"They all laughed when I spoke of greedy doctors."
Spoken by Dr Ralph Crawshaw at the Oregon Medical Association, as documented in the Western Journal of Medicine.
...the central clinical problem we physicians face in clinical practice is appetite control. Patients seem insatiably hungry for cigarettes, food, sex, money, love and pills. Are we so different from our patients?
My good friend Ralph was a leader in the development of the Oregon Health Plan. He also proposed that the Impaired Physician Program of the Oregon Medical Association look into physicians who were "impaired by money."
Let's face it: The American sickness care industry, with all of its disorganized elements and multiple protected revenue streams, has become a financial behemoth, and at the town, city, county, state, and federal levels, an untouchable political juggernaut. And, unlike anything seen since the US ramped up to fight the Second World War, it is a recession-proof engine for job creation. Who would not be impressed by those achievements?
Any questions? Did I hear the word "outcomes"? Uhhhh. A healthy population? Ooooh. Average lifespan of Americans? Efficiency and effectiveness? Quality of living and dying? National happiness? No need for psychoactive chemicals to escape reality? A happy workforce?
It's all about greed, but not only greedy doctors. Since Ralph's 1985 declaration, no one has said it better than Don Berwick, MD.
Can the American medical-industrial complex be tamed? Let's follow the money.
Wind up a capitalist doll and aim it at a large pile of money, and pretty soon the capitalist person or company will own a substantial portion of that pot, no matter what the entity or field may be. It is the nature of the for-profit beast.
Wind up a non-profit organization (NPO) doll in the same field as the capitalist doll and it may well assume the same characteristics as the capitalist doll to compete. And compete it will, often quite successfully. For practical purposes, little differentiates an NPO from the "capitalist beast."
A key difference is ownership: One has stock, which can compensate employed individuals with shares and options. NPOs do not have stock but must (and do) find other methods of compensation for their leaders to be able to compete for talent in the marketplace. The governing bodies of both organizational approaches are typically boards of directors. The "killer app" for successful NPOs is to populate their boards with the same kinds of people that comprise the for-profit boards, so the two approaches blend.
Of course, for-profit entities are subject to taxes in ways that NPOs are not. The laws that established such tax exemptions placed requirements to provide community goods and services on the NPOs. It is one of the worst-kept secrets in the medical industry that many (maybe most) of those tax-exempt organizations do not so contribute, or at least not enough. Enforcement ranges from none to limited and is essentially complaint driven. Everyone knows this but no one seems to care, as long as the money rolls in.
Did the United States (writ large) deliberately decide around 1980 (or was it the 1960s?) that it would build a "sickness" rather than a "health" system"? Or did the powerful motivators of human and organizational behavior simply evolve into a sickness system to the detriment of the public's health?
W. Edwards Deming (and others) observed and deduced that every system is perfectly designed to perform exactly as it does. A country cannot have money-driven medicine without a lot of money. It comes from health insurance, public (Medicare-Medicaid), private, for-profit companies, and individuals. The ability of an industry to generate goods and services to "find and treat sickness" is endless supply-driven demand. Voilà: "The New Medical-Industrial Complex" of Arnold Relman in 1980.
Greed Is Good, Right?
Just ask Gordon Gekko or F. Scott Fitzgerald's Gatsby, or in the medical domain, former governor and current senator Rick Scott. After Scott resigned from his post as CEO of Columbia/HCA in the 1990s, his lawyers kept him out of the slammer for billions of dollars in Medicare fraud that took place under his watch and led to the corporation pleading guilty to multiple felonies.
Greed certainly can motivate a lot of ambitious work.
On the other hand, according to Pope Gregory I in the 6th century, and many theological scholars since then, the seven deadly sins are pride, greed, lust, envy, gluttony, wrath, and sloth. Look at your everyday practices, docs. How many of your patients' illnesses are the result of lust, wrath, gluttony, and sloth? Yeah, a lot.
The most recent global report on health once again ranks the United States at the top of the list of developed countries for money expended on healthcare and at the bottom for health outcomes. And it isn't even close.
Many studies indicate that only 20% of healthcare comprises medical (sickness) care, while 80% results from social determinants such as education, housing, income, and environment.
