"Non-profit" hospital chains join for-profits in destroying our health system

The New York Times’ latest exposé on the despicable actions of large, ostensibly “non-profit” health systems, ‘How a Sprawling Hospital Chain Ignited Its Own Staffing Crisis’, examines Ascension Health, one of the largest such systems in the US. It is definitely worth reading, although you may want to try deep breathing first. Ascension owns hospitals over a wide area of the US, mainly in the Midwest, and took a bow in 2019 when it “was trumpeting its success at reducing its number of employees per occupied bed, a common industry staffing metric”, saving $500M! Unfortunately, cutting the number of employees to bare bones limited the quality of care available to patients. And when the COVID pandemic hit, and occupancy rates skyrocketed, they were woefully understaffed – except that the woe was experienced by the patients who sought, and to one degree or another, received care in those hospitals. It was and remains a disaster. Among the impacts cited in the article: at one hospital “there were so few nurses that psychiatric patients with Covid were left waiting a full day for beds, and a single aide was on hand to assist with 32 infected patients”; at another “Chronic understaffing meant that patients languished in dried feces, while robots replaced nursing assistants who would normally sit with mentally impaired patients.” Think about that patient being your parent! Disgusting? Upsetting? Dangerous? How about downright evil?

But, you might think, the cost cutting was necessary. After all we read about hospitals that are on the brink, are barely surviving, needing government bailouts to keep serving their communities. Oh, wait, those are different hospitals. Those are rural safety net hospitals. Ascension has $18 Billion in the bank. $18 Billion! In a “non-profit” hospital system! Boy, I’m sure that those C-suite execs who oversaw that got big 7-figure bonuses! And now? With that much in the bank, I doubt they are going to suffer much just because people are getting terrible care and dying in their hospitals.

So how are these systems non-profit? The Times does a good summary:

In exchange for avoiding taxes, the Internal Revenue Service requires them to offer services, such as free health care for low-income patients, that help their communities.

But…

The Times this year has documented how large chains of nonprofit hospitals have moved away from their charitable missions. Some have skimped on free care for the poor, illegally saddling tens of thousands of patients with debts. Others have plowed resources into affluent suburbs while siphoning money from poorer areas. And many have cut staff to skeletal levels, often at the expense of patient safety.

Oh. That doesn’t sound so good. And, to be sure, Ascension is far from the only “non-profit” hospital chain to behave in this manner; most of the big and “successful” ones do so. The West’s Providence Health System, the focus of a previous Times exposé and post on this blog ("Non-profit" hospital systems behaving worse than for-profits: No end to the scams”, October 1, 2022), ironically started by a group of nuns to care for the poor and underserved, also gets coverage in this article.

There is so much evil here it is hard to know where to start. Certainly, a key part is running networks of institutions ostensibly created to heal the sick and injured (“hospitals”) as if they were manufacturing businesses and employing au courant management strategies designed for manufacturing, such as “just in time” supply chains and cutting staff down to the bone. This is absurd; hospitals, to be effective, to be able to meet regular seasonal changes, not to mention disasters or pandemics, need to have excess capacity at all times. Running “lean and mean” is wrong on many levels. It is exploitive of the staff, and indeed puts staff in the position of providing poor-quality care to their patients, compromising their professionalism and commitment; the testimonies of the nurses at Ascension are the most damning part of the report. It makes it difficult to impossible to gear up in times of need. And it um, kills people. You cannot have a potential staff of on-again-off-again health care workers to be employed just when needed “just in time”. If you could, if such excess capacity existed in the society, it would be yet another sign of perversion, of oppressing people and their families and communities to make more money – profit for “non-profits”.

Another way that this is, to put it gently, inequitable, is described in the Times article: cutting back on services in high-need-but-low-income communities and reallocating them to wealthier neighborhoods. And, of course, emphasizing and marketing high profit-margin services (cancer care, orthopedics, neurosurgery, cardiac interventions). Again, a  morally bankrupt strategy to meet not the health needs of our country but rather the dollar desires of a board of directors!

So what do I have to add to the excellent coverage given to this issue by the NY Times? They even call it “Profits over Patients”, which it is. I think I can give the problem a name that the Times will not: Capitalism. Capitalism is the problem. And it is not just any capitalism, it is not the capitalism of mom-and-pop stores or small businesses or making a reasonable profit, it is the capitalism-run-amok, it is the capitalism of anything-for-a-buck, full-speed-ahead, don’t-care-who-gets-hurt, bigger-is-better, I-want-to-be-a-billionaire-too that we have seen increasingly over the last decades. It is the capitalism that Noam Chomsky calls “gangster capitalism”, but in many ways what these folks do worse than what gangsters do, because it threatens not only people but all of our society. Sure, a gangster may threaten or even kill you. These systems are designed in a way that will kill thousands! But you know what? That is capitalism, that is the end point of capitalism. That is the Gordon Gekko, greed-is-good, result of capitalism that is not only unfettered by government regulation (especially with the elimination of many of the best parts of the New Deal) but that is actively enabled by a government that is willing to let private companies take all the profits when they make them and bail them out when they lose. And it is arguably even more evil that the hospitals described in the Times article are large “non-profits” which behave exactly like for-profits except that they don’t pay taxes! Who would have thought I’d be arguing for for-profits? Well, I’m not; they actually providing even worse care for the community because there are almost no regulations governing what they do. But at least they pay taxes.

