Dear friends and readers,
A final blog of notes and links on an important book I read with my students this term: Mahar’s Money-Driven Medicine. This remarkable book should be required reading for all adult Americans.
Preface: Her achieved goal to tell the story of health care in the US through the eyes of doctors, patients, hospital administrators, health care executives, economists and Wall Street analysts. She wants to reach uninformed people and does; to show us that competition far from making medicine better and cheaper makes it far more expensive than it need be and deforms the system to the point where it’s dangerous. She teaches us about the messy realities of a world of medicine where a commercial marketplace is a primal motivating force, and show that all its parts and people are driven (or are here to) make a big profit as possible, not to keep people well and enable those who have genuinely become sick become well.
She begins with two maps: who is paying, what are we paying for? and shows that 7.1 per cent of the US gross national product is involved in health care; and increasingly US worker and employers cannot afford the premiums. 1 in 3 households making over $50,000 cannot afford the premium. You are not safe if you are insured because often what you think is covered is not: Michael Moore’s film Sicko was about this: people fooled to think they are covered, when after all they have paid, they are underinsured. Employers are gouged too so that the movement of jobs outside the US to countries where there is national health care is partly the result of not having to pay such health care bills. We are said not to ration care; but we do, it’s rationed by who can afford it; why is there the cost? more treatments? We get shorter stays if more intense care. It’s said malpractice suits are at fault:: they account for 0.5 per cent of spending; costs of defensive medicine impossible to calculate. In this area of life competition and the need to make a profit makes the system much worse: we pay much higher prices for same services; we have much higher administrative costs; we perform far more of complex dangerous specialized procedures than are needed.
The competitive system makes the health care delivered to individuals much worse: the competition makes it wasteful. Why: aggressive duplicate sales and very high high profit margins. The aim of corporations who involve themselves in the area is to make money for stockholders and they do what makes the most profit. One of 3 health care dollars spent on unnecessary unproven procedures, over-priced drugs, devices no better than inexpensive ones they replaced
She asks, What if individuals are being mistreated, over-charged, is this a personal or society’ responsibility? Yes because we cannot exist apart from one another and what others do affects us immediately in the area of health care. We are not individual automatons doing things that don’t affect one another in the area of health care because it is so central to our lives and we cannot do without it. When a for profit hospital lures customer with false advertising non-profit hospitals who are dependent on the money they bring in must change their ways and lure people. Many many people do know this. In 2004 a national coalition of businesses, unions, provider groups, insurers, called for price controls, national health insurance, restricting increases in insurance premiums. We cannot get reform because the system’s lobbyists pay huge sums to politicians to enable them to get into office, and once they need and have taken that money, they dare not vote in the interests of their constituencies.
There is also a film made from book and it too shows how a profit-hungry medical-industrial complex has turned health care into a system that squanders millions of dollars on unnecessary tests, unproven and sometimes unwanted procedures and overpriced prescription drugs; see the interview too.
Chapter 1: The Road to Corporate Health care: how did we get here? this chapter includes history
This is a story about how power trumped reason and ethics: like Gawande, she opens on the problem of uncertainty, how we cannot know the outcome of a visit or medicine, how doctors themselves operate uncertainly; the patient must buy blindly, and recovery unpredictable. Ironically in this system a well person is someone you can’t make a profit on. Medicine is not a commodity like buying a jar of coffee or car; the relationship is one which has to rely on trust and needs the doctor to put the patient’s interests first. If the product will do you more harm than good, you have still to pay for it. In a capitalist driven system doctors and hospitals are not paid to keep people well but treat them when they are sick. A pill or operation is a sale.
She tells the story of now in the later 19th and early 20th century physicians banded together (the AMA) to create autonomy for themselves. They control who gets what medicine, keep the number of schools limited, price high and their authority supreme and fight transparency (p. 4). In most other professions individuals do not remain independent; she thinks the way they did that was just this need for a relationship between a doctor and patient – and the relationship is needed and must be based on trust and honesty. What they did then was took their cultural authority and strategic position to make themselves gate-keepers to everything you might want or need for real.