Because we currently spend some 18.3% of our GDP ($4.3 trillion a year or $12,900 per capita) and have so little to show for it, maybe we should just take, let's say, 40% of that $4.3 trillion away from sickness care and invest it in healthy food, housing, crime reduction, education, clean air and water, public health, disease prevention, vaccinations, exercise, tobacco elimination, alcohol control, suicide prevention, and other drug-control and harm-reduction programs.
Millions of people could lose their jobs. I get it — the American medical-industrial complex is, at its essence, a jobs program.
I wrote about waste in the US healthcare system in 2009 and warned about an impending burst of the multitrillion-dollar healthcare "bubble," during which roughly 40% of the total expenditures (the parts that do not contribute to health) would/could/even should disappear or be transferred into something of value for the country and its people.
Of course, that did not happen. We would need an enormous retraining program for those hundreds of thousands of workers who are busily doing work that does not need to be done, especially those whose main function is following the money. I refer to the health insurance industry — be gone with you.
All you do is take as much money as possible, spend as little as possible on sickness care, consume as much as possible for unneeded processing, and pay your executives and shareholders as much as possible. We don't need you.
While we are at it, how about investing to save our planet for future generations of humans, other animals, and plants?
To illustrate the capacity of the system to resist downward economic pressure, one need look no further than the mostly well-intentioned people who believed that price transparency would shame hospitals into posting actual fair prices and empower consumers to make smart choices. Think again.
Among the fatal flaws of this plan is not recognizing that the leaders of healthcare institutions are far beyond feeling any shame for their gouging behavior, and the patient-consumers are far too naive to understand what a fair price would be, not understanding how competition and other factors enter into pricing decisions. Most hospitals simply ignored the directive and awaited compliance actions. CMS, in charge of implementing this rule, now seems overjoyed that compliance with hospital price transparency is coming along. But what about the effects of this initiative? It's too soon to tell.
I'm happy to report that physicians and other professionals across the United States are appalled by the current situation and are offering paths to reform.
In 2023, Don Berwick attempted to demonize "salve lucrum" (the glorification of profit), and called upon caring professionals of all stripes and their organizations to rise up and use all tools available to reverse this long-standing trend.
Chicago-based Eric Reinhart, MD, PhD, writing in 2023, opined that we need to shrink healthcare to build health, an ideologic change that benefits the population and could reassert professionalism.
In 2023 Tatiane Santos, PhD, MPH, of Tulane, has written about how to end the US health disadvantage by focusing on prevention and social policy rather than sick care. However, she notes that "the reallocation of resources from hospitals towards primary care, prevention, and the social determinants of health is complex." Oh yeah.
Political science professor Peter Swenson, of Yale, writing in his great 2022 book Disorder, proposed that the AMA revert to its earlier public health roots by increasing the number of members. Membership dues would become the main source of revenue (replacing corporate ventures and reliance on industry) and then lobbying transparently toward progressive ends.
In 2022, San Francisco–based controversial critic Vinay Prasad, MD, MPH, detailed how this mess has played out in oncology, and states that government regulation is the only avenue to reform.
It would help if more NPOs in medicine and health that generate enormous revenue would behave more like the charitable institutions that their charters (plus society and the law) expect, and less like their for-profit competitors.
Of course, we must always remember that one person's waste is another person's income.
What other field could so consistently convert sickness, pain, suffering, and dying into revenue centers, profit margins, shareholder value, and ultimately mega-mansions, yachts, islands, endowed professorships, eponymous educational palaces, hospitals, and art galleries?
It seems pretty obvious that profit-taking as a prime motive should have absolutely no place in what is historically the premier service profession.
Let's get real. Money is power. Huge money is huge power. If anything like this ideologic transition happens, it will have to be political and incremental. Recent CMS guidance authorized Medicaid to address such social determinants of health as housing and food insecurity, on a state-by-state basis.
Johnson and Berwick proposed redesigning Medicare. They envision a "Medicare 2.0" that would shift dollars away from fee-for-service medical care to meeting population-based social needs that improve health.
Sensible help may indeed be on the way.
That's my opinion. I'm Dr George Lundberg, at large for Medscape.
George Lundberg, MD, is editor-in-chief at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.
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Cite this: 'They All Laughed When I Spoke of Greedy Doctors' - Medscape - Mar 20, 2023.