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Coming Corporate Control of Medicine Will Throw Patients Under the Bus

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One of the most effective scare techniques employed to preserve our grotesquely inefficient, overpriced health care system has been to invoke the red peril of “socialized medicine”. Never mind that foreigners in advanced economies fail to recognize the caricatures scaremongers supply, or that Americans who need emergency care while overseas are almost without exception impressed with the caliber of care and astonished by the low (sometimes no) cost to them. After all, Americans live in the best of all possible worlds,and consumer and business freedom are always better.

In fact, business freedom here increasingly means the God-given right to exploit the vulnerability of the public. The example slouching into view is more corporate control over the practice of medicine. And based on the previews, it will make the horrors falsely attributed to socialized medicine look pale.

Two accounts last week bring the issue home. The first came in the Health Care Renewal blog (hat tip Lysa). It’s a reminder of how the current institutional efforts to regiment doctors undermine the caliber of medical care. It has become distressingly common for HMOs and other medical enterprises to have business-school trained managers putting factory-style production parameters on doctor visits. Outside of foreclosure mills, it’s hard to find similar approaches in other professions.

The post describes how a pediatrician, Pauline, who has developed a reputation for treating chronic conditions is at loggerheads with her for-profit practice. The suits don’t like her patient mix. She gets too many tough cases, when they’d rather have basically healthy kids who are there for a cold or ear infection. Mind you, this is only partly a money issue. These visits can be “up coded” so as to get larger insurance/patient payments, but she get a higher level of patients in less-generous state insurance programs. But some of the pushback is that her practice is perceived as disruptive, since she uses what is perceived as too much of her and staff time, separate and apart from the economics. She’s constantly breaking management’s precious guidelines. One of her turf struggles:

She had set up a visit to see a new medically complex patient and had blocked off 40 minutes, the amount of time she felt she needed to do a good job. The child had a complex genetic disorder, cerebral palsy, and heart, lung, and kidney problems. Both the cardiologist and the nephrologist had called asking her to take this patient. She agreed. After she had scheduled the visit, a manager called her and told her that she was being allowed only 15 minutes to see that patient. After some fruitless discussion with him, Pauline finally said, “Okay, I guess that means that you’ll be seeing the patient instead of me, right?” The shocked voice at the other end of the phone line replied, “What do you mean? I don’t know how to take care of patients.” “That’s exactly my point,” Pauline put in.

Pauline explained that this manager assigned to her office is not even a college graduate. Physicians cannot access the schedule electronically and have no control over scheduling. These functions are controlled by the office manager and (amazingly) by some of the medical assistants who have received some “leadership” training. These medical assistants are even allowed to evaluate the clinical competency and skills of the physicians.

And to add insult to injury, how long did this discussion take? All those minutes the doctor spent fighting with a petty bureaucrat come at the expense of patient care.

As an aside, it’s hard to stress enough that this sort of demoralizing micromanagement an unwillingness to listen to and learn from workers, is a widespread shortcoming of management American-style. And it has weirdly been airbrushed out of the media. When I was a kid in business school, US manufacturers were having their clocks cleaned by Germans and the Japanese. There was a good deal of critical self examination back then. One source of foreign ascendancy was that they had newer factories, so you couldn’t really blame American management for that one. But the second was that it was widely acknowledged that US managers were generally poor at dealing with labor. And this wasn’t “labor” in the union sense, but at having productive relationships with factory workers (note that there has been massive revisionist history since then. When I was in Bschool, none of my classmates, nearly half of whom had worked in major manufacturing companies, had bad things to say about unions. Now you’ll often see the decline of American manufacturing attributed to unions in an “everybody knows that” tone.

Now before you come running to the defense of management against the doctor, think twice:

So let me add a further nugget about Pauline’s background. In one of her previous jobs, she was made the manager of a pediatric outpatient center within a county hospital caring for a largely indigent population. This center had been running in the red for a good while. Pauline took over and within 28 months she’d streamlined the place and had them running well in the black, while still administering a quality of care that Pauline and her colleagues could be proud of. In short, Pauline could probably tell the managers of her current practice a thing or two about how to optimize patient scheduling without compromising care or cost —if they’d listen.

As bad as that is, most patients are unware of how much their care has been fitted to a Procrustean bed. The deliberate degradation in the name of profits is going to become more obvious, at least if the health care industry has its way.

I strongly encourage you to read this post from Whole Health Chicago (hat tip Lambert) in full. It shows how the future of American medicine is to fire the ones who are unhealthy. No, I am not making that up. The writer, Dr. David Edelberg, describes a recent presentation by a large insurance company. They’ve apparently been hosting similar sessions with physicians in the Chicago area in large medical practices. Here are the key bits (emphasis original):

The speaker at these evenings is always a physician employed by the insurance company. His/her title is medical director (I begin to think there must be dozens and dozens on their payroll) and he always begins by reassuring the audience that he was in clinical practice himself so he understands something of what physicians–especially primary care physicians–are facing. I view this physician more as a “Judas steer,” the animal that leads an innocent but doomed herd of cattle through the slaughterhouse corridors to the killing floor.

