By Paul Goldfinger, MD, FACC, Editor, Blogfinger.net
Last week we posted an article on Blogfinger that looked at the coercive effects of financial incentives in healthcare. We talked about ethics among doctors and we printed a letter to the editor from a physician who sent it to the New York Times. That doctor bemoaned the compromise of traditional medical ethics while doctors get caught up in the pursuit of profits. A Blogfinger Medical Commentary accompanies that post. The link to that BF article is below.
Part 1 of BF healthcare business for doctors
Today the conversation in the Times continued as some physicians and others concluded that capitalism was not a good way to provide healthcare because of the profit incentives which ensue from large corporations which have been taking over healthcare in this country. In the process, many doctors have become employees and have to function according to the mandates of bottom-line-oriented executives.
Below is a link to today’s Times article, kindly provided by one of our FOB’s (friends of Blogfinger) named Radar.
Medicine as a business NY Times Feb 9
Blogfinger Medical Commentary Part II on this subject by Paul Goldfinger, MD, FACC:
I am frustrated, as are many doctors, by how the current economic system which drives healthcare creates an environment for fraud, waste and abuse. To some physicians it seems that healthcare is a right which doesn’t lend itself to a capitalistic economic system. (see today’s NYT discussions linked above)
Our current healthcare is tarnished by out of control costs, corruptive fee- for-service reimbursement for doctors, and bottom-line oriented corporate management. The costs are driven up by super expensive device manufacturers and pharmaceutical companies which have contributed to an unaffordable situation.
But I hasten to add that our current capitalistic system has produced the highest quality in providers, medical education, innovators, and creators of extraordinary pharmaceuticals, high-tech diagnostic tests , and bioengineered/genetically driven advances of all sorts which promise a whole new future in medicine for this country and the world.
Other countries that have socialistic single payer systems may be spending less, but they are not the innovators, and their quality and access cannot compare to ours. They look to America for the new advances.
Finally I am especially leary of Obamacare because, so far, it is overwhelmingly about cost and insurance, with little apparent concerns about quality. As the ACA, with its mountains of regulations and restrictions , kicks in, Americans will, in my opinion, become furious over access issues, expensive premiums, and compromise of quality.
There is a chance that we will wind up with a single payer socialistic system. Perhaps a compromise healthcare economy can be worked out over time with the government providing infrastructure, universal coverage, and regulation, but keeping physicians in charge of patient care.
In Israel they have socialized medicine, but their medical care is excellent, and their high tech companies are world leaders and profitable. Similarly here there will have to be room for traditional American incentivization if we are to continue our successes while we fix the problems.
First, no country has a health care system with a structure remotely like ours; indeed virtually every one of our developed nation peers has a guaranteed right to health care in one form or another (as do many far less prosperous nations).
Second, and quite ironically — though access to health care is far from universal in the U.S. — unlike in, e.g.,, Switzerland, France, the U,K., Germany, Canada, et al, — we also spend massively more than any other country– regardless of relative wealth — on health care.
Third, the health care sector is a massive drag on our economy — and indeed (although the ACA will mitigate this) the system sends thousands of people quite literally into personal bankruptcy every year. Those who remain solvent nonetheless pay — directly or indirectly — huge amounts to keep the health care system rolling in profits.
That is not a good situation. In fact, it is simply untenable.
Thanks Paul, I will now stick to the name “Patient Protection and Affordable Care Act”. That actually sounds like something I might want. The slang term is totally non-informing.
Some research into the passage–and “acceptance”– of social security may be necessary.
Who or what would be the “regulator” needed to handle a replacement for our currently dysfunctional healthcare world?
I dread the brouhaha over anything proposed.
In this nation where a majority of citizens (the poor and a large share of the “middle class” ) cannot afford to pay for the best healthcare in the world (ours) now does anyone have a reasonable proposal acceptable to those who currently profit from the current set-up?
I posit only a “government controlled” one would have enough clout. Who believes those elected reps in Congress on the payroll of Big Pharma and the Healthcare INDUSTRY would ever pass that ? ? ?
ken.
CVS:
I want to point out the $2 billion number. That is gross sales. Not profit.
Most numbers are suspect …but you are correct…I read that too, but there is some major spin on that number and it shows nothing about how much money CVS actually profits from Tobacco or how much those figures have gone down over the last 20 years. If we had those numbers we would actually have a better picture and not a headline from a corporation that is telling us they are interested in our health. 🙂
ACA:
Regarding the ACA (that is shorter than the other word and my spell check leaves it alone…LOL)..I personally believe that if both parties (yeah I know I am dreaming) committed to making the ACA work instead of doing whatever can be done to thwart it, that ACA “could” have a chance to do what it is intended to and bring healthcare costs down for the average US citizen that is making under $100,000 a year.