Insurers stepped in to help pay the rapidly rising costs and that opened the door to endless price inflation; the only check was the patient’s ability to pay; now it’s the employer’s. he AMA allowed Blue Shield/Blue Cross to come in because they did not interfere with the doctor: doctors not required to charge patients controlled fees; they paid hospitals on basis of costs and let hospitals say what these costs were. The pre-deducted sum from the paycheck of the employer the final enabler. In the 1960s medicare, medicaid were brought in to fund the aged and poor; but the problem here is the gov’t pocketbook is open to be fleeced and was and is.
Meanwhile in world of scientific medicine and profit, you saw the rise of the specialist, and the entry of enterpreneurs who saw a world awash with sums if only they could get their hands on these: hospitals began to compete like hotels, and individual uninformed egos and profit motives allowed to control what is on offer and what people can choose.
By the 1970s this invented marketplace was in crisis. The earliest solutions were smaller groups within the system like HMOs: they would rationalize their groups within and apart. They learned they could not exist apart. Paul Starr has written two important books: one on the social transformation of American medicine and the other on how given the present political system, how we cannot change the bad results. He shows in the latter how the HMOs are too small and not in control; the goal is return on investments as corporations began to buy these entities (HMOs, hospitals, drug companies) whose business is one of selling false ideas about what medicine is and can do.
Chapter 2: The Cost of competition
WE have a Hobbesian system where all the players are pitted against one another and the aim of managed competition was not to deliver better care so much as to keep costs within the present system down: the idea was the insurance companies would dictate what a doctor could order for the patient and this would stop.
To save money you have to pay slow careful attention to the processes, and discover ways to really improve the care of individuals first, ask yourself what kinds of basic care are really effective. Medicine because it goes on between a doctor and patient is a cottage industry: doctors practice episodic medicine and if they don’t share what they are doing with one another, a patient ends up the recipient of mistakes.
She shows how hospital are pitted against hospitals; obtain lavish technology which others have because others have it; speciality hospitals take patients from community hospitals (p. 39). If we look at how she treats each individual area we see Gawande omitted important parts of explanations. He says we do so badly with pneumonia becasue no one cares enough for the average adult; Mahar show that that huge margins of profit are there for open-heart surgeries, while only small ones in for pneumonia care (which demands immediate tried antibiotics (p 40). Yet our population has little immediate need for heart-surgery programs (p 40): our real problems are smoking and bad eating habits. She goes over the ordeal of by-pass surgery and how it’s pushed on people (p 43) who have no watch-dog to help them.
Then there’s doctors versus hospitals (p 45): they have to pay unscrupulous doctors what they demand or they go to another hospital
Doctors want to be in control (p 47) and conflicts break out everywhere: the value system is so askew (p 49): drug-maker v drug-maker, insurer v insurer. The knowledge a physician needs to decide whether or not to give someone an operation, the problems and complications, the medicine, are called “trade secrets” and they cannot find out whether what they are doing is helpful or safe.
We see where whistle-blowers and patients are caught in cross-fire and trampled down, basically punished for being active on their own behalf (p 59). It’s a story with occasional decent people (heroes and heroines): Dench and Powers who blew whistle on doctors overseeing more than one surgery (pp. 59-79). The story of Diane Powers (pp. 63-69) — since it’s normal for patients to die people overlook the causes and increasingly autopsies are not done because they are not profit-making.
