Private Profit and the Public's Health: Which is More Important?

Health care is pretty complicated, and insurance coverage is even harder to understand.This is the message that comes through clearly from the interviews being done by Dr. Paul Gordon and recorded on his blog, https://bikelisteningtour.wordpress.com. Dr. Gordon is taking a unique sabbatical, riding his bicycle across the country from Washington (DC) to Washington (state), interviewing regular people, mostly in cafés and such, about their take on Obamacare. 

The economic status of these people varies from poor to pretty well-off (but none really wealthy), from well insured to uninsured. Their political perspectives range from “everyone should be covered” to “benefits just make people lazy”. Three recent quotes: ‘People use Medicaid as a crutch’, ‘You can’t penalize someone for not having health insurance when it’s so expensive and the economy is doing so poorly’, ‘Here’s my take on it – everyone should have insurance’. What they share with each other, and with most of us, is a general lack of understanding of how Obamacare works (or doesn’t) and why. The flaws in Obamacare are the result of the political tradeoffs that allowed insurance companies to continue to have control and make huge profits, but this is often not clear to most people.

Here is something that is easy to understand, however: when you call “911” as you have been trained to do in an emergency, and they don’t come. Or they don’t come for a long time. Or they come with inadequate supplies. Who do you get angry with when you, or your loved one, dies? The government? They are surely in part at fault, even though they probably contracted the service out, to save money, probably because voters want to pay less tax. But there is another reason, explained in an excellent special article in the New York Times, “When you dial 911 and Wall St. answers” (June 26, 2016). The piece, by Danielle Ivory, Ben Protess, and Kitty Bennett, details how many city services, including ambulance services, are provided by companies that are owned by “private equity firms”. These are companies whose investment capital comes from wealthy individuals and particularly from pension funds, unlike banks whose money comes from depositors. They are even less regulated than banks, and thus more able to pursue their core mission, making profit:

Unlike other for-profit companies, which often have years of experience making a product or offering a service, private equity is primarily skilled in making money. And in many of these businesses, The Times found, private equity firms applied a sophisticated moneymaking playbook: a mix of cost cuts, price increases, lobbying and litigation.

Whoa. This is starting to get complicated again. Banks vs. “private equity” vs. just plain old for-profit businesses? They are really just different forms of for-profit, and provide a stepwise progression, from public services operated by government for the benefit of the people, to private companies that are contracted by government to do a service but might care about doing it well, to having those companies owned by banks who really just want to make a profit, to having them owned by private equity companies who care about nothing but making a profit. The photo accompanying the Times article is of Lynn Tilton, owner of Patriarch Partners (an ironic name, given that she is a woman), which owned the emergency services company TransCare that served many East Coast communities. TransCare went bankrupt, leaving those communities without emergency medical services. Ms. Tilton’s picture is accompanied by the quote from her reality television stint “It’s only men I strip and flip.” As a poster child, she could become the Martin Shkreli of ripping off necessary public services the way he was of ripping off consumers of life-saving drugs.

“The business of America,” Calvin Coolidge is often paraphrased as saying, “is business.” This perspective, that it is not about doing things that are best for the American people, is based in a belief that capitalism – “business” – will, through the magic of the market, eventually meet those needs. OK, maybe not those of people at the margins, people too poor to buy, so maybe we need a safety net. But most people. A similar statement appeared today in the print edition of the Kansas City Star from KC Mayor Sly James, discussing the controversy over replacing the terminals at Kansas City International Airport with one big, new terminal. Surveys consistently show that the large majority of Kansas Citians (84% in this article, “Regarding KCI’s future, city ponders a new flight path”) like the current arrangement, with short security lines and easy access in and out from one story terminals, but the airlines and big businesses do not. In the large-type quote accompanying his picture in the print edition (but, along with the photo, left out of the online edition), Mayor James said “The people of this city need to be convinced of what I believe is a basic reality, that this airport is about a lot more than ‘how fast can you get out of your car and get to your gate?’” Right. Business interests first. Take that, 84% of Kansas Citians!