Here is the thing ….I think that we can all agree on one thing. Healthcare costs are too high. If nothing changes then nothing changes. The costs just keep getting higher. If everyone is working together to make the ACA work (instead of jumping to conclusions and pointing fingers that it doesn’t work this early in the game). Perhaps it can work for the majority of Americans. I don’t know. It is new, this will take time.
The status quo was not working. The problem that I have with ALL of the naysayers to ACA is this. What is your plan to bring the cost of healthcare down? Saying that ACA is no good but offering no solution is not acceptable.
The course we were on before ACA was unacceptable. Again…I do not have any answers, but right now a lot of people in this country are suffering with medical problems and/or their lives have been destroyed by the huge costs of healthcare. That is not the USA I grew up in as a child. Corporate-run healthcare is not working either? So I hope we can change the course of the situation.
Bob B: I’d argue the basic premise that “physicians” ever WERE the primary forces in charge of one’s health care!
According to US gov’t statistics, in 2000, 46.7% of all deaths in the US were caused by modifiable health behaviors. The U.S. Department of Health and Human Services has estimated that approximately 33% of all deaths in the United States are attributable to just three modifiable health behaviors: smoking, physical inactivity, and poor eating habits. The individual/patient is responsible for maybe half of his or her health risk.
For illness that’s out of one’s own control, one needs to rely on the health care system, and it would be good if one could suffer an unexpected medical emergency without that emergency being followed by huge bills. But the basic “bronze” Obamacare policies don’t do that.
I don’t see “greed” as much of a driver as the “Law of Unintended Consequences”. I can’t think of too many places where government programs have brought us a higher quality product at a lower cost. (If you think the inflation in health care costs has been jaw-dropping, look at the inflation in college tuition over the last 30 years! The result of making college “accessible” and “affordable” for everyone!)
Paul: Having worked in gov’t health care for a time, I wouldn’t call the gov’t run health care systems particularly successful. I’m just suggesting that if the Germans and English won’t tolerate a 100% single payer system, the chances that this will happen in the US are remote.
The last time health care was governed by true free market forces was in the 19th century, and that isn’t going to happen now. Unfortunately, ACA /Obamacare introduces anti-market forces to an extent never before seen.
Strangely enough, when the ACA /Obamacare was being debated, nobody brought up the example of the several large health care systems that the US gov’t was already running. I can well understand why the Democrats didn’t bring it up, but I really can’t understand why the Republicans didn’t.
Of course I don’t smoke, but I do wonder how many smokers buy cigarettes from a drug store. I suspect that CVS decided to stop selling tobacco because it found a more profitable use for the shelf space.
Any nurse practitioners working for CVS would need to be covered by malpractice insurance. CVS has the deep pockets, so I’d expect them to be at risk for events that occur in their own clinics.
Bob B: Not to belabor the point, but you did imply that “educated adults” would not use the “slang” name “Obamacare.” Consider the following:
Polling Matters: “When President Barack Obama and his Democratic allies in the Senate and House passed healthcare reform legislation in 2010, they developed an official name for the law that they thought would convey the positive benefits of the bill: “Patient Protection and Affordable Care Act.” That name has often been shortened to “Affordable Care Act” in the years since its passage, but the bill has also come to be known as “Obamacare,” a name frequently used by Obama himself. Others simply call it the healthcare law.”
NBC News: “Democrats, including President Obama, accepted the moniker, at first with reluctance and now proudly.”
CNN: “The word “Obamacare” has taken on a roller-coaster trajectory of its own, first coming into favor with Republicans as a criticism of the law, and more recently, as the subject of Democratic efforts to reclaim it.”
CNN: “By August 2011, Obama was using the word in some of his own speeches.”
And Bob B., if you want to stick to the name of the “actual law” you need to say, “Patient Protection and Affordable Care Act.”
Bob B: I understand that CVS will lose $2 billion per year in tobacco sales. Evidently the product they will sell instead is healthcare including drug sales, actual patient care, counseling, and all sorts of other health related services/items.
In some states, nurse practitioners can open their own practices without the supervision of doctors, so it is not far fetched to believe that the new healthcare system will look to have “physician extenders” become sole providers of care. It will be a multibillion dollar business if the law encourages it and reimburses for it, and it will be cheaper to pay for than physician fees.
Note that it is already happening. Nursing schools are turning out “nurse doctors”—a new kind of nurse who will be trained to practice medicine like a doctor.
http://www.npr.org/templates/story/story.php?storyId=100921215
Paul…I do not pretend to know of a solution to our healthcare situation. I do know that I cannot change it. I do agree that I should go to the doctor, have him diagnose me, and tell me what needs to be done for “us” to solve the health problem. In a prefect world I would go there for professional help with no prejudices and I would be provided by a physician with no prejudices. ..and for a large part I believe that is still happening.
