It's all corporate now. Why do we stand for it?

"Sick. Help. That’s it!”

“John Q,” played by Denzel Washington, whose son needs a heart transplant which the insurance company has denied coverage for

 

There are still people in health care – admittedly mostly administrators and pundits and some doctors, highly-paid folks who think of themselves as “leaders” rather than “bosses” – who see the restrictions that the health insurance system places on people accessing health care as a good thing. They say that it keeps the lid on health care costs by limiting the use of “expensive and unnecessary” services by people who want “too much” of it. Luckily, for me, I no longer run into those with such views very often, and I like to think that there are fewer of them now.

These are often the same folks who supported, and continue to support, “managed care”, generally thought of as HMOs and PPOs, and their senior partner, Medicare Advantage plans (which are essentially HMOs or PPOs paid for with Medicare dollars). The techniques developed for restricting care in these plans have now been adopted by the health insurance industry overall. “Prior authorization”, which often means “delayed or denied authorization” has become one of the key strategies for restricting your access to health care services.

Restricting your access to health care is presumably not the specific intention of these practices. It would be mostly incorrect to portray health insurance executives as mean, grasping devils rubbing their hands together, like Mr. Burns, the boss in “The Simpsons”, in pleasure at your pain. They are actually mean, grasping devils rubbing their hands together in pleasure at the amount of money that they are making; your pain is incidental. I don’t know how many look like Mr. Burns.

HMOs, or what we now call HMOs, were not always money-grubbing deniers of care. Most of the early ones were consumer cooperatives (with the notable exception of Kaiser-Permanente, developed by Henry Kaiser for employees of his steel company, so he and not the insurance companies would make more money) like Group Health in Seattle, HIP in New York, and Ross-Loos in LA, designed to cut out the insurance companies so that members could get the same care for less money, or more care for the same money.  Without the profit motive in play, truly unnecessary care (sometimes that had been ordered by physicians or hospitals who stood to make money on it) could be avoided, and more necessary care provided. They often contracted with physician practice groups that were owned by the physicians themselves, rather than a corporation that violated the laws against corporate practice of medicine. Kind of vaguely socialist. Kind of good for people. Kind of quaint.

If you’re old enough, you may remember this kind of thing. In the 1980s the Reagan administration sought to expand them (naming them HMOs) as a method of cutting the cost of health care. Or, at least, cutting the costs that were expended in delivering actual health care. The plan involved encouraging insurance companies to buy up and establish their own HMOs, so it wasn’t too long before the reality of a consumer cooperative HMO was, in most places, history. Owned mostly by insurance companies, and increasingly with vertical integration, those dollars formerly “wasted” on providing “unnecessary” health care could now be turned into executive compensation and corporate profit. Some people may think this is a bad trade-off, that making money for corporations instead of providing health care for people is truly waste, but those holding such anachronistic and naïve ideas are wrong. At least in the opinion of those controlling the corporations! And their policy apologists.

This innovation was such a success (at making money) that it was expanded to a much wider base of health insurance. The old kind of insurance (often managed by the non-profit Blue Cross/Blue Shield, before they became the for-profit Anthem), that covered people for their health care needs, did not try to beat them down with denials, paid a reasonable amount to providers, and took a reasonable fee for their work, gradually became a thing of the past. These were sneered at as “Cadillac plans” (only when the beneficiaries were union members, of course not when they were executives!)  losing hold with each successive series of union contract negotiations. The executives kept their solid gold Cadillacs while union members and other employees were pushed lower and lower down until their coverage became a shadow of what it formerly was, and they often found themselves denied the care they needed and used to get.

There is a little historical irony here, in that the labor movement sowed the seeds of its own destruction by making health insurance a contract benefit. After World War II, unions in other countries fought to make health care available to all people; in Britain the party that was elected to govern actually had “Labour” in its name and introduced the National Health Service. In the US, the government instituted wage and price controls, so, unable to bargain for higher wages, unions bargained for health insurance as a way to recruit members. It was good for the members, but not so good for the nonunionized workforce. And the bosses liked it too; employer contributions to health insurance are not taxed, whereas wages are. Anyone who thinks that that such things as employer-sponsored health insurance is a “generous benefit” that is not paid for by the employee through lower wages is wrong. So, while the poor and non-unionized ended up on their own, the US labor movement got its members health insurance, often excellent health insurance. For about 30 years.

