Commercialization of Healthcare
Js md brought up an issue that has been noted on previous threads here but I haven't presented it as a specific thread--the commercialization of healthcare in the United States. I would like to present this subject now. Obviously, this is a major issue in the upcoming presidential debates because how healthcare is to be provided for everyone in the U.S. should be a concern for all of us. I look forward to read responses from my visitors to js md's comment. ..Maurice.
The commercialization of health care is harmful to everyone, especially patients. I'm not a big fan of Michael Moore either. He gives a one sided biased view to make a point, but his anecdotes are all valid.We have an insurance based system which is not rational to begin with. You shouldn't insure expenses which absolutely everyone will face sometime in their lives; it cries out for a different mechanism. The insurance companies provide no health care; they just shuffle paper and soak up profits. The CEO of I believe United Healthcare retired with the better part of a billion dollar bonus! What a colossal misuse of health care dollars. We are I believe the only Western country in the world which doesn't have a national health care system and doesn't regulate the price of pharmaceuticals. We only regulate doctor's fees.I could go on, but I'll quit now.
posted by Maurice Bernstein, M.D. @ 9:52:00 AM
24 comments
24 Comments:
In one sense, as long as physicians have been billing for their services, health care has been a commercial enterprise. I think a much more relevant question is what priorities characterize the provision of health care. In other words, what takes precedence, the pursuit of health or the pursuit of profits?
Bob, as long as physicians must support and develop their practice with profits going to the benefit for the healthcare of their patients, profits are necessary. What is unnecessary is behavior which encourages the pursuit of profits in medicine. It should be a known to all students who start a medical career that their goal is not to try to be rich or be rich but that medicine is an altruistic profession and the goal is to be the best professional in medicine.
There are many other careers one can enter where, yes, getting rich is an accepted endpoint but it shouldn't be the endpoint in medicine and medical care. That also means that those who are involved in medical care of patient, not just physicians, but also HMOs and insurance companies and pharmaceutical companies should look at their decision to participate in healthcare means that there is going to be altruism also involved for them and they should not look or tell their stockholders they are on the road to becoming rich. If none of these stakeholders will agree that the pursuit of healthcare trumps the pursuit of profits, well.. that is where complete governmental control of the whole health system should step in. I think the current status of our healthcare system in the U.S. is pointed in the direction of such governmental control. ..Maurice.
I thik the above comments are interesting. I do work in the healthcare industry and see so many people that just don't understand how the system really works, and what has been tried already.
First, take a look at the late 90s and all of the physician practice companies. They mostly failed. Why? because the doctors were paid on salaries and lost the profit motive. There is nothing wrong with a profit motive, it gives us incentive to work. What will you do when the government decides to regulate your salary and your industry?
Take a close look at the failed program of Tenncare in Tennessee. It was basically a form of the proposed Hillarycare of 1993. It was a mess and ended up being challended by Attorneys at every corner wanting even better coverage for what was a "gold standard" healthcare program. 25% of all Tennesseans were on Tenncare at one point.
The Universal Healthcare bandwagon may be in full play, but the American solution is to let companies compete, allow medical practicioners to make money as the market allows, and control cost through total competition. Come on look for ways to have American solutions not a French, British, or Canadian system. We have 300 million residence not 58 million.
Anonymous, thanks for expressing your view. But should the perspective for medical care to be as you say "allow medical practitioners to make money as the market allows"? Should we really look at medical care as a "market" activity? And then you write:
"There is nothing wrong with a profit motive, it gives us incentive to work."
But that was my point--of course physicians and all those in the healthcare profession should be allowed adequate income to provide for a comfortable life for them and their families, but my view as a physician who is not rich, is that the incentive to work should be approached as altruistic and not self-serving when it comes to treating sick patients. If everyone cooperated in this approach, there would be less unnecessary tests, less unnecessary procedures, less pressure on physicians to prescribe unnecessarily expensive and unnecessary drugs and drug combinations (simply for the benefit of the pharmaceutical companies) and the costs of care would be reduced.
