This letter appeared in the New York Times on February 5, 2014 from a physician who is concerned about the loss of traditional medical practice ethics:
To the Editor: 2014
Recent accusations against the for-profit hospital chain Health Management Associates (“Hospital Chain Said to Scheme to Inflate Bills,” front page, Jan. 24), including that it put pressure on doctors to admit patients to increase profits, demonstrate the destructive power of the corporatization of medicine on the practice of medicine. The ethical base is lost when businesspeople take over and destroy the traditions of medical practice. Hospital Corporation of America, the nation’s largest for-profit hospital chain, is under investigation for similar practices.
Leaders of corporate America care little about the credo that established medicine as a noble profession, operated not for profitability but for the good of the patients. Sadly, doctors within the corporate system who have opposed fraudulent and illegal practices designed to maximize profitability are punished and terminated. Meanwhile, the white-collar criminal behavior of corporate executives is not adequately punished.
Such practices have a corrosive effect on independent doctors as well. This leads many to game the system and find loopholes to maximize profits. Costs soar. Hospitals and medical schools are often complicit.
Many decent doctors deplore the changes in health care delivery systems that foster such abuses. But I find it hard to be heard when I speak of accountability. I call on our current and next generation of medical school graduates to have the vision and courage to take back the leadership of medicine and restore its right to be considered a noble profession.
HOWARD A. CORWIN
Naples, Fla., Feb. 3, 2014
The writer was a clinical professor of psychiatry at Tufts University School of Medicine.
Medical Commentary by Paul Goldfinger, MD, FACC, in reply to Dr. Corwin’s letter above:
I think we must agree that medicine, a “noble profession,” has not been totally squeaky-clean when it comes to putting financial gain ahead of the best interests of patients. But Dr Corwin is certainly correct when he claims that the medical profession, for the most part, has lived up to its credo to always put the best interests of patients first.
Of course there are exceptions, but somehow, without an actual ruling body, doctors have usually done what’s right, and it is a source of pride to those of us who are physicians that we adhere to long-standing traditions regarding ethics, and most doctors can be trusted to honor their traditional priorities.
But, in my experience, financial conflicts of interest due to the fee-for-service system cause an ethical tug of war for some doctors, and such ethical failings have been going on for a long time including fee splitting which I saw when I first entered private practice.
Insurance companies are part of the problem in the other direction because they make more money by trying to withhold care. And patients are also sometimes complicit because they don’t worry about such “abuses” as long as they are not paying directly.
Dr. Corwin is correct when he puts his finger on recent corporate practices that attempt to require doctors to churn services such as when employee-physicians are pressured to admit more patients just to increase the numbers. If healthcare allocation decisions are put into the hands of bureaucrats or corporate managers, the financial bottom line will be the guiding touchstone for practice policies.
Whatever ethical shortcomings might exist among doctors, they can be dealt with in a new healthcare system, but, as I have repeatedly said, doctors need to be in charge of patient-care decisions.
September 2023. At Blogfinger we were all over this topic when it first appeared on the scene nearly 10 years ago. We raised warning flags regarding quality issues under Obamacare.
And we revisited these topics in our Sept. 2, 2023 article:
The letter below shows how the lives of supposedly privileged individuals can spiral downhill due to economic deprivation in the face of a serious illness. Although my career was spent in the free market system, I saw very early how shameful it was when someone could get sick and then lose everything they have. My own contribution was to never refuse to see a patient and to always provide free care when necessary. Doctors must never lose their compassion.
This country needs to offer affordable care for all, but that is a huge challenge if we also want quality to be maintained. I’m waiting to see if any candidate for President can tell us how that could be accomplished. –Paul Goldfinger, MD. Editor @Blogfinger August 29, 2015. Ocean Grove, NJ
As a long term patient, requiring many specialists over the course of my 56 year lifespan. I can say with absolute certainty that in fact, healthcare has declined. As corporatization grows and as long as this is a for profit industry, why would these very profitable corporate entities cure anything? As the very nature of their business is to make profits, why would they put themselves out of business?
The for profit system perpetuates illness. Billions spent on advertising big Pharm medications, and more and more hospitals and doctors refusing Medicare, put very ill patients such as myself at a crossroads. Do I pay high copays for ongoing, inconclusive expensive tests and medicines, ad nauseam, or pay my rent and suffer significantly, having no quality of life?
Having complex medical issues in the current state of affairs is difficult, to put it mildly. As I am referred to numerous sub- specialities and compartmentalized-minded doctors, no one is seeing the patient as an entire being. My primary care physician is a middleman—sending me out to others who look at their assigned part only.
Considering all options available in the medical field, many are not available to those patients in my position—-Medicare and fixed income. All options are only available to the privileged few who have high-end coverage or incomes which allow top medical care.
Having worked my entire life dispite my illnesses, and having worked in the healthcare field, and having been a patient, I have the rare perspective of being on all sides of this situation. As of now in 2015, we have a “sickcare system.” I am grateful for having the meager coverage I have now, as for 6 years during the disability process I had no coverage at all.
Spending my life savings and selling my house as well, it cost $3000.00 a month for doctor visits and medication.
My case took 6 years just to come up on the court docket. I lost everything in that time. Therefore I say knowingly that sick patients are falling through the cracks, neglected, and disregarded regularly. In the state I reside in, as an under 65 recipient of Medicare, I am not allowed to have a supplemental policy—–our laws prohibit it.
My goal here is to inform those who may not be aware of the difficulties so so many sick patients face daily in the wealthiest country on earth. I believe this is a huge ethics issue and conflict of interest. Many medications that would be beneficial to me are not covered. Recently it took me more than 4 months to locate a neurologist who accepted Medicare; it goes on and on.
In closing, healthcare, as a for profit business model, does not work. Everyone needs to be recognized as valuable.