The health industry hopes that individual medical practices and small medical groups will ultimately disappear from the landscape by being financially absorbed into larger groups owned by hospital systems.

And why do the powers that be regard this as desirable? Although the article does not stress this point, doctors have an established revenue stream. So the acquirers buy them out and impose discipline on those artistic, freewheeling doctors. The “practice style,” which used to mean the independence that doctors once enjoyed, is now an Orwellianism and includes hewing to corporate guidelines as to how to operate.

And here’s what to expect:

Physicians are expected to spend a limited amount of time with each patient, and are encouraged to see as many patients as possible during a workday. The insurance companies, sometimes with the token cooperation of a few physician-employees, create vast books of patient-care guidelines to which they believe their physicians must be “accountable” (remember this word, it will crop up again). These guidelines might mean documented Pap smear and mammogram frequency, weight management and exercise, colonoscopies for patients over 50, and getting that evil LDL (bad cholesterol) below 99 by any means possible…

If the chart audit system discovers that a physician, for whatever reason, is an “outlier”–that she’s either not following the guidelines exactly or not getting the results anticipated for her patient population—she’ll be financially penalized. A quick example of what might occur: if your LDL is 115, you may be on the receiving end of a statin sales pitch from your doctor, not because bringing it down to 99 will improve your longevity, but because your refusal to do so will impact her financial bottom line.

Now of course, you might say, “Well, in fairness, medicine is too much of a cottage industry. Look at how many doctors give unnecessary annual EKGs to patients in low risk groups. How else are we going to get to evidence-based medicine?” The problem is that what we as patients will get isn’t driven by best outcomes, it’s driven by profits. Edelberg explains:

…the subtext of “standardized” always includes the unspoken “spend less money on the patient.” Thus, a doctor might be financially penalized for recommending nutritional counseling to lower cholesterol (“counseling is expensive”) instead of writing a generic statin drug (cheap). Or recommending psychotherapy (“therapy is very expensive”) instead of generic Prozac (cheaper than M&M’s). Or referring patients for massage, acupuncture, or even chiropractic (“expensive, expensive, expensive!”) instead of pushing an over-the-counter antiinflammatory (free to the insurance company, as it’s OTC).

And I shudder to think what becomes of patients who don’t hew to standard templates: the person who had a high body mass but not due to dangerous abdominal fat (which is what creates the health risk) who is pushed to take the latest, greatest diet drug. What about people who don’t buy into the religion of getting your LDL down to below 100 (one reader argued that while it may lower your risk of heart disease, it increases your all-factor death risk by reducing your ability to fight MRSA)? Will they face penalties if they fail to comply?

No, you just will find it nearly impossible to get a doctor to take you:

• Let me close with a best-as-I-recall quote from an insurance company medical director. “We can no longer afford to pay for health care under the PPO model. Our plan is to phase out all fee-for-service care during the next few years. We’ll pay you doctors a finite amount of money to take care of a defined population. We tell doctors, ‘Don’t spend much money and you can keep the difference. Period. Don’t follow guidelines, and you’ll be leaving behind some serious money on the table and we’ll just take it back.’”

In case you think I overstated the implications, Edelberg recapped the discussion that ensued:

One physician piped up…. “But what about the non-compliant patients who won’t take the meds, don’t eat well, don’t have mammograms, continue to smoke? And what about super-health-conscious patients who want their vitamin levels measured and want referrals to acupuncturists?”

Another physician answered wearily for the medical director (who didn’t disagree): “You’ve got to fire patients like that. Get the non-compliant and the super-demanding out of your system. They’ll drag your numbers down. Hit your personal bottom line.”

Hey you, patient. Yes, I mean YOU. Pink slip time! Canned! Take your medical records and don’t let the frosted glass door hit you in the…on the way out.

In other words, if you are high maintenance because you don’t do what your doctor says (and remember, “non-compliant” includes people who don’t follow orders because they think the cookie-cutter approach isn’t right for them) or want higher service or per the example of the pediatrician Patricia’s 40 minute case, have a complicated set of ailments, you’ll be shunted. The brave new world of corporate medicine will eject you.

The rich are unlikely even to know that this change is occurring. There will be a tier of doctors on the high end to cater to patients who want more personalized, cutting edge treatment and might need some prodding. And they can always go abroad if they can’t find what they need here. But for ordinary schlubs, expect to find the doctor’s office become more hostile as the brave new world of corporatized medicine becomes entrenched.

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99 comments

  1. Roland

    Proletarianization of medical doctors? Still well-paid proletarians, tbs, but no longer independent petty bourgeois professionals. Gone is the control over their own means of production.

    1. Gregory Plotnikoff, MD

      Yes, you understand the loss of small business in this country.

      Please note that many physicians do reject the “Pill for Every Ill” dogma.

      They practice integrative and holistic medicine. And they take their oath to do no harm quite seriously. This includes the harm of “disempowerment” by pharmaceuticals.

      Examples include:
      Mark Hyman, MD, “The Blood Sugar Solution” (Diabesity)

      Henry Emmons, MD, “The Chemistry of Joy.” and “The Chemistry of Calm” (depression, anxiety)

      Gregory Plotnikoff, MD and Mark Weisberg,PhD, “Trust Your Gut” (irritable bowel and all chronic gut distress)

      True primary care is what we do for ourselves. These books are powerful tools that lead people to reclaim their lives.