Still from Bill Moyer’s Journal: discussing movie from book
Chapter 3: The for profit hospital
For profit hospitals lead to higher prices, well, duh, of course they do; study after study shows this (p 127)
This chapter includes a central revealing history of three pirate companies: National Medical Enterprises, Tenet and Health South. It was run by CEOs who she describes as inherently sociopathic types: these are people good at guessing others motives and manipulating that. Three took away huge sums with impunity: Richard Eamer, a story of billing fraud at psychiatric hospitals (p. 87)); he was replaced by Jefferey Barbakow (p. 93); whole centers set up to obtain and gouge customers was Redding’s contribution (p. 102, 104); Trevor Fetter (p. 114); Dr Tommy Frist a dangerous man because he was himself a respected physician, he worked as a front (p 119) and used his position to enrichen his family fantastically (p. 122); Richard M. Scrushy (p. 125) another “empire” builder. Most of these have gotten out with huge sums. Wall street applauds, (p 101).
Outlier payments: the way they gamed the system was to take the patients whose so-called costs were outrageous and actually bill for these (p 100). In reality no one pays these sums; they are notional except when the patient has no insurance. What happens is the institution figures out how much he or she needs to get to make a big profit and then divvies up the costs for individual items so they add up to that price. It’s also a kickback game (p 115) where settlements are a form of coverup (p. 112).
Shanghaii-ing Patients: I’ve seen this kind of grabbing mentally and socially troubled wreaking of people’s lives when parents of disabled children and young adults mistakenly put them in institutions (p 86); you are in absolute danger (p 89). Victims’ stories include John David Deaner, p 69, Christy Scheck (p. 90); Tony Ginocchio (p. 102); Shirley Wooten (p. 103). The psychiatric industry exists within a a climate of pervasive fraud.
Here and there a quiet hero: the new editor of New England Journal of Medicine, Arnold Relman (p 97), an editor; Jim Moriarity, an attorney (p. 90) and his brother-in-law (p. 108); Louis Parisi (p. 96); Robert F. Stuckey (p. 96); Skolnick Sheryl, pp 106-109
An institution that started life as charity ends an irresponsible investment opportunity wrung dry by ruthless operators (p 131); historically hospitals (like schools) were unprofitable institutions (p 132). Problems includes those who work to game the technology; instill fear in patients and an over-confidence in technology; it’s revealing to see a stock market exuberance characterized early phases of “for profit” hospitals
Chapter 4: Not-for-Profit hospitals driven to change their act so they make a profit. Their original mission is lost.
She begins this chapter with an advertising campaign in a hospital to attract patients as if it were a hotel (pp 139-40). They are not emphasizing safety and not setting up what happens with safety criteria in mind, but rather luring patients in. Academic medical centers also need to be scrutinized because increasingly they are operated with a central aim of bringing in money too.
During the first half of 20th century, hospitals not expected to be self-supporting; paid for by progressive taxes. Boards saw themselves as providing a social service; they were not a crew of savvy entrepreneurs, but pillars of the community. There is always a gap between ideal and real, but now it’s exacerbated and central.
Today not-for-profts rely on borrowed money and what they can bring in for themselves. They are (like churches) still exempt from property and corporate taxes. They do provide charity; they must stabilize patients before ejecting them, only we discover that often they do not do this.
Some results: only 20 per cent of community hospitals invest in palliative care; 4 brand new hospitals in one area where wealthy people live; the hospital has to offer handsome bonuses to keep doctors (p 146). A race on to lure well-insured; high-margin services to cardiac patients (p 148); proliferation of Neo-Natal units p 149: yet infant mortality rates no lower; infants with less serious disease put into ICUs. Ironically, the plans set up for people cost more and provide less (to make this profit).
Chapter 5: When More Care is Not Better Care
She begins with the story of Maureen Silverman who made the mistake of calling an ambulance for her father who was again seriously ill (p 156): he had had many operations and he didn’t want dialysis. The family was told this is what we do; this kind of medicine; the doctors were not interested in what Silverman himself wanted. Instead of hugely expensive painful technology, an IV should have been put in the man. In the middle of the night the old man died and escape them all.
