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!

Doctors, patients, corporatization, and moral crisis

In the last few years a fair amount has been published, especially in the medical media, about physician burnout. This term includes everything from frustration, to saying they would not encourage their children to become doctors, to leaving the profession or retiring early, to, in extreme but sadly not rare cases, suicide. The emphasis has usually been on the amount of work that the doctors have to do, the stress of new technologies such as the “electronic medical record” that, rather than simplifying things or making them more efficient, mainly create much more time-consuming work, and the ever-present threat of malpractice suits and other litigation against them. Recently, the NY Times Magazine, in “The Moral Crisis of American Doctors” by Eyal Press (June 15, 2023), presents more balanced and accurate coverage.

The article discusses the work of Wendy Dean, a psychiatrist and administrator at the US Army research center. Dr. Dean was shocked to learn that the rate of suicide in physicians was higher than that of the active-duty military.

The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients.

Dr. Dean thought about this issue in terms of “moral injury”, generally thought to affect those who participated in or observed horrible violations of their moral compass in war, such as the murder of civilians.

Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, Dean and [her co-worker] Talbot submitted, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”

The article goes on at length, comparing the doctors to assembly-line workers who fear for their jobs if they speak out, to non-compete and non-disclosure agreements they are forced to sign, to the way that this manifests in particular specialties, such as Emergency Medicine.

This piece gets to the heart of the matter more than almost anything that has been published in the mainstream media. I would summarize the lesson as: The pursuit of profit is dangerous to your health. The transformation of medical care from control by doctors to control by accountants and venture capitalists means that something other than what is best for the health of people, as individuals and as a population, is the primary consideration driving the structure and implementation of health care. It is not a pretty picture. Yes, doctors make and have always made mistakes. Yes, doctor have often been avaricious themselves. Yes, sometimes people have been hurt or died from unnecessary procedures. But at least in theory most doctors believed that what they were doing was for the best interests of their patients.

We have moved beyond (or backward from) that. We have entered an era in which an assembly-line mentality has been implemented in American healthcare, when doctors and other healthcare workers are seen as replaceable cogs, when the provision of healthcare is, like selling cars or liquor or financial instruments, not mainly about the “product” but is just a vehicle for generating money for its owners and managers. Tough luck, all you “burned out” doctors, probably suffering from moral injury. Tough luck, sick people.

This has been a long time coming. The deprofessionalization of medicine should have been predictable decades ago, and it was. In a recent blog post (Private equity, private profit, Medicare and your health: They are incompatible, May 11, 2023) I cite two books. “American Health Empire” (1971) by Barbara and John Ehrenreich and other members of the HealthPAC collective, showed how even then hospitals and health systems were being corporatized. Paul Starr’s 1982 book “The Social Transformation of American Medicine” focused on the impact of this on the professional role of physicians.

Another huge warning signal was, or should have been, the explosion of the space shuttle Challenger on January 28, 1986. As reported at the time and in multiple more recent articles (e.g., Engineer Who Opposed Challenger Launch Offers Personal Look at Tragedy, and Remembering Roger Boisjoly: He Tried To Stop Shuttle Challenger Launch, both from 2012), engineers for the Morton Thiokol corporation knew that there was a problem with key pieces of the shuttle (the infamous “O-rings”), and had been ignored by their bosses when they called attention to it. And never went public with it for fear of losing their livelihoods. Until after the disaster. At the time, it was noted often how this conflicted with the codes of ethics of the engineering profession. But engineers were no longer self-employed independent professionals; they were employees of huge profit-seeking corporations. Many of us who were doctors pointed to this, saying this trend was not limited to engineering, but was happening to other professions, including medicine. It had not yet progressed that far, but was fast moving down that track.

Independent physician practice, solo or group, single or multi-specialty, had begun to disappear, as practices were acquired by larger companies. Sometimes these were physician-owned, and seemed to continue to carry the same “old” values. But then they were bought out by hospitals, health systems and private investors. So were the hospitals. We got a lot of glitz -- fountains and art work in our entry halls and fancy new machines, and investment in our practices, particularly those “product lines” that had the greatest “return on investment” measured, of course, in dollars and not human health. How could we, as ethical medical professionals, buy into the casual use of such terms as “product lines” and “return on investment” when talking about the health of our patients?

Some of the explanation is greed, and some of it is psychological, as doctor began to think that using corporate-speak meant that they were cool, and allowed them to hobnob with the real power players in control of the industry. Many doctors obtained MBAs.  And now some of them are very rich. Some are even CEOs. It’s not surprising that doctors can be smart enough to achieve this, or that they can be as susceptible to the lure of power and money as anyone else. It also does not mean that all doctors who get MBAs use it to limit care in order for their company to make more money. But that does not make it good for the people of the nation. And it can, and often does, create another moral conflict, perhaps even moral crisis.

Another recent piece, by the Reverend William Barber and Gregg Gonsalves in The Guardian, “The fourth leading cause of death in the US? Cumulative poverty”, is scarcely unrelated, although rather than focusing on physicians it focuses on patients (the medical term for “people”). It clearly and thoroughly documents the impact that poverty has upon health. And while the poor are the tip of the iceberg, the most vulnerable, the cutbacks on care that come from megalomaniacal pursuit of money affects much larger parts of the population.

Because we have a healthcare system that is designed to make money for the corporate entities that control it, that system does not deliver quality care to many (or most) people. As a result it creates unfulfilling, stressful, and sometimes intolerable working conditions for its employees, including physicians. Moreover, in the classic “divide and conquer” technique long used by those in control, it leads to people being angry at their doctors for the frustrations and denials that they experience, which they mistakenly believe the doctors control. The denials of care are made by the insurance companies that they have (and often choose, such as Medicare Advantage). The long delays for getting appointments and the inadequate time physicians spend listening is the result of the management of the health systems that employ them, not only treating doctors as assembly-line workers but patients as widgets to be produced. If it seems impersonal and uncaring, it is.

So what is to be done? Doctors can start by demanding that their professional organizations, beginning with the AMA, condemn and resist this corporate transformation. They also must recognize that they are no longer independent practitioners, but employees, just as the Morton Thiokol engineers were, and that the greatest protection that they – and their patients – have is unionization. You, doctors, may be well-paid workers, but you are workers! Unions can educate people, their members and the public, about how the power is actually distributed and who is calling the shots. Other people can respond by contacting their political representatives and demanding that the power and authority of private corporations over their health care be drastically curbed; this includes insurance companies and health-care companies. A great first step would be to repeatedly demand that every representative and senator, every state legislator, sign on to support a universal health insurance system, such as Medicare for All.

There will still be plenty to do after that, but it would provide a structure for making things better.