Doctors in the trenches speak out – Part three

Here’s the third and last installment from the documentary Money-Driven Medicine. The topics this time focus on the financial issues of health care: Insurance premiums, competitive hospitals, the control of medicine by profit-driven corporations, the disconnect between money and health. The first and second installments are in previous posts.

Is it possible for opponents and proponents to find common ground here? Are these issues that could unite concerned citizens of various political persuasions? Could we all agree there’s something profoundly wrong with the existing health care system that needs to be addressed?

One of the most disturbing quotations comes near the end of this post: “The end product of all of this mess and confusion in [medical] technological innovation is going to be a system that cannot be sustained, because it will be so expensive that only the extremely well to do, the elite, will have access to it.”

Can those of us who are not financially elite agree to all just get along while we attempt to reform health care? Just long enough to do something that’s in the ultimate interests of all of us? (emphasis added in following excerpts from transcript)

From Rationing to Higher Premiums

Maggie Mahar: The fact of the matter is that insurance companies tried saying no in the 90s, in that era of managed care, when the great many HMOs would say, “No, we’re not going to pay for that.” The problem is that HMOs made their decisions on what they are going to pay for based, too often, simply on cost. If something was too pricy, they would say no. But they weren’t looking at the quality of the procedure. They weren’t asking, “Well, would it really benefit the patient?” They were simply saying, “Well, where does it fit on our schedule of costs?” So, sometimes, they denied ineffective, unnecessary, expensive care and sometimes they denied very good, effective, expensive care.

There was a backlash, needless to say, in the media, on the part of patients, on the part of doctors, so by the late 90s HMOs began to say, “Okay, okay, we won’t try to manage care. By and large, we will pay for whatever Medicare pays for. Medicare tends to pay for whatever the FDA approves. We’ll just pass the cost along to you in the form of higher premiums.” And that’s why, since 1998-99, premiums have just skyrocketed.

Competition

Maggie Mahar: One time Dr. Donald Berwick called a hospital in Texas and said, “We’ve heard you have a very good procedure for treating a particular disease. We’d like to learn more about your protocol so other hospitals can use it.” And the hospital said, “We can’t tell you that. It’s a competitive advantage in our market that we’re better at treating this disease and it is very lucrative. So this is proprietary information.”

Dr. Donald Berwick: We believe in markets, right? Isn’t that the American way? Well, markets mean competition. Isn’t that the American way? Competition makes things come out right. Well, what does that mean in health care? More hospitals so they compete with each other. More doctors compete with each other. More pharmaceutical companies. We set up war. Wait a minute, let’s talk about the patient. The patient doesn’t need a war.

Maggie Mahar: The patient isn’t the center of a collaboration. The patient is the victim of a competition. There’s a saying in Swahili, “When…” I can’t remember this one… “When the elephants fight the grass is trampled.” The patient is essentially the grass.

The industrial medical complex achieves lift off

Maggie Mahar: After World War II, while other countries let their government begin to intervene in health care to make sure everyone got care, to regulate it to make sure it was good care, in this country doctors very, very strongly opposed any government involvement or anyone being involved in telling a doctor what to do. After Medicare was passed in 1965, elderly patients were getting far more care than they had been before then.

Then that’s when our industrial medical complex, I would say, took off. By the early 70s, there was so much money involved that suddenly people began to say, “You know what? Medicine is too important to be managed by doctors. We all know doctors are bad managers. What we need are businessmen managing health care.” And that’s when health care went from being physician centered and controlled, to a large degree, by doctors, to being controlled by the corporation and the CEOs of those corporations.

And, over time, more and more the CEO of the Hospital would not even be somebody with an MD. He would be somebody with an MBA. And CEOs bent on growth, bent on higher quarterly earnings, quarter after quarter, and year after year, are always pushing for more sales, more revenues, more and more and more. It produces more. But more may not be better for our health.

The worst for the health care industry? Everybody is healthy

Rashi Fein: The worst thing that could happen to a director of a hospital is that everybody, all of the sudden, would be healthy. I’m not saying that he’s overjoyed when there’s an epidemic. Clearly, he isn’t. I’m not saying that he’s overjoyed when people are sick. Clearly, they’re decent folks. But they’re running something where what they are selling is hospital beds.

… somebody could say, “Well, we have chosen to spend money on health care and that’s also a good thing.” True. But interestingly, disturbingly, frighteningly, pick your own word, we spend more money and we are not healthier. We don’t live longer. We don’t seem to be getting as much value for money.

Larry Churchill: It shouldn’t be any surprise that there is a huge disconnect between the amount of dollars that are actually poured into health care and the health indicators of a population because this system was not designed to serve this end. That’s a fundamental realization that we need to come to. And until we do I think … we’ll still be trying to tinker with the market in some kind of funny way. Just a little tweak or adjustment to make it work better, but it was never designed, actually, to meet health care needs.

Profit-Driven Medicine

Maggie Mahar: A physician takes an oath to put his patient’s interests ahead of his own. A corporation is legally bound to put its shareholders’ interests first. And this is part of the inherent conflict between health care as a business, part of our economy, and health care as a public good and part of our society. Health care has become a growth industry. That means higher health care bills. That means more and more middle class people cannot afford health care in this country.

Larry Churchill: For Americans right now I think the primary question is, “How vulnerable am I in terms of the current system? Am I just a pink slip away from being uninsured and potentially uninsurable?” And I think there’s a very profound question about whether we are creating a health care system that is sustainable over time. Some people have suggested, and I agree with them, that, actually, the end product of all of this mess and confusion in technological innovation, is going to be a system that cannot be sustained, because it will be so expensive that only the extremely well to do, the elite, will have access to it.

Dr. Espinoza: When you have a system that’s built around generation of revenue, when that revenue is going somewhere, and that money is not being put back into the system to help people, you’ve really kind of lost, you know, we’ve lost our way.

Related posts:
Doctors in the trenches speak out – Part One
Doctors in the trenches speak out – Part two
Why are US health care costs so high?
Health care reform: Navigating the maze
Health Culture Daily Dose #6: Health care reform
Health Culture Daily Dose #11: Health care reform
Edward Kennedy: Healthcare is a fundamental right, not a privilege