Now it’s all owned by corporations, the whole shebang. Insurance, providers groups, pharmacies, nursing homes. Many of these corporations are insurance companies, like the biggest, UnitedHealth, which also owns doctor group Optum and pharmaceutical benefit (PBM) manager OptumRx. And I am sure that, while many practices went under because they weren’t paid as a result of a major cyberattack on United subsidiary Change Healthcare, United itself is doing fine, making $8.5B in the first quarter (after all, by not paying those practices, they got to keep their money in the bank paying interest)! Other corporations are owned by private equity funds, which don’t even pretend to have any interest whatever other than maximizing their profit. Indeed, these are arguably even worse since they are sometimes happy to destroy the companies (and thus the services they provide) if that makes them the most.

The idea that a significant part of the cost of health care is overuse of services by patients would be pretty funny if it were not so serious, and for the fact that any such overuse is dwarfed by the number of people not getting adequate care, paying too much (in premiums and deductibles and co-payments and lost wages) for care, or being unable to access care altogether. That is the big problem, and as always it is the lowest income (and disproportionately minority) people who are hurt worst.

And even if you do believe that overuse is a problem, there is no conceivable way that any half-sentient, half-decent human being could possibly believe that money going to corporate and private equity profits is not waste and is a better use than providing health care to people. It is amazing that there any who do, but they include a lot of folks being paid by them – including members of Congress.

So: tell your Congressperson that YOU don’t think so, and that money appropriated for health care for people should be use for that, not raked off by insurance companies and other corporations, and it is their job to make that happen!

Outrageous behavior by hospitals harms Americans' health to make money

The article in the NY Times (June 1, 2023) titled “This Nonprofit Health System Cuts Off Patients With Medical Debt” carries the subhead “Doctors at the Allina Health System, a wealthy nonprofit in the Midwest, aren’t allowed to see poor patients or children with too many unpaid medical bills”. That sounds bad. It is bad. It is disgusting. It is reprehensible. But it is only one example of the extreme lengths many “non-profit” hospitals go to in order to maximize their income (their “non” profit!) at the cost of limiting care to people.

I don’t know how many hospitals, hospital chains, or “health systems” have gone as far as Allina in explicitly refusing to see patients, but most of them go as far as they think they can – and maybe tiptoe over the line. The article states that “Many hospitals in the United States use aggressive tactics to collect medical debt. They flood local courts with collections lawsuits. They garnish patients’ wages. They seize their tax refunds.” This is, unsurprisingly, most prevalent among those that can do it, those that are wealthy, those that are in urban or suburban areas where they can make money taking care of insured people. (A different calculus informs the often-marginal rural hospital.)

It is, in theory, possible to have two different worldviews regarding this situation. One (mine) is that the main purpose of health care, hospitals, doctors, etc., is to improve the health of the population, not to make money. To the extent that the pursuit of money gets in the way of (or explicitly blocks) caring for the health of people, it is wrong, unethical, and should be condemned. Another possible view, however, is that the business of any business (making widgets, providing income tax services, flogging corporate interests on the internet) is to make money, and that healthcare is just another business, and if some people can’t afford it this is no different from someone not being able to afford a car. I do not believe this, and think it is a morally vacuous position (and, more important, one that actually hurts people), but it is popular in some circles. Folks cite the maxim attributed to economist Milton Friedman that the only responsibility a corporation has is to make profit for its shareholders.

But wait – these are NON-profits! They do not HAVE shareholders! They do have Boards of Directors and (very) highly paid management teams, but they don’t pay taxes. Because they are non-profits! The reason that they don’t is because, under the law, they are expected to provide “community benefit”. While such systems often try to claim that they are doing so by occasionally sponsoring low-cost events such as health fairs where you can get your blood pressure or blood sugar checked, that is not what the requirement actually intended. The Times article correctly states “Nonprofit hospitals like Allina get enormous tax breaks in exchange for providing care for the poorest people in their communities.” That means taking care of people who have need, and not pursuing ANY of the gross collection tactics, not to mention refusing care. “But a New York Times investigation last year found that over the past several decades, nonprofits have fallen short of their charitable missions, with few consequences.” Put simply, these non-profit hospitals are given very large benefits (no taxes) because they are supposed to care for those with need, for the poor, but then they do not. But they keep the money.

These non-profit hospitals (and systems), run by finance people and accountants, operate as if they were for-profits, seeking to maximize income just as much as the for-profits do. Not having to pay shareholders, they can pay huge salaries to management, and accumulate enormous bank balances. In fact, this is an incredible competitive advantage – if you are a for-profit, you have to pay taxes! As a result, most for-profit hospitals in large urban markets cannot, and do not seek to,  compete with non-profits, and are found primarily in niche markets, for example in subspecialty hospitals providing particular kinds of procedural care to well-insured people.

