The results can be disastrous for their patients, particularly when encouraged by the government, as in the ACO/REACH program which I recently discussed (Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!, Jan 20, 2023). Of course, one reason these (misad-)ventures are successful is that their downsides tend to only be apparent once you need care, when you are sick, when the less obvious odious characteristics of such arrangements can stymie you effective access to care. And, of course (and thankfully!) most of us are not sick at any given time.

I have often written that profit, in any form, does not belong in health care. This is absolutely true. The most egregious forms are the corporations that make and sell pharmaceuticals and the insurance companies that existence as parasitic middlemen between health care and patients, not only sucking off money but also limiting care in ways that actually and frequently harm people. But that is only the tip of the corrupt iceberg. Being “non-profit” does not prevent a health system from acting in the same fashion, to maximize revenue, and reward “successful” (i.e., money-making) management accordingly in seven figures.

It is time to have no incentives of any kind that allow any person or organization in health care to make money beyond that which is required to run a high-quality operation and pay workers a reasonable salary or wage. Indeed, the impact on the health care of patients should be the sole criterion for anything that is done or reimbursed.

AND, then, we need to start taking much of the money saved by having less or none going to insurers, pharma, and hospitals and health systems and spending it on ensuring everyone has good financial health care coverage and the social systems needed to support the social determinants of health are in place.


Deborah Harrington said...

1/ In the U.K. we properly recognised the main socio-economic determinants of health in the 1930s and 1940s. Beveridge’s 1942 Report was an important milestone, even when taking into account the limitations of the social and political context of the day. A healthy society needs an educated population, full employment (with proper wages, terms and conditions), decent housing for all, a social security system to provide for those who can’t work and, last but not least, healthcare to provide all preventative, advisory and curative services. It may not need a genius to work this out but it takes a heck of a lot of political will and determination to stand up to corporate interests to create and maintain a system that does it. We had the National Health Service and the Welfare State from the late 40s to the late 70s, created by the post-war Labour government. It was never really allowed to develop its full potential but even what it did do was transformative. But it was under ideological attack from the start.

(Hope you don’t mind this response to your article being left in 3 sections!!

Deborah Harrington said...

2/ In the UK we didn’t have ‘not for profits’ we had public ownership and provision of our services. Oh - and just a note that public services do pay tax! Every penny spent is someone’s income (taxable) which they will spend on taxable goods and services just like every other employee in the country. Buildings are built and maintained (building companies paying tax at every level of their business), plant, equipment and consumables are bought (ditto). The sell off of the public estate began in earnest in the 1980s and has continued unabated since under all governments. Whilst the population’s politics still range from right to left, our political parties have merged into an indistinguishable neoliberal mush, completely in thrall to free market ideology. And our health service has paid the price. Our once fully comprehensive, universal and national service which strove for equitable care (even though it didn’t properly achieve it) has fallen foul of US influence. Your policy makers have become our policy makers. An ex-CEO of Centene is chief adviser on Integrated (Accountable) Care to the Prime Minister. The CEO of the NHS was from 2014 to 2021 was an ex VP of United Health. Palantir and Optum are in pole position to harvest the unimaginably rich data from our health records (there’s nothing like them in the world for continuity and comprehensiveness). Government ministers who lead on legislation subsequently gain seats on the boards of companies that have profited from that legislation. Corporate sponsorship of our political parties helps maintain the direction of travel. The ownership of hospitals, once in the public estate, now resides in offshore accounts. Private equity sniffs out the best investments. Meanwhile our (expensive) hospitals are closed and downgraded in preference to care in the community (cheaper and already the playground for corporates). Maternity units and A&E (Emergency rooms) are ‘rationalised’ for ‘efficiency’ which means less local access and longer journeys for many, all sold under the label of ‘better care’. Waiting lists for treatment are reaching a staggering and previously unheard of level. People are dying for lack of access. Buildings that remain in the public estate are in poor condition. Staff are leaving in droves, exacerbating the stress for remaining staff and patients alike. Corporate hospital and primary care services have a hitherto undreamed of presence in the health landscape. The USA has come to the UK

Deborah Harrington said...

3/ Our public housing stock, once the provider of good quality homes to low income working families have been sold off or have ghettoised those who rely on social security benefits. Our education has become corporate though the Academy system. University students amass huge debts to pay for what once was free for tuition and state subsidised for living expenses. Welfare benefits have been pared down to bare subsistence levels and food banks have multiplied to cater for those who cannot feed themselves or their children on such poor incomes. Street homelessness has increased. Precarity has become normalised for the working poor. We make people ill with their living conditions then systematically find ways to deprive them of care. We should hang our heads in shame.

Hugh Blumenfeld said...

Great column. Have you written about what constitutes a "reasonable salary" for a physician? And if we subsidized medical school, would that allow lower salaries and ultimately cost savings down the line (not to mention incentivizing primary care)?

Total Pageviews