All people deserve care, respect and responsible doctors. Having had top shelf care in the past, it is appauling to see the inequality of the current system.
Thanks for your blog.
I wish continued good health to all.
The comments contributed on this issue have answered most of my questions
and doubts.
One that still fascinates is why proven practices such as the three mentioned have not been expanded nationwide. I will not speculate beyond my comment above but welcome others to.
Ken: As usual, you always have interesting things to say. Of course healthcare corporations should have “standards and ethics” as should the legal profession, financial companies, government agencies (eg the FDA), politicians, health device manufacturers, pharmaceutical companies, food growers and distributors, and so many other categories and institutions involved in healthcare. Without such standards and ethics across the board, a new healthcare system cannot be cost-effective and provide quality services.
But you seem to think that I believe that only physicians can be relied on to watch out for the public, but that is, of course, not true. However, when it comes to decisions about patient care, then healthcare organizations should listen to and empower physicians and not marginalize them into just another “provider” group.
As for blue chip institutions like the Cleveland Clinic and Kaiser, those entities have evolved unique team-based cultures that provide ideal models for patient care, but no one has yet devised a way to emulate those very special places as the gold standard for the entire country. As for the doctors at those places, they are largely salaried, although even there they have some performance incentives for physicians; but there is nothing wrong with incentives that are quality based.
As for government involvement, some of that will be necessary for infrastructure, but the government should not be running all of healthcare.
One must presume that doctors always practice the best medicine they can. Many doctors become board certified, which provides further evidence of their knowledge and skill. What bothers me is the assumed belief by (apparently) many that doctors are not competently practicing medicine.
The notion that they should be punished (e.g., earn reduced payments or be expelled from the network) if they don’t practice in a certain way suggests this: physicians could practice better medicine, but won’t unless threatened with penalties. Also suggested is the converse: pay physicians more if they meet certain “quality” standards.
Physicians are the most professional of professionals. They are not rats that require punishments and rewards to elicit the desired behavior. Let’s all be honest. The quest for “quality” is really the quest for “spend less to take of your patients”. The quality “standard of care” is really an average solution that works for many people. By enforcing the standard of care on all patients (e.g., through practice guidelines,) the CFOs of the insurance companies (and the Government) are trying to force doctors to undertreat many patients who are not in the center of the normal distribution of care.
Either you trust your doctor is excellent, or you don’t. If you don’t like your doctor, move on and find another. All this layering of regulation and “quality” standards just serves to lower the quality of care for everyone (and make shareholders of insurance companies happy with their profits from denying care). Please, leave doctors alone!
As a resident of CA and from NJ (we summer at the Grove), there is system that works, Kaiser Permanente of CA. Doctors are employees and the system is very pro active working to keep members healthy. I should also mention that Walnut Creek CA (city of 60,000) where we live recently passed a law prohibiting smoking throughout the downtown area and in all multiple dwelling residents I.e. condo buildings, etc. There is no going out for a smoke in downtown Walnut Creek!
Paul, Don’t you believe the for-profit healthcare corporations should also have standards and ethics for the public good? Relying on doctors alone will never get it done. I am so disappointed the well known high quality care standards and best practices of the Mayo and Cleveland Clinics have not been widely adopted. I must conclude there is simply not enough profit in them for other Healthcare operations to voluntarily adopt them.
Dare I suggest “the government come in with [healthcare industry] regulations designed for the public good”?
When will the realization, like it or not, that some things require “government” or it will never get done sink in?
ken.
When I entered into the workforce in 1971 until about 1988, I had indemnity insurance. I paid 20% and the insurance company paid 80%. No network, no restrictions, My out of pocket was capped at $2,000. I had this insurance at DuPont, IBM, and AT&T. Then in the late eighties, I was forced into a PPO. since then, things have gone downhill with skyrocketing premiums and all kinds of restrictions.
Back when there was indemnity insurance, people were happy. No one talked about “bean-counters” and insurance companies denying care just to make a profit. My physician was totally free to give me the best care he could. AND it was all much cheaper than today. Let’s bring back indemnity!!! Why did we ever give up such a superior system?
Ken: I don’t think that the final properties of the healthcare system have been worked out yet, so I retain hope that principled physicians will still be in charge of how medicine is to be practiced. When I saw the CEO’s of the Cleveland Clinic and the Mayo clinic on TV recently, both places being roll models for how to reform the system, those CEO’s were both MD’s, and both those places have high standards of care. I bet those leaders do not pressure their doctors to admit patients who do not need admission.
Practice guidelines based on what is best for patients should dictate how physicians practice within large systems; then the financial models should be built around that basic idea.
I guess insurance companies and financial firms also should have standards and ethics and that’s where the government comes in with regulations designed for the public good.
But, at least for the healthcare industry, high quality care standards must be demanded by doctors on behalf of patients, and the public needs to demand that. This is not idealism; it is merely good medicine, and it is attainable in this country and must be a foundational principal for whatever system we wind up with. —-Paul
Paul,
You expect too much of the doctors employed by these healthcare businesses. By that standard the employees of financial and insurance firms to “lead the charge” against abuses. Can you really be that idealistic?
Even those within do try to report abuses find themselves unprotected by the “Whistleblower Laws” which are supposed to shield them from adverse retaliation.
But Ken: Healthcare SHOULD be different than other business models.
Doctors must lead the charge to quality, ethical care in this country. We can’t trust politicians or cynical corporate types to do it on their own.
The healthcare “business” turns out to be no different from the financial or insurance industries never ending pursuit of increased profits at the expense of their “customers”.
Until violators of existing laws or regulations are held responsible (public flogging, imprisonment and confiscation of assets come to mind) for their misdeeds, there will be no end to what is going on.
Any other suggestions?
ken.