Not that I am endorsing overtly for-profit health care. It is also slimy and disgusting, meeting some needs of some people and openly refusing care to others. The pursuit of profit and money is the root of the failure of our health system to do what most of us think it is there for: to improve health. However, non-profits operating in this sector get huge government (meaning taxpayer!) subsidy for doing – things that they do not do, do not want to do, and will take every legal (and often extra-legal) avenue to avoid doing. Indeed, in addition to not paying taxes they get great financial payments from other government programs, such as the 340B drug program, often worth tens of millions (see "Non-profit" hospital systems behaving worse than for-profits: No end to the scams, October 1, 2022).

If there is anyone left who is still taking evidence-free issue with the idea that the US health non-system is a failure at providing health, take a look at this recent piece from the Washington Post by Steven Woolf and Laudan Aron. Yes, it is an “Opinion” piece, but it is full of facts (see graphic) and backed up by the work of the National Academy of Medicine in its report “Shorter Lives, Poorer Health”. Since 1980, when the life expectancy of Americans was in the lower half of wealthy countries, it has slowly dropped so that by the early 2000s it was the lowest, and well before COVID arrived, had plateaued while that of other countries continued to rise. Almost all countries took a “life-expectancy” hit with COVID, but for most it was short-lived and has since rebounded. Except the US, where it has just started to drop a little more slowly.

 

Life expectancy is not the only measure of health system function or success. However, there is no accepted measure (deaths of middle-aged people, infant mortality, maternal mortality, years of productive life lost, etc. etc.) in which the US does not lag its peers, and often poorer countries. Unless you think the provision of boutique specialty care to wealthy people (including foreigners) is somehow a measure of health system success.

Woolf and Aron cite the National Academy report which lists a number of reasons why the US does poorly:

(1) unhealthy behaviors, such as our diets and use of firearms;

(2) inadequate health care and public health systems;

(3) poor socioeconomic conditions;

(4) unhealthy and unsafe environments; and

(5) deficient public policies.

They note the last is most important, including failure to address basic human needs for food, housing, education, and jobs. The continuing effects of racism. The failure to have an adequately funded public health infrastructure.

The National Academy did not look at the fact that our gangster-capitalist system has taken over health care as a cash cow to have money extracted and only incidentally (when convenient and profitable) provide health care, but this too is a clear failure of public policy.

If hospitals, non-profit or for-profit, are not providing all the health needs of our people, rich and poor, they must be forced to do so, by public policy. They should be provided with a negotiated, global, annual budget for operations (and a separate one for capital, so they don’t milk patients to make money to expand) by a national health system. And be held to it.

Addressing the problem of greedy hospitals, the pursuit of money rather than health, will not solve our health problems. Not only does it leave the other parasites, insurance and pharmaceutic companies, it leaves all the other societal inequities cited above, that also must be aggressively acted on.

But it is a necessary step, and a good start.

What is the problem with Primary Care? The US health system!

What is wrong with primary care in the US? Shall I count the ways? Medscape details a number of them in its recent article, citing much of the data provided in the Commonwealth Fund report “Mirror, Mirror on the Wall” which I discussed in my last blog post, Our health system: Not equitable, not effective, and not even efficient. Bad business!, (March 4, 2022). The spoiler answer is: what is wrong with primary care in the US is the US health care system – how it is designed, how it is implemented, the purposes for which it is intended, and the intrinsic corruption of it. If the primary care portion of the US health care system is in particular disarray, it is because it is the (relatively) poor stepchild of a system that is all about making lots of money for corporations, particularly large health systems, insurance companies, and the vendors of drugs, devices, and equipment. The way our health system is currently structured is to feature those parts of it that generate this money, rather than those that maximize the people’s health, and under our current reimbursement system primary care is not in the game. Thus, it is unsurprising – if incredibly depressing – that our primary care sector performs poorly on the metrics assessed by Commonwealth (and reported on by Medscape), because they are looking at different markers, that is, how it meets the health needs of our people, and a robust and effective primary care capacity is critical to that. If only they would look at corporate profit they would see how well the health system, by neglecting primary care, is doing!