I think we should be teaching our medical students altruism in the care of their patients as their goal. Perhaps, the altruism should extend into the medical school and those who supply medical schools so that the enormous tuitions required of med students will be reduced and the students later burden to get large amounts of money just to pay back their tuitions will be much lightened.
I currently have a group of five second year medical students that I facilitate clinical medicine learning. For next week's session with them I plan to bring up the topic of the contrasting goals of altruism vs profits in the treatment of their future patients and maybe bring back here something of their responses. ..Maurice.
Maurice -
I agree with your observation that it's not just physicians, but all those in the "healthcare industry" who should view profit, not as an end in itself, but as a means to providing better healthcare. But then, I tend to think that a similar ordering of ends would be appropriate in quite a few sectors of the economy. Just imagine if the transportation industry was focused on providing the safest, most economical means for moving people and goods from one point to another, rather than maximizing profits. Would that we all were a bit more altruistic; but I don't think a political solution is the answer. You can't, after all, compel people to be altruistic.
Bob, I agree one can't compel everyone to be altruistic in their work..but there are some activities that demand great degrees of altruism such as police, firefighters and military where their self-risks and the benefit given to others far outweighs their pay. I think those involved in the medical care profession, at the outset, should be aware that altruism is a major component of how they look at and behave in their work. ..Maurice.
Maurice - I think it would be a good thing if compassion for one's fellows was a powerful motivator for every physician, but that needs to be distinguished from altruism, the willing sacrifice of one's own good to promote the good of others.
I do believe that physicians function in a "special" moral environment, but I think you might be conflating the fiduciary duties of medical professionals with altruistic motivations. The former are usually thought to reflect the power imbalance of the physician-patient relationship, and require that physicians provide the best care they can without regard to whether doing so is also the most profitiable to them personally. Fiduciary duties are akin to what are sometimes called "perfect duties," which must be fulfilled always, while altruism is generally viewed as an "imperfect duty" that a good person tries to fulfill at least some of the time; but the boundaries of such a duty are quite vague.
Some people also understand professionalism to require the provision of at least some "charity care," which is more properly seen as altruistic, since the physician actually "absorbs the costs" of such treatment.
I think we might agree that the provision of universal access to a high standard of healthcare involves altruism, at least to some extent, since some costs will be absorbed by people who don't personally benefit -- either because they are lucky enough to not need more than very basic healthcare services, or because they would be able to secure any needed services even without universal access. But the altruism implicit in policies providing for universal access needs to be distinguished from altruistic behaviors of physicians who are providing the care in question.
Bob, thanks for clarifying the difference between fiduciary responsibilities of physicians and the concept of physician altruism.
Why can't we all get together and solve this medical care dilemma in the United States? Is the problem the age old belief that the thing that has made America so great and powerful is the skill and motivation of American business people to be profitable? Shouldn't there be some other trait or factor in the American gene makeup that has made our country great? Maybe the trait, under our Constitution, encouraging personal freedom and development of the individual but also tempering that by providing humanistic concern for our fellow citizens would be the approach that we should follow with healthcare rather than encourage profits. ..Maurice.
Maurice - I don't think there's a simple explanation for our failure in the U.S. to provide universal access to decent primary care. (Of course, once a medical crisis develops, any emergency room has to provide care -- but that's an obscene caricature of what universal access should be.) Although I think the explanation for the situation in the U.S. is very complex, I have no doubt whatever that _all_ parties bear some responsibility; i.e., corporations operating in the healthcare industry, physicians and support staff, _and_ consumers/patients all contribute to the mess we're in (i.e., about a sixth of our GDP going towards healthcare, but producing results only marginally better than some nations that spend a tiny fraction of that).
Personally, I favor guaranteed access to a reasonable minimum standard of healthcare services, the provision of which would be based soley on medical need. There is room for debate about what that reasonable minimum should include, but in a nation as wealthy as the U.S., I think we could guarantee care _at least_ as good as was "standard of care" 15 or 20 years ago...
