My Dear mol family, I ran across this article today and thought that it summarized what has been happening to our "Health Care System" in the United States. Some of you may recall that I had mentioned I was a hospital administrator at one time. The transition to "The Business Model of Medicine" refered to by Dr. Lown is the reason that I left hospital for research administration. Just last year, I was talking with the head of a prestegious Pediatric Department in a major NYC medical center. When asked how medicine was doing as compared to the 70's when we first met, he responded "VERY CORPORATE". How very sad. I will be interested in the reaction of others to this transition from "medical care" to "medical management". Keep in mind that we all have a voice and that voice needs to be heard in Washington. God Bless. JohnTitle: Physicians Need To Fight The Business Model Of Medicine
|Medscape Managed Care|
Physicians Need To Fight The Business Model Of MedicineBernard Lown, M.D
[Hippocrates 12(5): 25-28, 1998. © 1998 Time Publishing Ventures Inc.]
When I emerged from medical school in the mid-1940s, the profession was in a golden age. During my 50 years as a doctor, the field enjoyed tremendous success and respect. Now, nearing the end of my career, I watch with a heavy heart as a corporate tidal wave threatens to destroy medicine as a healing profession. How did this come to pass? More important, what can we do about it?
Paradoxically, the decline began as medicine was basking in the scientific and technological breakthroughs that came after World War II. The huge resources the federal government poured into medical research helped fuel these advances. In the following era prestige no longer went to the family physician but to scientific researchers. Medical centers measured achievement not by an astute bedside manner but by hefty grant support and publications. Media headlines greeted every advance, large or trivial, and research funding soon followed.
I know this well from my own career. Only after achieving a certain measure of success in my research -- inventing the cardioverter, devising the modern DC defibrillator, and introducing the antiarrhythmic drug lidocaine -- was I promoted to the rank of full professor. By then my investigations were readily funded, but before that I had been low man on the academic totem pole, scrounging for research grants.
Our mission as physicians was to heal, but healing had become a lost art. The skills of human interaction were considered passé and therefore barely even cultivated. Chart rounds focusing on biochemistry replaced bedside teaching rounds. Medical school chairs, who became the academic trendsetters, were chosen from those skilled in writing grants. Forget ailing human beings: The new biochemical model of care emphasized malfunctioning organs responsive to some technological fix.
For many physicians, it was an exciting time. What seemed like miracle cures were on the horizon, and young doctors gloried in being scientists. But there was a catch. Health care, now frequently dispensed from impersonal megasize hospital centers, aimed to cure acute problems. Yet as longevity increased, ill health often consisted of chronic, noncommunicable diseases such as arthritis, cancer, and diabetes. Since these ailments lacked a cure, they required a knowledge of the healing arts -- in which the modern physician was poorly trained.
Patients were no longer parents, children, elders, employees of this office or that factory, or distinguished by their wit, dignity, thoughtfulness, or bad humor. In the new scientific paradigm, each patient was a statistic, similar to any other patient with the same illness. As patients lost their individual identities, the ancient covenant of trust between doctor and patient began to unravel. Ignored was a deeper truth: If physicians limited their expertise to the technical realm, they were interchangeable with lesser-trained and far less costly personnel.
Lucrative rewards hastened the shift from a health care system focused on patients to one based on disease. A doctor could earn far more from an invasive procedure requiring a single hour than from an entire day spent with patients, and specialists earned the most. Contemporary medical practice trivialized discourse and listening. While enthralled by heroic cures, physicians remained largely indifferent to preventing disease and promoting health. They knew, of course, that preventive medicine was the most cost-effective approach to illness but neglected it because it took so much time. Further distorting medical practice was fee-for-service reimbursement, which encouraged a glut of unnecessary procedures.
The massive amounts of money infusing the health sector after World War II also sent medical costs spiraling. The wartime wage freeze forced unionized labor to seek higher earnings through fringe benefits such as employer-financed health care. In the early 1960s government-sponsored social programs such as Medicare and Medicaid also invested hundreds of billions of dollars of tax revenue in health care, with few constraints on how it was spent. And increasingly centralized hospitals, unaccountable and wildly inefficient in the way they dispensed sickness care, encouraged cost inflation.