So what can be done? A great deal actually.

•  Ban for profit corporations, or any entity controlled by private equity, from health care delivery. Yes, hospitals, but also clinics, urgent care centers, nursing homes, etc.
• Require not-for-profit entities to behave like non-profits are supposed to, with community benefit being the SOLE criterion by which they are judged. Do not allow building of facilities, expansion, or the dissolution of “product lines” except when it can be demonstrated that this will benefit the health of the overall community. Not allow “we’re moving into/building into this prosperous expanding suburb because, you know, they will need health care” if it means there will be inadequate resources to serve the people in the most needy, sickest, and poorest communities. No cannibalizing inner-cities to feed wealthier suburbs. And while it may not be possible to directly regulate the income (salary and bonuses) of C-suite executives of non-profits, the requirements should ensure that they cannot make loads of money and build huge reserves ($18 billion! Come  on!) If they won’t do this, tax them
  
• ·Ensure that the communities most in need, especially in rural areas, have their needs met on a case by case basis. The absurd Hobson’s Choice the federal government is offering rural hospitals, crystallized in the headline of the article cited in the second paragraph, “A Rural Hospital’s Excruciating Choice: $3.2 Million a Year or Inpatient Care?” must be changed so that each hospital, and the larger community it serves (sometimes geographically enormous) gets support for what it needs, inpatient care, outpatient care, and usually both.

Even better, while eliminating private for-profit ownership, discourage misbehavior by non-profit owners by creating and implementing a single payer health system, such as Medicare for All, which as the sole payer would be able to with and regulate these health systems for the benefit of the health care of the people of our country.

A Paradigm Shift in Medicine? Gabor Maté’s "The Myth of Normal"

This is a guest blog post by Seiji Yamada, MD

 

 TRAUMA, ILLNESS, AND HEALING IN A TOXIC CULTURE

 

Published by Avery
Sep 13, 2022 | 576 Pages | 6 x 9 | ISBN 9780593083888

In The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture, family physician Gabor Maté presents a new formulation for understanding health and illness. Perhaps it is fair to call it a paradigm shift. Maté’s formulation implies that those of us who work in health care should be practicing differently. What might such a healing practice look like?

Firstly, the healer takes the side of the patient and the family – against the toxic culture that surrounds us. One component of the toxic culture that Maté identifies is capitalism, the valuing of corporate profits over human life, the relentless drive to extract private wealth while killing our ecosystem. Under capitalism, in order to stay financially solvent, pregnant women stay on the job until they go into labor. They return to their workplaces within weeks of giving birth. The stresses of working while pregnant, or the infant’s need for nurturing and attention, receive little attention.

Another component of the toxic culture is patriarchy, the control exerted over women and children’s bodies by men. In its ugliest form, this takes the form of sexual abuse and rape. Maté presents a number of case examples of how such past events become manifest as disease, not just psychological but also physical. The author, activist, and playwright V, who wrote The Vagina Monologues, recounts to Maté how abuse by her biological father led to her endometrial cancer.

Maté reviews the scientific basis for how our toxic culture leads to disease. As manifested by behaviors seemingly as trivial as not picking up a crying infant to crimes such as sexual abuse, the toxic culture of contemporary capitalism, patriarchy, and white supremacy leads to trauma.

What is trauma? As I use the word, “trauma” is an inner injury, a lasting rupture or split within the self due to difficult or hurtful events. By this definition, trauma is primarily what happens within someone as a result of the difficult or hurtful events that befall them; it is not the events themselves. (p. 20)

This trauma then leads to the somatic and psychological dysfunction that becomes manifest as both bodily and psychiatric disease as well as problematic behaviors such as attention deficit and addiction. Of note, this account of disease is dynamic, changing over time. Rather than an entity that one possesses (e.g. “my cancer” or “my bipolar disorder”), Maté views disease as a temporal process with roots in the toxic culture within which we all live, as well as in events that might not even be subject to conscious recall.

Thus Maté seeks to transcend conventional biomedical modes of analysis. The biomedical paradigm is reflected in traditional medical education. Premedical students must take basic science classes such as biology, physics, chemistry, and organic chemistry as prerequisites for medical school. In the conventional medical curriculum, medical students learn basic sciences such as anatomy, physiology, pathology, and pharmacology before they learn clinical medicine. The biomedical paradigm is reductionist in the sense that it seeks explanations in more and more fundamental levels of analysis: Thus, the search for genes that cause this or that disease, or dysregulated neurotransmitters as explaining this or that psychiatric disorder.