There is no business case for learning how to do less: system stubborn, set up to do more even if all is uncertain (p 174): no capacity or teams of people hired to study what truly works; too much thrown at people (pp 176-77). Too many drugs, and people die from therapy — one of 8 stories in Near Death; you are told it’s your only hope for survival when no one knows if treatment actually works (p 177).
The Insured often receive too much care in the forms of newly-patented medicine and expensive technology: 65 billion is spent in overtreatment; but those with this kind of lavish care do not do any better. By not talking about price we don’t discuss why we do what we do: excess capacity then governs (p 170)
The regional variations: Gawande has a long article in the New Yorker on this too: Manhattan and Miami people receive far more and aggressive care than counterparts in Minneapolis and Missouri, Montana (p 159). Underlying competitive and price gouging system accounts for 1/4 of cost. Geography becomes destiny because the values and types of doctors who exist in one place don’t exist in the other: with more intensity of care, the outcomes are often worse: you are being cut up, so you have greater risk of complications or medical errors; hospitals are dangerous places if you don’t have to be there.
Speciality hospitals syphon off expensive patients and leave longterm care to community hospitals. Often the high-tech treatment is worse for the person (like bone marrow treatment plus chemotherapy often kills instead of saves). Non-invasive treatments reap less profits so doctors do more operations and hospitals participate in this over-sale and attempt to make money.
High tech distracts by from going little things that work and that count (p 165) to big things that may not and are dangerous and painful: antibiotics must be immediately to pneumonia patients, beta blockers to people with heart attacks. Patients expect more care; an ago-old instinct is to want to see something done and not understand that sometimes nothing can be done but palliative help (p 173) and comfort.
Story of Dr Donald Berwick whose wife was several times nearly badly harmed and suffered unnecessarily (he comes up in Gawande’s “Bell Curve”). Ann: we see continual mistakes, continual errors, no one caring for her, no one watching to see what others are doing; she experienced long waits with no attention paid to her – and this is the wife of a big doctor in the best institutions (pp. 182-89).
In End of life care: doctors not trained to listen, not paid to listen; team comes to tell you your options; not paid to do that. The ICU; Meier makes $100 an hour to talk; cardiologist brings in $1000; Hsaio’s famous formula leaves out usefulness (p 193). Technology is defining the patient; no one paid to listen; talking to families major part of what’s done in ICU physicians trained to treat specific illness not whole person
Chapter 6: Too Little Too late
So who is uninsured? 1 in 8 children for a start. Veterans. States decide how to allocate money that is given them by the federal gov’t, and when programs are set up without funds, the states respond by making it difficult for individuals to get health care (p 199). When they are forced to give out immediately, they sharply limit future enrollments. They get rid of the list that tells who is not insured.
Who is at risk: 47 million plus: when uninsured you pay gross bills which insurance companies do not pay (see outlier payments); they receive no preventive care and less or no immediate care (p 201). They do turn people away (p 203); screen them, (p 205); hospitals shun and dun people ruthlessly (p 208); no cash, no cure, no research. We see the capricious access to specialists
People in hospitals made gate-keepers who have forced of character not to take you in unless you have the money (p 202), and sometimes not then. Poignant stories of Martin Martinez and Buddy Rich. Mr North (pp 216-22): the terrible suffering of a working man reveals why in political arenas people get so bitter. They or relatives and friends have been badly mistreated.
Shunning and dunning. Hospitals overprice services to the poor and uninsured: first they refuse to treat you if you are uninsured unless you bring money up front; then they charge you the literal unreal price they send the insurance companies. These are the prices they have to get from a procedure based on cost and profit, not what each thing really costs. Then they sell the debt to a collector. So the person experiences ludicrously high costs, is shunned and then dunned. He or she does not return to the hospital.
Finally, the high costs to taxpayers and the system in general of not treating uninsured and the irrational ways things are cut (p 222-224).
For last part of book, see comments. And see also Gawande’s Complications and essays; Marcia Angell on privatizing medical knowledge: harm spreads through globe; Frederick Wiseman’s Hospital.
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