Given the bottomless financial pit of hospital-based medicine and limitless human greed, is it any wonder that the health system imploded? Within a quarter of a century health costs rose astronomically, reaching about 14 percent of the gross national product -- or a trillion dollars by 1996. This was by far the highest among developed nations.
Despite these enormous expenditures, American medicine did not become the best in the world. In fact, we are significantly behind. If one accepts life expectancy as the best indicator of health care quality, we rank in the bottom quartile of a list of 29 industrialized nations, according to the Organization for Economic Cooperation and Development. We're behind less affluent countries such as Spain and Greece. And though other nations spend far less than we do, they deliver far more health care. Germany and Japan, for instance, more than doubled psychiatric beds between 1960 and 1989, while we slashed the number of ours by three quarters. Mentally ill patients were dumped into communities poorly prepared for them, and tens of thousands joined the street people suffering in our large cities.
Another problem is that a large section of our population lacks health insurance, a phenomenon unheard of among other developed nations. According to the latest available figures, 41.7 million people, or 15.6 percent of all Americans, were (in industry jargon) going bare; among those with incomes below the federal poverty line nearly a third had no health insurance. At this rate the number of uninsured Americans could reach 50 million by the year 2000. This corrodes our country's overall health: Among Americans who are inadequately insured, a significant number are sicker and die younger than those who have insurance.
There is no mystery about why this is happening. It's because the insurance industry so thoroughly dominates our health care system. At the crux of the problem is our concept of health insurance, which profoundly differs from that of other industrialized nations. The United States subscribes to a business model that characterizes insurers as commercial entities. Like all businesses, their goal is to make money. The bottom line is indeed the bottom line.
Most other developed countries have adopted a model in which health insurance serves as an instrument of social policy. Rather than generating profit, the aim is to promote universal access to affordable health care. To achieve this goal, other countries try to more evenly spread the risk of sickness across society.
Under the business model, casual inhumanity is built in and the common good ignored. Excluding the poor, the aged, the disabled, and the ill is sound policy since it maximizes profit. Under the social model, denying coverage to any member of society would refute the fundamental purpose of health insurance.
These failings of our health care system have done grievous harm to American medicine. Most evident is the loss of public trust in the profession. Patients who routinely seek second opinions and physicians who practice defensive medicine to avoid malpractice suits reflect this fractured relationship. Another sign of patient dissatisfaction is the rising popularity of alternative medicine: A 1993 study found that more visits were recorded with alternative medical practitioners than with primary care physicians. But perhaps the most significant omen is the public indifference to the corporate takeover of publicly owned health care institutions and the loss of physicians' autonomy in medical decision making.
The rationale for the sweeping corporatization of medicine is the need to contain outrageous and ever-increasing spending in the health sector. Proponents of managed care have argued that only competitive investor-owned health maintenance organizations have the financial discipline to stem such inflation without sacrificing quality; hmos, they insist, will correct the intractable problems of fee-for-service medicine. No longer will physicians have financial incentives to overtreat or to indulge in excessive procedures. Instead the system would reward doctors who exercise restraint in resorting to costly interventions. Advocates propose to contain costs through efficient hmo chains that downsize their bureaucracy, replace costly personnel, and get the best bargains for medical supplies by buying on a large scale.
Proponents for managed care also argue that the system imparts a central role to primary care physicians, who become gatekeepers determining the propriety of visits to specialists or emergency care services. In this new role they are supposed to emphasize prevention and reduce the balkanization of patient care among a host of specialists. As for the criticism that doctors in a market-driven system have a financial incentive to skimp on care, supporters claim that patients would blunt such temptation by quickly shifting to a better physician.
Many doctors have accepted this line of reasoning. Sacrificing their right to make decisions didn't seem so onerous when accompanied by seductive buyout schemes, partnership arrangements, and hefty bonuses. Fear that government regulation was the sole alternative to corporate takeover also hastened this trading of autonomy for cash. Doctors agreed with the premise of market medicine: that the patient is empowered to exercise the judgment of a seasoned shopper.
