To judge from the priorities of the American medical establishment, Hippocrates, the patron saint of physicians, did not say, First, do no harm, but rather, First, make money. Its become abundantly clear that, in the US at least, medical practice is no longer a profession; its a business.
While public-policy makers are wrestling with the question of how to finance health insurance, as they should, another healthcare problem, the biggest one perhaps, is hanging out there awaiting a solution. The dilemma posed by the need to control mushrooming health costs, generated by the way care is delivered, will remain no matter which particular system of insurance we ultimately settle upon.
Up to now, whats been called health reform is really an attempt to devise a rational means of providing universal, or near-universal, health-insurance coverage for the population at large; it deals, on paper anyway, with little else. In the arcane world of health policy, however, there is a concept known as bending the cost curve. This attempt to rein in projected expenses over time (or bend the curve downward) has been aimed by liberals at slowing the growth of insurance premiums and by conservatives at limiting public demands on the overall system by implementing managed care.
The Affordable Care Act (Obamacare) does a little of both forms of cost cutting, but it doesnt get at the essence of the dysfunction. The core of the problem, the great unmentionable, is the systemic drag created by the medical profession itself, which is killing the golden calf, bit by bit.
An analysis of national health expenditures for 2010 by the publication Health Affairs showed that nearly two-thirds of the estimated $2.3 trillion spent was allocated for hospital care, physician and clinical services, and prescription drugs. Approximately 20% of the healthcare dollar went for doctors incomes alone, actually a higher percentage than for health insurance.
This was no anomaly. According to a tax study for 2005, published in The Economist, one out of six members of the reviled 1% were in medical professions; only executives and managers earned more among occupational groups. To put this in perspective, the average income of the 1% in 2008 was $1.2 million, and admission to that exclusive club started at $380,000.
Not all doctors broke into the 1%, of course. Most didnt. But physicians are among the highest-paid Americans. In 2010, a Medical Group Management Association survey indicated that primary-care doctors (GPs) earned a median annual income of $202,000, while the median for specialists was $357,000. The elite among specialists (top cardiologists, neurosurgeons, orthopedic surgeons, etc.) easily commanded yearly compensation packages in the $500,000 range.
The question is whether these incomes are objectively justifiable or affordable in light of our haywire medical system, the most expensive in the world by far despite its very average outcomes. Not if you judge by performance.
What celebrated reform advocate Dr. Atul Gawande of the Harvard School of Public Health calls Americas dominant medical culture that is, a business-oriented model of financial incentives and income maximization has pretty much taken over. A dispiriting look at contemporary medical practice by Shannon Brownlee, appearing recently in Newsweek, portrayed American clinicians as betraying the doctor-patient relationship with an HMO-inspired emphasis on speed, lack of communication, excessive procedures, and an over-reliance on prescription drugs, all aimed at revenue enhancement.
My personal GP, a group-practice physician independent practitioners are becoming a thing of the past in North America except, ironically, in socialist Canada conducts a stop-watch operation geared to seeing the maximum number of patients in a day; a 15-minute consultation is generous. There are, apparently, no more dedicated, empathetic Marcus Welbys in private practice. My gatekeeper, whose job is to run interference for the unapproachable specialists, resembles Gregory House without the charm.
It was not always this way. The best physician of my experience, long retired and deceased, was an Austrian immigrant classically trained in Vienna. Dr. Weiss by name, he was broadly educated, and his diagnoses were based on knowledge, experience, and intuition. He did not turn patients into test dummies by overusing expensive medical technology, the diagnostic crutch of modern doctors (and their protection from lawsuits), and did not engage in the current fad for drug therapies.
Then again, Dr. Weiss did not practice in the era of Big Pharma. Heres a frightening statistic, courtesy of the US Department of Health and Human Services: almost half of all Americans take at least one prescription drug, and one in six, including half of the elderly, take three or more.
Since the mid-1990s, prescriptions for anti-inflammatories, antidepressants, blood-sugar and blood-pressure regulators, and cholesterol-lowering statins have gone through the roof. Seniors alone doubled their use of prescription medications between 1992 and 2010. Predictably, pharmaceutical expenditures in the US have risen by at least 15% every year since 1998.
The health community will claim, with some justification, that there are sound medical reasons for all this pill popping. But theres little doubt that much of it is corporate driven, and that doctors are either directly or indirectly under the influence of corporate drug interests. One bit of evidence is the uniform tendency of what providers consider normal test levels (for blood pressure, cholesterol, blood glucose, etc.) to be constantly ratcheted downward, producing ever more patients in need of drug therapies and further monitoring. The doctors benefit, their testing facilities benefit, and Big Pharma benefits.
What most people have, however, are conditions, which have been reclassified as diseases. Could their ailments be remedied by lifestyle changes (diet, exercise)? Of course, but wheres the profit in that? The system needs to classify more Americans as sick, so they can be treated.
Numerous critics of our marketplace mode of medicine have called for attacking this abuse at the source by doing away with fee-for-service (pay-per-procedure), pooling institutional revenues, adopting global budgets, and placing doctors on salary, as in Great Britains National Health Service. There are ample precedents in this country: the Veterans Administration (VA), for example, and private nonprofits like the world-famous Mayo Clinic.
Combining salaried physicians with a single-payer insurance system may be just what American medicine needs. How will we get there from here? Thats the rub.
Wayne OLeary is a writer in Orono, Maine, specializing in political economy. He holds a doctorate in American history.
From The Progressive Populist, July 1-15, 2012
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