But I wouldn't want such a system to be the only avenue available to access healthcare. If someone thought they could operate "in parallel" with such a system and make a living at it, they should not be prevented from trying to do so. And of course, people who want services that wouldn't be included in the universally available minimum level of care should not be prevented from spending their own disposal income to get it outside the universal system.
Healthcare is a market good like any other. The problem is that the market is massively distorted by government intervention. For example, what we call "insurance" is not really, since it's required to cover things that are NOT insurable risks (to understand this, imagine that the government passed laws to remedy "driving injustice" by requiring that a married mother of 3 with a perfect driving safety record and no tickets pay the same rates as a 22 year old man with multiple tickets and 4 DUI convictions). Insurance companies are not in the profit business, they are in the risk business. They should be deregulated and allowed to function the way insurance is supposed to. Also, insurance really, really needs to be decoupled from employment by changing the tax incentives that distort the way people buy insurance. That would go a long way toward making insurance and health care in general affordable in a functioning market.
LisaMarie - Sorry to have to disagree, but your premise that "healthcare is a market like any other," is pretty shaky. There's ample evidence that demand for healthcare is virtually unlimited, so no matter how much of it you provide to people they will want more. At the very least, supply and demand in this domain don't quite fit the "standard model."
Beyond that, the demand for "healthcare" is very easily manipulated, to the point where marketing departments can persuade people that they have new diseases, never before recognized by the medical profession which, as luck would have it, have "cures" waiting on the shelf back at corporate headquarters.
None of this is meant to argue that we ought to create a centrally controlled medical monopoly, but just to indicate that healthcare isn't quite like dry goods.
There is nothing per se wrong with the profit motive in medicine. Capitalism has made this country vibrant. But untamed capitalism has severe limitations when the public welfare and health is at stake. If the present healthcare system worked, we wouldn't be having this discussion.
Million of Americans are uninsured or underinsured and do not get decent care. And healthcare cannot indeed be compared to other non essential markets. Everyone requires healthcare for survival and it shouldn't be limited to only those who can afford it.
The government has mostly controlled physician and hospital fees, but they are unwilling (at least under this administration) to tackle the big corporate insurance and pharmaceutical interests. There is no rationale to allow insurance companies to siphon off billions of healthcare dollars. They provide no services at all; they only control access. I'm not thrilled about big government bureaucracies, but they couldn't be any worse than the insurance companies. At least then the only 'stock holders' would be taxpayers and the system would to some degree be responsive to them. If healthcare needs to be rationed at any level, it should not be based on the profit motive of insurance companies.
Hillary was right to propose national health care before, but she missed the boat by proposing to hand it all to private insurance companies. Maybe it was a political assessment of what was possible, but it was nothing more than a start. Unfortunately I do not see the political will presently to try again.
Bob,
Healthcare really is a good like any other. The demand for practically anything people want is "virtually unlimited"- the science of economics is fundamentally about how we allocate things when our resources are scarce and our wants are infinite (wouldn't you consume a lot of things you don't now if they suddenly became free?). I'm not sure what you mean by demand being manipulated. Advertising is information. It does not manipulate anyone. To declare that people are being convinced they have diseases they don't assumes you have a great degree of insight into other people's minds, and you know their needs and wants better than they do. That's quite a shaky proposition.
js,
Insurance companies do indeed provide a service. Does your auto insurance company "just consume dollars?" I'm guessing it provides you a service- the service of insurance. Medical insurance companies should be allowed to do the same. More importantly, we do not have some sort of free market capitalist health care system. We have a market heavily distorted by government intervention that has had very negative unintended consequences. We should look at getting rid of the distortion before scrapping the whole thing.
