Wayne O'Leary

Here’s to Your Health (Or Not)

I recently had the dubious privilege of seeing the American health-care system up close and personal during an involuntary 48-hour visit to my local hospital via its emergency room. The visit was a revelation; conditions really are as bad as you’ve probably heard.

In my case, being on Medicare — original Medicare, not the semi-privatized Medicare Advantage variety George W. Bush foisted on us in 2003 — eased the experience somewhat. Nevertheless, the local branch of our regional health-care conglomerate still operated much in the vein of the dystopian institution run by George C. Scott in the satirical, award-winning 1971 film “The Hospital.” That is, it was a netherworld combination of overcrowding (my ER wait time was three hours), bad morale, shortages of almost everything, excessive noise, overworked doctors, young and inexperienced nurses, and on and on.

The situation was not entirely (or even mostly) the fault of staff. A majority appeared to be dedicated employees doing their best in an untenable situation — in a health-care environment operating for the benefit of insurance and drug companies, medical technology firms, institutional bureaucrats, and administrative bean counters, one whose priorities are out of whack and only incidentally related to good medical care.

US hospitals, which The Economist magazine concluded (in a November 2019 special report) account for one-third of inflated health-related costs, are 80% nonprofits (4,700 out of 6,000). On paper, that’s a good thing, but only on paper. The problem is this nonprofit sector has been modeled on the corporate world. Hospital administrators, who used to be called “directors” and were paid like small-college presidents, now refer to themselves as “CEOs” and command salaries accordingly. And, like their corporate colleagues, hospital CEOs spend an inordinate amount of their time looking for likely acquisition targets — smaller hospitals, physician group practices, clinics, etc.

In my area, the dominant hospital system has already absorbed nine regional hospitals and is about to acquire a tenth; it’s close to monopolizing health care in half the state, enabling it to eliminate most competition and to centralize care in one location, turning patients into long-distance commuters in the process. Along the way, it’s contracted out several of its ERs to a for-profit, out-of-state staffing firm, a practice that usually leads to added “surprise” billing (separate medical bills from the hospital and its associated ER staffing firm) and raises insurance charges for going “out of network.”

As for the area’s formerly independent doctors’ practices, most of them have been taken over as well, converting physicians into hospital employees. When this happens, New York Times investigators discovered in 2014, prices for medical procedures invariably go up, and many more are unnecessarily performed to meet management quotas.

But there is another looming contributor to creeping dysfunctionality in America’s health-care system, and this one can be laid at the door of the nation’s political class. I’m referring here to the false promise of technological efficiency sold to Washington’s gullible policymakers by the self-interested barons of Silicon Valley, whose arrogant industry mantra (coined by Mark Zuckerberg) is “Move fast and break things;” as regards health care, they certainly have. Within the past decade, 90% of US hospitals have been computerized, with dire consequences for American medicine.

The role of electronic record-keeping in the monopolistic wave of hospital consolidation washing over the system and decimating rural health care in particular was discussed in a previous column (“The Trouble with Obamacare,” 2/1/20 TPP), but it’s had other devastating effects as well. These were initially raised in a prescient New Yorker article (“The Upgrade,” 11/11/18) by Dr. Atul Gawande, celebrated professor, surgeon, and health-policy writer affiliated with Harvard’s School of Public Health and Boston’s Brigham and Women’s Hospital. Gawande’s findings have since been seconded by clinicians Theresa Brown and Stephen Bergman in a recent New York Times op-ed.

Sad to say, the onus largely falls on the Obama administration, which, mesmerized by digitization, pushed through the awkwardly named Health Information Technology for Economic and Clinical Health Act (or HITECH) in 2009 and then compounded its error the following year in the Affordable Care Act (ACA). HITECH basically provided financial incentives for hospitals to adopt electronic health records and added financial penalties for those not doing so under Medicare; the ACA established the requirement as part of its broader health reform.

The first thing the conversion to electronic record-keeping did was to accelerate the takeover of American health care by giant hospital chains, some of which presently own dozens of hospitals in multiple states. Money is the major factor. Atul Gawande reports that half of all Americans now have their health information on a software system called Epic, introduced in 2015, which cost hospital systems up to $1.6 billion each — $100 million for the software, the rest for lost patient revenue while it was being implemented. Small regional hospitals, mostly in rural areas, couldn’t afford the tab; they either went under, or allowed themselves to be merged with larger institutions.

The industry consolidation expedited by the changeover to digitization has inevitably led to market control and price increases, the latter passed along indirectly to the public in the form of higher health-insurance premiums. But that’s only part of the story. Electronic record-keeping has literally changed the practice of medicine — for the worse. In Gawande’s estimation, it’s turning medical personnel into Taylorized “robots,” products of scientific management who spend their time dealing not with patients, but with computers, software programs, and record documentation (two hours spent on line, he says, for every hour with patients and an average workday stretched to nearly 12 hours).

In addition to a doubling of mistakes in health records due to computer error, resultant side effects include rising rates of technologically generated occupational “burnout” producing levels of depression that are driving doctors and nurses out of their professions. Medical clinicians “actively, viscerally, volubly hate their computers,” says Gawande. One of these is my longtime general practitioner, who recently took early retirement because he could no longer tolerate the aggravation.

Why is this allowed to happen? You might ask. Well, it’s just one more manifestation of a private health-care system whose hospital conglomerates and insurance companies demand ever more data and documentation for purposes of payments and billing. In short, it’s market-based medicine in action.

Wayne O’Leary is a writer in Orono, Maine, specializing in political economy. He holds a doctorate in American history and is the author of two prizewinning books.

From The Progressive Populist, February 15, 2020

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