Consider the serious flaws in such an argument, flaws that bedevil both the theory and practice of market-driven managed health care. First, the patient is not a sovereign consumer informed well enough to determine whether his or her treatment is always quality care. "Medical care is fundamentally different from any other service bought or sold in our market economy," says Arnold Relman, former editor of the New England Journal of Medicine. "Sick people are not like consumers in a shopping mall."
Health care is not fast food. A McDonald's customer knows the taste of a hamburger, but sick people do not know what ails them, which doctor to seek out, what tests are required for diagnosis, or how their condition should be treated. Patients have to rely on physicians to determine their medical needs and to provide the required services. Market theorists disregard the fact that unlike consumers who buy ordinary products, patients rarely pay for all their medical services; they are often insured because the flat cost of services is beyond their means. Since a majority are provided health insurance by their employers, they cannot readily shift out of an hmo when they receive poor care. In any case, exercising consumer choice by switching to another plan is growing more difficult with the ongoing mergers and monopolization of hmos.
Why else is it foolish to compare medical care with other commodities? It is not offered to patients at different levels of price and quality, nor is it optional. The patient has no bargaining power and little choice but to buy. Furthermore, since patients can't be standardized, health care resists commodification and market regulation. Each patient is unique, and every health problem requires an individualized approach. Managed care advocates insist that doctors, operating as gatekeepers, will resist financial incentives and merely do what is best for the patient. This contradicts one of the fundamental tenets of the market: that people invariably act out of self-interest. Rather than ask whether a procedure is medically justified, doctors may act to preserve their own incomes, thus sacrificing the quality of care.
Even doctors determined to put their patients first may be overruled by hmo underlings. The hidden hand of the market is evident in a growing army of clerks and bureaucrats who reign in doctors by denying expensive procedures. These constraints are not arbitrary but guided by the administrators' bible. As physician and former hmo medical reviewer Linda Peeno said about her denial of a heart transplant to a California patient who subsequently died, "My clinical goal was to figure out how to avoid payment. If I had approved the coverage, I would have been gone the next day."
The patient-doctor relationship cannot survive the suspicion that a physician's advice is guided by the corporate bottom line. Says James T. C. Li, an immunologist at the Mayo Clinic, "The gatekeeper serves the interests of the owner of the gate, not of the people trying to get through the gate." And as not-for-profit institutions adopt market principles, they are growing indistinguishable from hmos, whose reason for existing is profitability.
We now have more than a decade of experience with the conversion of health care into business. In practice it has been far worse than even critics anticipated. Patients are losing freedom to choose caregivers; doctors are prevented from rendering sound clinical judgments deemed too costly. The pressure is on to hurry the sick through the system as though on an assembly belt. Health care is being rationed, its guidelines determined by profitability and secretly decided in corporate boardrooms. To realize the large returns demanded by Wall Street investors, the system must attract the healthy and turn away the very sick, the disabled, the poor, and the old. According to reports from the General Accounting Office and a 1997 study published in the New England Journal of Medicine, a large number of Medicare hmos engage in favorable selection: They "cherry picked" and enrolled the healthier individuals. Since 1987 the number of uninsured has grown by a million each year, and hospital charity care has dwindled.
Moreover, an increasing number of nonprofit hospitals are being converted into for-profit ventures, to patients' detriment. Data gathered from 6,227 hospitals by David Himmelstein and Stephanie Woolhandler, published in the March 1997 issue of nejm, demonstrates that for-profit hospitals are costlier, are less efficient, and spend less on patient care than not-for-profit ones.
Even the ostensible advantages of managed care have failed to materialize. Competition among providers was supposed to be a virtue of market medicine, but this benefit is disappearing as managed care groups rush to consolidate. Despite growing enrollment, the number of hmos has plummeted. More than 90 percent of rural Americans live in communities unable to support two hmos. Another victim of market medicine may be clinical research, the jewel in the crown of American medicine; it's being undermined by the diversion of funds to increase profits for investors.
And while many employers' premium costs have indeed stabilized, overall health spending continues to increase faster than inflation, with government and employees picking up the tab. Salaries for hmo executives and profits for investors are skyrocketing at the very time millions of Americans are denied basic care. Administrative overhead, a mark of business inefficiency, is more than twice that of any other developed nation. The resources that are now squandered on profit and overflowing paperwork would be more than adequate to provide for the uninsured and to improve the quality of everyone's health care.