Hello, I just found this interesting blog. Unfortunately for the topics you are discussing here, there is no a simple answer. How I am going to change the way doctors think about themselves and about the work they do. What is the role of doctors play in society? to become rich? to help people? Are we playing the role we used to have in society? I doubt it. When people look at us, they just see money makers. Ask yourself: Do we really care about our patients and the society they live in? Do we really want to change how this system -based on ignorance- work?
Victor Castilla M.D.
LisaMarie - I think we might be talking at cross purposes here. Of course health can be treated as a commodity, and it's delivery can be left to market forces. But the question here is whether it should be. That's a moral question, not any economic question.
I don't think healthcare is a "good like any other." People who have very serious health deficiences are not able to compete on a "level playing field." They are incapacitated in a way that makes them less able to participate in the economic sphere. In other words, unless they get healthcare, which they might not be able to get without assistance, they can't even get to the starting line in the game of life. What's the moral response? I say, offer them a helping hand.
Advertising is most definitely not "just" information. It's also intended to be persuasive, and marketing departments use the very latest information about human motivation to craft their messages to push the buttons of consumers. (It's notable that during the last century, marketing departments have risen to be dominant in corporate culture, hiring the best and the brightest graduates of psychology departments to help them craft their advertisements. Not manipulative?...)
As for the construction of new "diseases," just consider whether baldness is really a "medical problem." Then find some good literature about the process of medicalization.
Finally, don't assume that I'm proposing a government operated system of universal healthcare -- I'm an anarchist. I think that beyond being a political issue, healthcare is a moral issue. And I'd prefer to see people with strong moral motivations come together in voluntary associations to provide access to those with unmet medical needs. But for reasons alluded to above, the "pure market" where each pursues his/her own economic interest can't do this. Again, moral motivations don't reduce to economic motivations.
Sure insurance companies provide a service Lisamarie, that's not the point. The point is that they do it at high cost reducing the healthcare dollars available. Yes it is a philosophical question, do you think it is more important that we all be entitled to make a large profit or that we all have healthcare that we can afford? We don't seem able to do both. It needs to be done in a way that is cost contained, and there are just no controls in place. The same arguments apply to pharmaceuticals as well as physicians and hospitals, but the latter two already have significant controls in place. Whether it's a national health system or some other system, drastic changes are needed.
Joel Sherman
It really is time for universal heath care in the US. The politicians like to talk about meeting the needs of the poor but it really is more of the middle-class that ends up going without. The very poor will qualify for Medicaid and the upper-class can always afford private insurance.
People with plenty of money seem to resent the idea of being on the same level with everyone else and are reluctant to give up the current system.
LB,
I certainly don't have plenty of money. But I do have Crohn's disease, which I will have until the day I die. And I fear socialized medicine more than just about anything else.
Lisamarie, I don't have any idea why you fear 'socialized' medicine more than any other system. Not likely that any system would refuse to treat a chronic disease like Crohn's. You don't really believe that private health insurance is more reliable? All corporations seem to be cutting back on health benefits for current employees and pensioners. The only people who seem to have reliable health insurance are federal and state employees, and of course congressmen. As a solo practitioner in my 60's, I pay over $20000 per year for limited high deductible coverage from Anthem Blue for me and my wife. That's a stretch for me, higher than my malpractice insurance, and totally inconceivable for the large majority of the population. How could a national system be worse than that?
The truth is that no society can likely afford to pay all unfettered health costs without some limitations, rationing or control. Some societies limit this by delays (Canada may be an example). Others use age (England restricts the use of dialysis to patients under a given age). We use the ability to pay leaving a large number of people with no coverage or minimal Medicaid coverage. You decide which is fairer, but I think that we're the only society in the western world which would even consider a debate on this. No one else thinks that the poor should have no health coverage.
I clearly agree with l.b. that it is time for national health insurance, managed by a non profit bureaucracy that has to answer to the public. We already have Medicare. It's not perfect, far from it, but it could be easily expanded to cover everyone.