What is primary care and what are primary care doctors? They care for all the issues that a person has, not limited to disease, organ system, procedure, etc. They care for people with as-yet undiagnosed problems, with undifferentiated conditions. They provide care over time, and consider the physical, mental, and social conditions affecting a person. They provide care in the context of a person’s family and community. Any issue that is affecting a person’s health, or that they think is, is fair game to bring to a primary care doctor, who will try to diagnose and treat it, referring if necessary. In a coherent and effective health system, they continue to be involved with the person, even after referral or hospitalization. The characteristics of primary care, and the reasons for its benefit to people and to society are discussed most clearly by Barbara Starfield, MD, in many papers including this one. I like to think that while the relationship between primary care doctors and their patient is defined by the relationship, not the disease, or procedure involved. Family medicine, unlike even other specialties in primary care does not even limit its practice to certain age groups. But even these doctors are being relegated to practice only part of what they could; few deliver babies, most don’t do hospital work, and a large number do not care for children.

But few of us have seen such a physician lately, still less with a “full scope” practice. There are not enough family physicians or other primary care doctors in the US. There are not enough to meet the primary care needs of our people, nor to adequately perform the role that primary care should play in regard to specialists – that is, assessing a patient, determining if they can be treated by the primary care doctor, and if not referring. Otherwise subspecialists spend a lot of time caring for things that could have been done by a primary care physician. Or missing problems that are outside their specialty focus when people directly self-refer. And it is not only in the US; in parts of Canada, there are such shortages of primary care doctors (there they are virtually all family physicians) that consideration is being given to a new profession, possibly called associate physicians. In the US, much primary care is delivered by nurse practitioners and physician’s assistants. Some of them do excellent work, but they are also hampered by the same constraints as those primary care physicians face – excessive workload, assembly line production, (relative) underpayment, and a perverted reimbursement system.

To the extent that the move to non-physicians is driven by the fact that they cost less because they earn less money, any such effort is doomed. Nurse practitioners are increasingly being recruited by hospitals and subspecialty physician groups where they can earn, as do the doctors in those specialties, more money. This has overwhelmingly already happened in the case of physician assistants. The answer to the need for more primary care is simple: PAY MORE MONEY. Pay them as much as, or almost as much as (70% would probably do it) other specialists. There are a lot of students, residents, doctors, nurse practitioner and physician’s assistant trainees who would like to do primary care, and would be good at it, but are dissuaded because they can earn WAY more in another specialty. It is not that complicated; virtually all reimbursement for health care in the US is based on Medicare rates; private insurers pay some multiple of what Medicare pays. So all that has to happen is for Medicare to completely revise its reimbursement schedule so that primary care is paid a lot more, and interventive procedural specialty care less. Don’t increase the size of the pie; reallocate!

Sadly, the reallocation (under both Republican and Democratic administrations) has been instead to increase the privatization of Medicare, effectively enhancing corporate profits rather than quality health care. The Medicare Advantage program, while it can be good for some seniors, is being touted as the greatest thing since sliced bread by many in Congress, although it is heavily subsidized and saps funds from Traditional Medicare (TM). MedPac (not a “political action committee”, but the official group convened by Congress to make recommendations on Medicare) has raised serious concerns about the program, which essentially cherry picks healthy seniors, gives them low cost benefits, and eschews sick people while getting more money from Medicare. As I have written before (Direct Contracting Entities: Scamming Medicare and you and bad for your health!, Feb 7, 2022), a program called Direct Contracting Entities (DCEs) was developed to push even those who have chosen TM into corporate controlled profit centers. And now, after DCEs have received criticism in Congress, they haven’t been abandoned, but re-branded as REACH, essentially the same model.

The problems with primary care are not with the clinicians. The problem is with the corporate model that seeks to limit the practices of the clinicians and speed up their work so they cannot provide the benefits of primary care. The key part here is being the core person who knows about you and your family and manages directly or in conjunction with others all your care. It cannot effectively happen if you are seeing different doctors in every setting, and no one is responsible for YOU. This is much different from being the person who orders the tests or prior authorizations. Family physicians and other primary care doctors and clinicians need to have the time to spend with the patients, getting to know them, getting to know them well enough that they are trusted by their patients, who may then reveal the Pandora’s box of complicated, difficult-or-impossible to solve problems that physicians dread to hear about and corporate employers hate to pay for. You can’t get to these, not to mention begin to solve them, in 15 minute visits. Often you can’t really begin to solve them at all, since they are based in the overall circumstances of life that people find themselves in, what are often referred to as the "social determinants of health" -- their income, jobs, education, housing, food, safety, and discrimination for starters. But they need to be revealed.

This is scary to corporate types, who want to continue to do what they do – generate big bucks by hiring procedural specialists to care for well-insured or rich people for big reimbursement.