That something is rotten in the state of health care is indicated by the flurry of legislation seeking to curb its abuses. According to the National Committee for Quality Assurance, thousands of individual pieces of legislation have been introduced across the country to correct shortcomings in managed care plans. However, overturning drive-through mastectomies and 24-hour limits to hospital stays for maternal deliveries cannot address the deeper perversity of for-profit managed care.
There can be no doubt that a public backlash is coming. The explanation is straightforward. To maintain high rates of profit, costs must be cut by placing draconian limits on good treatment. Since this measure may not be enough, hmos are tempted to break the rules and even to indulge in flagrant corruption: Witness the rampant profiteering and widespread enrollment fraud by Medicaid hmos in Florida in the early- to mid-1990s and the recent shareholder accusations that Columbia-hca inflated its billing to defraud the government.
A movement to oppose market medicine is well under way in Massachusetts, led by nurses and physicians (including myself) who have launched the Ad Hoc Committee to Defend Health Care. Our call to action has been endorsed by more than 4,000 health professionals in the state who have found common ground on a number of principles. Among them: Doctors and nurses must not be diverted from their primary task of attending to patients, the pursuit of profit and personal fortune has no place in caregiving, the patient has a right to the physician of his choice, and access to health care is everyone's right. The new movement is aiming for a moratorium on corporate expansion and a stop to for-profit takeovers in Massachusetts. Another major objective is to open up a national public debate on the issue of high-quality cost-effective medical care for the American people. They deserve no less.
Here's what I'd most like to hear debated. From my perspective, far more objectionable than corporate takeovers and expansion is the reality that our profession's fundamental ethical precepts are under assault. Medicine is a calling. At its core it is a moral enterprise grounded in a covenant of trust between health professionals and patients. The primary mission of the doctor is to heal, to care, to advocate for the sick, and to work for the promotion of everyone's health. Central to the doctor-patient relationship is the expectation that the physician will put the needs of the patient first, over and beyond personal interests or the interests of any third party.
In contrast, market medicine is organized like any other business, and hmos are far more concerned with the flow of revenues, market share, and the value of their stock than the well-being of the sick. The warm and fuzzy rhetoric that patients come first is a transparent marketing ploy. For-profit health care is essentially an oxymoron. The moment health care is rendered with profit as its highest goal, it is emptied of genuine caring. This moral contradiction cannot be resolved.
I'd like to see a national debate on the morality of usurping physicians' time-honored right to make medical decisions and replacing it with arbitrary regulations enforced by an army of technocrats. In my mind this is not only burdensome but immoral. Such a path leads to homogenized care, which denies patients their unique humanity. It depersonalizes patients and robs health care of its professionalism.
No other issue faced by our field is as ethically challenging as that of market-driven medicine. Since 1955 the American Medical Association's principles of medical ethics has forbidden a doctor to dispose of his services under terms or conditions that tend to interfere with or impair the free and complete exercise of his medical judgment or skill. This statement embodies the ethical ideal of separating clinical judgment from money. It reflects the long struggle to make doctoring a scientific and humane calling rather than a commercial enterprise. Will the ama go back on its commitment and permit market values to replace human values in the practice of medicine?
One may only hope that Winston Churchill's [paraphrased] quip will soon be realized: "You can always count on Americans to do the right thing, after they have tried everything else." The United States has tried any number of bad solutions for providing its people with health care. Long overdue is the recognition that medicine is a necessary social service that should be accessible to all citizens.
Physician Bernard Lown is a Nobel Prize recipient on behalf of International Physicians for the Prevention of Nuclear War, which he cofounded. He is a professor emeritus of cardiology at the Harvard School of Public Health and a senior physician at Brigham and Women's Hospital. Chair and founder of SatelLife, a computer communications network that shares medical information with developing countries, he also serves as chair of the Cambridge-based Ad Hoc Committee to Defend Health Care, which opposes corporate intrusion into medicine. His book The Lost Art of Healing was published by Houghton Mifflin in 1996.