Because they most obviously involve life and death, emergency medical services and firefighting (yes, firefighting too has been contracted out to companies owned by private equity firms!) get the greatest play in the Times article, but many other services (like water!) are in the same situation: controlled by companies whose goal is to make a profit rather than to provide effective service for people. This is what happens when municipalities are starved of funds because people vote to cut taxes.

Whether it is health insurance or emergency medical services or municipal water, the system becomes very complicated and hard to understand when it is trying to meet conflicting agendas. When the need for people to receive critical, health-producing service (fire and police protection, clean water, garbage collection, ambulances) is compromised by provisions built into contracts (or the law) for companies (insurance companies, banks, private equity firms) to make profit. I guess it is fine if these services can be effectively and reliably provided by for-profit companies, but when their pursuit of profit through “a mix of cost cuts, price increases, lobbying and litigation” conflict with actually providing services, there is a big problem. In the case of emergency medical services, the problem was that “…many newly insured Americans turned out to be on Medicaid, according to the Kaiser Family Foundation. Medicaid restricts some of the most aggressive billing tactics.”

A variety of other difficult to understand strategies are also employed at the macro level to place the interests of wealthy corporations above those of the people. These include the unlimited political contributions permitted by the Supreme Court’s Citizen’s United decision, incredible gerrymandering of congressional districts so that we have states where the majority of voters vote for Democrats but most districts are solidly Republican (see the New York Times Book Review “Where votes go to die”, June 26, 2016), and the provisions of the Trans-Pacific Partnership (TPP) that prevent national governments from regulating multi-national corporations.

We could solve this if there was a single, over-arching principle, always codified into law, that the interests of the people as a whole always trumps the profit potential of corporations. I vote for that.

Specialty Hospitalists: what is best for the patient?

In a “Viewpoint” article in JAMA, April 25, 2012, John Nelson, Laurence Wellikson, and Robert Wachter discuss “Specialty hospitalists: analyzing an emerging phenomenon”.[1] They describe the progression of the hospitalist model – doctors who just care for patients in the hospital, rather than seeing them also in the office from general medical care to specialty care. They note that in recent years hospitals have hired physicians in a variety of specialties, including neurology, orthopedics, obstetrics/gynecology and others, to take care of patients, particularly at night or in emergency situations, so that other doctors to not have to come in to do so.

An argument in favor of this arrangement is that these physicians are present for urgent events (e.g., the neurology stroke specialist who is there right away to care for a person who comes to the emergency room with an acute stroke) and that they may have specialized knowledge that a more “general specialist” doesn’t. In a useful “box”, the authors summarize the criteria that might be applied to deciding if a specialty hospitalist is a good idea. These include the number of inpatients who might require their services, the urgency of the need for those services (is it a matter of minutes that may save a life?), whether the other specialists are so tied up in the operating room or office that they could not respond promptly, and if there so much “sub-specialization” that many doctors in that specialty would not be capable of addressing the needs that arise in the hospital.

I have previously written about “generalist” hospitalists, (Hospitalists, Dec 4, 2008) and expressed my concerns about this movement from the point of view of the patient. The advantage for hospitals and health systems that employ physicians is obvious – they can have some doctors that work in the ambulatory setting, and some that work in the hospital, and each can be most “productive” in that setting and not have to leave to go to the other, decreasing efficiency.  In theory, at least, the hospitalists are very good at managing the problems of people in the hospital, so quality may improve. And, to be sure, doctors often like it also – it makes their lives easier, or more controllable – they are only responsible for outpatient medicine, and don’t have to travel to the hospital to see their patients, or if they are hospitalists, don’t have to go to the office. While not one of those listed by Nelson et al. as a benefit of having hospitalists, this advantage for doctors is real.They can work set shifts, like many of the most popular specialties such as emergency medicine and anesthesiology and intensive care – and then be off.  