The biopsychosocial model was formulated by the psychiatrist George Engel in the 1970s in opposition to the biomedical model. Engel incorporated the atoms, cells, organs, cognitive and emotional factors, and social influences such as family, community, even the nation-state into the model. (See figure.) As such, the biopsychosocial model is all-encompassing and potentially powerful in its explanatory reach, but the details of its workings, i.e. the underlying mechanisms were insufficiently fleshed out by Engel.

Indeed, the role of large-scale social forces on health and illness has long been the concern of social medicine. Social medicine practitioners take a step back and examine the root causes of why the people become sick. The social medicine practitioner continues to ask questions until she gets down to the fundamental causes of illness—the social structure. The late Paul Farmer was a practitioner of social medicine. Howard Waitzkin, Alina Pérez, and Matthew Anderson provide us with a how-to manual on how to become a social medicine practitioner in Social Medicine and the Coming Transformation.

While Maté views himself as working within the biopsychosocial and social medicine paradigms, his contribution is to elucidate the epigenetic, psychological, neurologic, and immunological mechanisms by which oppressive social structures and the toxic culture of “hypermaterialist, consumerist capitalism” (p. 198) become manifest as disease.

As well, Maté critiques the reductionist program of behavioral psychology, originally formulated by B.F. Skinner, who derived his theories of behavior modification via rewards and punishments through experiments with pigeons caged in boxes. Maté is particularly critical of the child-rearing practices based on operant conditioning principles, e.g. advising parents not to comfort crying infants lest they feel “rewarded” for their “bad behavior.”

In discussing contemporary practices relating to the treatment of the young or the treatment of pregnant mothers-to-be, Maté references ethnographic accounts of the practices of cultures more in touch with nature, as well as how other mammals besides humans raise their young.

Maté reviews many cases to illustrate his points, but he also references his own failings. He attributes his touchiness about his wife not picking him up at the airport to fears of abandonment stemming from being placed under the care of strangers when he was an infant when the Nazis occupied Hungary. He regrets how his workaholism led to his absence from his children’s lives when they were small. By pointing to his own flaws and sharing how he is still trying to overcome them -  he holds out hope for the rest of us to heal ourselves also.

In the Structure of Scientific Revolutions (1962), Thomas Kuhn described how paradigm shifts work in science. Normal science under the old paradigm, e.g. the Aristotelian view of the cosmos with the earth at its center, seems to work well enough, but there are just a few anomalies that cannot be accounted for. Over time, these anomalies and contradictions accumulate – until somebody, e.g. Copernicus, comes up with a new way of looking at the data. The new way of looking at things works much better, of course, and has much better explanatory and predictive power.

When I introduce medical students to family medicine, I often reference chapter five, “Philosophical and Scientific Foundations of Family Medicine,” from the 2009 edition of McWhinney’s Textbook of Family Medicine, the last edition before Ian McWhinney’s death in 2012. In chapter five, McWhinney discusses the paradigm shift in medicine  - from the biomedical model to the biopsychosocial model – in the Kuhnian sense. Of course, the reductionist, biomedical paradigm continues to advance medicine. Take a look at the studies reported in any issue of the New England Journal of Medicine. In the clinical setting, however, we need to do a better job of understanding our patients’ pasts, their emotional lives. Organized medicine needs to do a better job of ending the hypermaterialist, consumerist capitalism that is making our patients sick.

I have advocated for the biopsychosocial model during my own medical and teaching career, though I will admit to (following Farmer) emphasizing “structural violence” sometimes and (following Waitzkin) “social medicine” at other times. (Farmer actually left out the “psycho” part and called his own approach “biosocial,” Pathologies of Power, p. 19.) Maté puts the “psycho” back into the biopsychosocial.

What does the practice of biopsychosocial medicine, informed by The Myth of Normal look like? How do I envision practicing medicine within the new paradigm?

Firstly, I will need to examine my own faults and shortcomings – similarly to how Maté subjects himself to self-scrutiny. In order to be an effective instrument of healing, I must first work on healing myself. Maté suggests how one might engage in “compassionate self-inquiry” (p. 431).

Secondly, I will pay more attention to the social lives of children. Are they given the opportunity to play freely? Do their parents have the wherewithal to bond with them? Do I encourage parents to respond meaningfully to their children’s emotional needs?

Thirdly, I will work on adopting a trauma-informed stance with patients. A first approximation will be to ask about adverse childhood experiences (ACEs). Many of those who share their illness narratives with Maté tell him, “None of my doctors ever asked me about that.” I hope to help patients recognize the roles that their illness plays in their life trajectories. I hope to help them heal.