A year or two ago I would have agreed that the market distributes goods and services most equitably. After some antitrust health care experience and from consulting on managed care programs, and from reading a bit more widely, I have to question this supposition. The threats to our society can either be too much market or too little market. For the best discussion of this, see Atlantic Monthly February 1997;article by George Soros on The Capitalist Threat or some of his books. This millionaire battled the lack of open society in communist nations, and now sees more threat in unbridled capitalist efforts.
Still not convinced, try this quote from the AAMC 2000 meeting:
The Business of Becoming a Business - Academic medical centers are often called the intellectual backbone of the health care system, but they do not adequately exploit the commercial potential of the innovations produced by their faculty members, according to several forum members. An investment banker asserted their university-based research institutions could produce enormous profits through their innovations, but that it is difficult to know the real potential at any given institution. As a result, he said, the university that he serves as a member of its board of directors is examining closely which of its research products could be successfully commercialized. He characterized that step as revolutionary. Another subject of discussion was the important role that academic centers play in providing uncompensated patient care to uninsured people. Approximately half of all charity care is provided by the nation's major teaching hospitals, even though they contain only 20% of the nation's acute-care beds. A department chair said that being the provider of last resort should be examined closely because the high cost of delivering care at academic centers may not equal the value of this function to society.
In past decades, academic physicians would be fired and blackballed for filing for a patent, much less commercializing their research. See involvement issues about compromises and past medical education ethics
What is apparent is that capitalism in the form of unbridled profiteering in medicine is only now being revealed as a major problem in today's society. I didn't believe it during the Stark hearings, but reputable research on physician referral documented this and much more. I didn't believe it in most of my practices, but I have had the chance to compare various health systems and examine internal memos and operations. In fact the financial dealings were so blatant, that I would have invested big bucks in this corporation if I had the money and I hadn't been convinced they were so wrong.
I have been amazed to see how much doctors and physician operations rationalize decisions for profit as conditions for quality of care - without any documentation of same. One of the most blatant rationalizations is cost shifting. We say it's ok to overbill some to care for others. This easily gets out of hand. Another one is "bigger is always better." Bigger in health care has as many problems in bigness as benefits. I agree with Terry Kane and others that somehow we must preserve the accountability of smaller groups of physicians, but yet working with larger entities.
In previous bulleting board listings we noted the Counterintuitive thread, how many times the traditional medical therapy was wrong or harmful. In my own situations I have been abused by physicians regarding decisions on IUDs for my wife, work-ups on myself, Ritalin for kids (now seems to work RCB 2000), and work-ups of suspected neurologic disease in my wife. In every instance the cost of care was more and the risk of treatment to my family members was at times significant.
For other large scale examples, ask folks like Larry Culpepper about the deliberations regarding the use of PE tubes for kids and other efforts regarding guidelines and approvals of modes of therapy. Ask yourself what happened when we first realized HBP was a killer but only had diuretics to use or when we had the first lipid drugs. In both cases we probably killed off as many by destabilizing their membranes as we did save them from heart disease and stroke. Would people really spend hundreds of thousands of dollars over 20 years to live an extra 9 months?
We physicians need to quit selling out to unbridled capitalists, whether they be major pharmaceutical corps, major health systems, or in our own practices, even in our day to day decision making. No longer should we be fighting tobacco companies on Madison Avenue, we should be battling our own health corps entrenched on Madison Ave.
Our academic centers are threatened with survival. Again a year or two ago I would not have missed them, but now I see them as essential to preserving the spirit of independence in physicians and instilling it in trainees. This independence also needs to be balanced with a much greater emphasis on self- and system evaluation. See excerpts from The Atlantic Monthly; The Capitalist Threat; Volume 279, No. 2; pages 45-58. full text likely on internet access through magazine web have included in separate email to listing under George Soros on The Capitalist Threat
I suspect that I am like most of the rest of you in that when I am convicted about a potential threat to medical care, I get rather passionate, whether it be my transexual patient who is denied hysterectomy on the basis of 'gender' bias or whether unbridled capitalism threatens our health care.
Also I am convinced, as most academics or physicians are, that an open society is preferable to a closed one. I was hoping not to look like just another physician railing against the system from an outside perspective. We already get enough anecdotal stories.
I was attempting to share a unique perspective on corporate medicine that was also reinforced by another with a unique perspective on the business world in the US and internationally. Unfortunately I am not the writer that George Soros and others are and also I do not have his experience in dealing directly with the problems noted, but I do know how much trouble that we have delivering top quality care.
Perhaps many of you know too well the problems of dealing with the closed society premises of medical capitalists. My fear is that the threat is not recognized as well as it should be. Frankly I was surprised that there was little response to my posting. This could be because I was late in posting my response, or perhaps the medical capitalist situation has happened so incrementally that we do not realize the threat. Perhaps we wish not to bring up a difficult area, preferring to stick with more relevant issues to daily lives and health care rather than the future.
I certainly hope that the other participants see the increasing takeovers of sponsoring hospitals that have FP residencies, the closer relationship of our associations with various health system entities, etc., as having great potential to impact their futures as well.
We have only seen the beginning of the anything goes mentality that oppresses our patients and our careers. Physicians face major limitations to gather together to discuss pricing, care issues, etc. Physicians in our region of the country have averaged 30-50 insurance companies contacted before finding one that was flexible enough to work with them on products or proposals. Yet these same insurance companies and hospitals use state and federal entities to investigate physician efforts. The Justice Department has become a tool not only to abuse not only medical schools, but also the attempts of physicians to work together to provide the best care for patients at the local level (NW Missiouri, SW Colorado).
I have witnessed the abuses of physician groups following closed society policies. I also keep up on some good studies regarding the major declines in physician and physician group ownership as many of you do. I see a similar parallel in organized medical efforts to combat tobacco. It took years for active anti-tobacco efforts to take hold. Isn't it interesting that 30 years of major subspecialization and technology advance resulted in little impact in overall cancer mortality, whereas the decrease in smoking resulted in the first decline in this statistic ever. Why did we wait so long and stay so comfortable?
It may be much more difficult for us to separate from, observe, and deal with medical capitalists, integrationists, closed system entrepreneurs, etc., because
Academic medicine, particularly family medicine, is in a most advantageous position.
1. We have not been so long 'in and accepted' that we don't remember what it was like to be out and uncomfortable.
2. We have great potential for control of patient lives and training that will influence health care now and in the future.
3. We are still primarily devoted to service to our patients, even though this service can at times be subverted to other interests.
We must encourage residents to choose practices where they will be given opportunities to make their own practice decisions. We need to strengthen physician skills in negotiation and communication on both a patient care and management basis. Needless to say the research community needs to study decision-making in a major way.
For a refresher, you might look at open vs closed system studies in the literature. The more open community health centers came out looking pretty good in this one. Would be interested in your perspective on other relevant studies.
Robert C. Bowman, M.D. 3/1999