This, of course, leaves the patients. While hospitalized patients certainly want to be cared for by a physician or physicians who are skilled in addressing the problems that they have, it is also often a very scary time, and a good time to have the involvement of someone who knows you, who knew what you were like before you got so ill that you had to be hospitalized. Your primary care doctor, if you are lucky enough to have one. The technical skills of the hospitalist may be fine, but they do not know what you were like before, and will not be involved in your care after, your hospitalization. Plus the same attractions that lead to hospitalists in the first place now have led to a sub-species of hospitalist called “nocturnists”, and mean that you will not necessarily even have the same hospitalist making decisions about your care, even during the day, for the duration of your stay.

In addition, the skill sets of hospitalists vary. Dr. Wachter is one of the founders of the hospitalist movement and heads a long-standing hospitalist service at the University of California San Francisco (UCSF). His 1996 article, The emerging role of "hospitalists" in the American health care system,[2] written with Lee Goldman, is one of the seminal articles in the field. But the results that are achieved by teams of experienced career hospitalist groups such as his, in terms of both quality and cost, may well not be replicated by hospitalists who are just out of their residency training and spending a year working in this role prior to subspecialty fellowships in cardiology or gastroenterology. Nelson, et al., cite a study by Seiler et al. showing that patient satisfaction with hospitalist care is equal to that provided by primary care doctors,[3] but this doesn’t separate out the satisfaction of patients who have primary care doctors who are now not seeing them from those who do not.

That said, I do not have a problem with most specialty hospitalists. Specialists are not generalists, unlike primary care providers, we don’t think that every person should have one of each. The person who comes in to the Emergency Department with an acute stroke and benefits from having a stroke neurologist right there is not likely to have a general neurologist. The same can be said for orthopedics and otorhinolaryngology (ENT) and neurosurgery, among others, or for people who need emergency intervention for an acute heart attack. The case of “laborists” is somewhat different; the women having a baby (arguably the most common reason for people being glad to be in the hospital) who has been followed by an obstetrician or family doctor might well want and expect to be delivered by that doctor (a point acknowledged by Nelson). While many primary care doctors would like to provide this continuity to their patients, they may be unable to in the system they work in. And if it is not their “fault”, it is a pretty guilt-free way to enjoy the benefit.

If the hospitals and health systems make more money and operate more “efficiently” with separate hospitalist and “ambulists” (yes, this term is being used by some!), and if the doctors are happy with the arrangement because it makes their lives more controllable, the boat on generalist hospitalists and “laborists” has probably already sailed, at least in communities large enough for this to be feasible.

Anyone who has flown in and out of the Kansas City International Airport (KCI) knows what a pleasure it is compared to other airports in even relatively big cities. Built on only one level in 3 almost-circular terminals, there are only a few gates for each security checkpoint so the lines are relatively short (compared to, say, the nightmare at Denver International). Once you come in you get off your plane, walk right out into the hall where your baggage carousel is nearby, and then you walk right out to the street (even sooner if you have no checked bag), where you can be picked up or go to your car in the garage right there. It is a true pleasure for the traveler.

But it is not so desirable for the airport and airlines. I have heard that this setup requires more security people than any airport except Heathrow. There are rumblings about redesigning, maybe rebuilding, the airport to make it more “efficient”. Sure, it will be worse for the traveler, but that’s the way it goes.

So maybe you want to ask your doctor if s/he will see you in the hospital. And let the hospital and health system know that you think it is important, too. It is unreasonable to ask your primary care doctor to work a full day in the office and also care for patients in the hospital; that time needs to be built into their schedules by their employers. It could work; you never know. What’s good for people sometimes actually happens.

And if you haven’t flown in and out of KCI, you should do it soon before it becomes Denver. 

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[1] Nelson JR, Wellikson L, Wachter RM. Specialty hospitalists: analyzing an emerging phenomenon. JAMA. 2012 Apr 25;307(16):1699-700.

[2] Wachter RM, Goldman L., The emerging role of "hospitalists" in the American health care system, N Engl J Med. 1996 Aug 15;335(7):514-7.

[3] Seiler A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med. 2012;7(2):131–136, pmid:22042532.