Joel Sherman
The results of our current healthcare system is said to contribute to a number of families becoming bankrupt and other harms in family life. If the story is as reported, the results of our failing healthcare system may have led to the death of a woman who had multiple medical problems when her husband allegedly pushed her off a 4th floor balcony of their Kansas City apartment last week.
The report is in the Kansas City Star
In court records filed with the charges, police say Reimer killed his wife because he no longer could afford the avalanche of medical bills from the treatment of her uterine cancer and neurological problems.
The broken and inadequate healthcare system may lead to desperate measures. Probably more common result leading to complications or even death is the known medication non-complience by patients because of the expense of drugs and the need to balance income with food and other life expenses beyond the drugs prescribed. ..Maurice.
That man is a murderer! Because we don't have national health care, he deserves sympathy for deliberately throwing a sick, helpless woman off a balcony? How many other social programs' shortfalls justify murder? Social Security doesn't pay enough so I bludgeoned my spouse for the life insurance? Welfare is too stingy so I shot my kids? People make up excuses all the time for why they kill other people. I'm surprised that people are so blinded by the supposed wonderfulness of socialized medicine, and so unwilling to consider any other alternatives, that they are actually suggesting the lack of it makes a cold-blooded murder of a helpless human being "justified". I expected better from people who are always claiming their advocacy of socialized medicine makes them compassionate. It sounds more like they're using a horrible crime to push a political agenda.
js md wrote the following to this thread today. ..Maurice.
Here's a link [Free full text] to an important editorial on this subject from the New England Journal of Medicine. It's well worth reading.-Joel Sherman
Has anyone here given any thoughts to the patients? The thought that I may not have a choice of the doctor that provides my care just sickens me. What's worse is you throw in the poor or middle class people that have no insurance, these people will now be the first in line to get the care under a plan like this (just from my limited knowledge). I'm sorry, but I don't feel like this is the right thing for our country to do. Part of my compensation is my health insurance. I have a great plan and I like the choices I have, that is what this country is suppose to be about. I realize that many Americans have no health insurance but I'd also be willing to bet that most are able to work, just don't. They need to focus on fixing what we have in place instead of completly changing. Could end up hurting more, than helping. Take a look at those that have a medical card, if they can walk, they should have to work just like the rest of us. I know people my age that have had a medical card for as long as I've had insurance, that is where the main problem is. I hate to be blunt, but I shouldn't have the same as a poor person! Not unless he is doing my job, working the hours that I work, and having the knowledge that I have. That is bad buisness IMO. If you give this type of access to all, you'll have more taking advantage. That's just the way it is. Jimmy
With all due respect to the above forum members,
Commercialization is an inexorable element in this age. Healthcare sector is one of the most lucrative sectors for investment nowadays since healthcare is a necessity and not a luxury.
The people think that overcharging or increasing the fees of the doctor is commercialization However they must understand that it is just a vacuous activity deployed by a simpleton who thinks short term. The actual or pure commercialization happens when the hospital reduces the charges and the doctors to fees to very low levels. This strategy has been followed by some of the biggest hospitals around the world and they have found success.
When a hospital charges exorbitant prices, they are likely to pull back the potential customers from visiting the hospital and if the services rendered by the hospital does not match the level of the prices they demand, it add to the problem making it even more worse and giving it a bad word of mouth. Hospitals which charge high prices may get enough patients from the ultra rich and creamy layer of the society for a short term but in the long term its sure to send their profits declining.
When a Hospital charges reasonable prices and provide high quality services, it pulls in a large amount of customers/patients thus sending their profits high in the long term. The only problem here is that the payback period of the project will be slightly longer than Hospitals which charge high prices. This also creates a positive word of mouth.
Another thing to be noticed is the Luxury Factor. The luxury quotient of a product goes high when the price of the product goes high. Likewise, hospitals that provide luxury services cannot compromise on the prices since that will have a drastic affect on the luxury quotient of the services they provide.
Keeping aside the luxury factor, commercialization happens when they begin to dedicate their hospital for a social cause.
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