I do feel that if we discuss things on a clean playing field like educated adults the term Affordable Care Act should be used. Congress did not enact Obamacare (my spell check lights up when I type that word). It enacted The Affordable Care Act. I also think that anyone of my “paid” representatives (senators and congressmen) should be professional and use the term of the actual law that our congress enacted. Not a slang. Just my opinion and I am sticking with it.
Also, I want to make a note about the CVS announcement, that it seems everyone has overlooked. When a corporation does something it is usually done for financial (gain) reasons, not for the good of the public. I know that the tobacco companies have paid large sums to retailers for placement, and marketing incentives in the past. ( I worked in that industry in the 70’s and actually delivered some of those checks. We are talking millions and millions of dollars here…especially to corporations). Those monies have virtually dried up. Smokers are declining (yeah!) so sales are continually going down. Tobacco products are also one of the highest theft items buy customer and employees.
Perhaps the reason CVS is moving out of the tobacco trade is that they have a plan to use that space to sell a more profitable product that has sales growth?
Someone in marketing just might have made it a win/win for CVS?
Just a thought.
Bob: Those examples of single-payer systems are not exactly paragons of success. Medicare is in danger of financial collapse, Indian health is abysmal, and Medicaid is a bottom-of-the-barrel program that few people aspire to.
If we do wind up with a single payer system because the insurance industry collapses under the weight of Obamacare, it will have to be better than Medicare, etc. As for a free market healthcare system in its purest form, that is totally incompatible with healthcare. We will need a highly regulated system whichever way this situation ends up.
Bob B:
1. Without incentives, there is little motivation to work/create. And one man’s greed is another man’s legitimate profit. Who gets to draw those greed lines? Who pays the pharmaceutical firms back for $1 billion in research on one kind of drug?
2. I heard President Obama say on national TV that he likes the name “Obamacare.” He said, “I embrace that name.” Up to that point I also thought it was disrespectful. So there no bias inherent in that word. It is a convenient way to say what it is. It probably means more to most people than saying “The Affordable Care Act or ACA.”
3. You are right about how distorted the process of healthcare has become to the average patient. CVS just announced that they will stop selling tobacco. That is because they want to be considered a “healthcare provider” through about 800 mini-clnics across the country. Those clinics will be staffed by nurse practitioners who will be “practicing” on their own. I want to know whom the patient’s lawyer will sue when that doc-in-a-box misdiagnosis a serious problem.
I agree with the basic premise that we need to keep “physicians” in charge of patient care. I think that greed is the driving force of all of the problems with current healthcare. (Greed is also at the root of all of the problems with housing, banking and student loans, hmmm…there is probably more).Greed is at the root of many negative situations that we are now facing in our society. I am not saying that I have a solution. I am just pointing that out.
I for one would like to not live in a society where a corporation advertises a drug on TV, in print and on the web that they then, want a patient (customer) then to go ask my doctor for (self diagnosis). Yes, the doctor (facilitator) that has been given incentives from same manufacturer/corporation that advertised it to me. Who then, prescribes the (overpriced) drug and the patient uses their health insurance to pay for the services and the drug only (many times) to get a “refusal-of-coverage” from the insurer that he then has to fight a battle to get the service that he has already paid for.
Now my above paragraph is not what happens in every case, but it is prevalent in our healthcare culture. Most of the problems there go back to greed. Also, to expect the patient, the doctor, or one or two employees inside the corporation or the insurance company to change the basic culture is not realistic. Something bigger is needed here. Something that is grass-roots driven by people in the society not corporations or lobbyists. I am not saying that I have the answer, but I think we all agree that something has got to change.
I would also like to point out that to me, whenever anyone uses the term “Obamacare”, that you have already shown me your politics and your biases. The term in itself is a derisive slur. I do know what The Affordable Care Act is. It is a law that was passed by the Congress of the United States. You can read about that here: http://www.hhs.gov/healthcare/rights/law
Just sayin.
I’ve read that In Germany about 15% have private health insurance and in the UK the number is about 10%.
In 2011, Medicare amounted 22% of total US health care spending. Federal and state spending for Medicaid and CHIP were 16%. State and local government programs, the DOD, the VA, the Indian Health Service and workers’ compensation programs were another 9%. That’s close to 50% already, and with the aging Boomers that number is going to go up, not down under any scenario.
I don’t think a 100% single-payer system is likely in the US because enough need not and will not ever tolerate DMV-type health care. So it will end up as something in between 50% and 100%.
As we’re now seeing, the ACA managed to do something that I had thought would be nearly impossible — take a dysfunctional and expensive health care system and make it even more dysfunctional and more expensive. There wasn’t too much of a free market in health care before congress passed the ACA, there is even less today.
Nothing need be added to the NYTIMES Letters points ( Paul, thank Radar.),
Realistic criticisms without decrying Obamacare. There appears to be a consensus that in more perfect world healthcare would be a right for all rather than a profit center.