      1. Nathanael

        Gregory: you may be interested to know that my so-called “irritable bowel syndrome” turned out to be a side-effect of Wellbutrin.

        This isn’t well-understood by doctors, but it’s well-documented physiologically: Wellbutrin (like many psychiatric drugs) increases dopamine and norepinephrine; dopamine and norepinephrine slow down the digestive system; finally, an unusually slow digestive system causes the symptoms of “irritable bowel syndrome”.

        In case you didn’t know, you might want to add that possible diagnosis (psych drugs) to your book. Psychiatric drugs, by changing the neurotransmitter imbalance, can alter the functioning of the gut, potentially in very bad ways. This is all known, and really quite obvious in the scientific literature, yet ignored by 99% of gasteroenterologists.

        1. Greg plotnikoff

          Thank you. Yes, a significant percentage of my consultative practice relates to the side effects of prescription medications. This includes SSRis and SNRIs. I am puzzled by the fact that your physicians did not recognize go side effects of your medications. I am pleased that you wrote and that you are doing well now.
          Take care,
          GP

  2. mmckinl

    We need Single Payer Healthcare …

    As envisioned in the US only the insurer would be a public entity. This is not socialized medicine but a socialized insurer … Doctors, hospitals and pharma would all remain in private hands. It would be similar to Medicare but much more inclusive and much more efficient.

    What they, the providers, don’t like is that their ability to gouge, escape best practice and push ineffective even dangerous drugs would be severely curtailed. And of course we would not need to pay health insurers their 25% overhead for denying services …

    Thanks for your attention to this huge rip-off of the American people Yves … The future will be very bleak indeed if these health care companies take over our health care delivery completely. And it looks as though the US is trying to push this nonsense on Japan and the EU as well through trade deals.

    1. bhikshuni

      What is the point of Obamacare if we still have to keep a budget for paying for accupuncturists and flying to Cuba or India to get real care?

      Time for consumers to build our own coops and pool resources to hire their own doctors.

      Whatever happened to the SRI funds? Can we not make our own Socially responsible health coop?

      1. mmckinl

        Why not Single Payer? Do you think most people have the where-with-all to arrange a setup like the one you described?

        1. Goin' South

          Single Payer will end up with the same kind of metrics as the insurance companies. Cost-cutting rather than healing will still be the focus. What do you think is happening to Medicare right now? What has always been the case with Medicaid?

          The key to forming coops is the physicians. Will all of them be willing to become cogs in the corporate profit machine, or would a few of them still like to practice medicine? Some established docs, out from under their ed loans, will need to lead the way. Establishing primary care in communities won’t be that difficult, but the communities will have to bring pressure on medical centers to provide more specialized services as the price of being located in those communities. Some non-profits in urban centers basically do that already.

          It baffles me how Propertarians manage to fool themselves that Capital is not the enemy. It puzzles me how Democrats fool themselves that the State is not the enemy. The only way to restore human values to all our relationships is to get rid of the dominance of both over us.

          1. Heron

            On What do you based this assertion? That isn’t what has happened in Britain, in Canada, in Japan, in Taiwan, in any place with single-payer or a national healthcare system, so why do you think that’s what will happen in the US?

          2. Goin' South

            Re: Heron—

            You needn’t go further than today’s “Links” on this site:

            Austerity and the Unraveling of European Universal Health Care

            And you don’t admit that these same kind of metrics are being employed with increasing frequency in Medicare and Medicaid in this country?

            And read the commenter’s account below of dealing with the Canadian system. Patients are effectively “fired” from that system as well.

            Community-based and community-run healthcare staffed by people who care more about healing than profit is the only real solution.

          3. Lambert Strether

            I guess where people’s health is concerned I tend to go with proven, if flawed, solutions rather than ideas that sound really good but don’t have a lot of experience behind them at the national scale (although I notice you don’t provide any examples or evidence even at the local scale). Your mileage may vary, and apparently does.

            As far as austerity goes, the single payer systems have a long way to go before they become as bad as ours.

          4. lolcar

            It’s the “praire schoolhouse” model. No government. No corporate insurer. Just citizens banding together to hire their own doctor. Good solid plan for a North Dakota frontier town circa 1873.

          5. Goin' South

            It seems to me that those who are stuck on Medicare-for-all are the dreamers. This political system will never enact it. Instead, the direction is toward privatizing what Single Payer systems that exist.

            Small community-based coops are more likely to become reality. Bernie Sanders’ community health centers were a step in that direction, but hasn’t a lot of its funding been eliminated?

            Again, without doctors taking some responsibility for offering an alternative to medicine-for-profit, very little will change.

          6. Goin' South

            Not “prairie schoolhouse,” but REA electrical, phone and water coops. Worked pretty well in my experience.

          7. Lambert Strether

            “[T]he Rural Electrification Administration (REA) [was] one of the New Deal agencies created under President Franklin Delano Roosevelt. The REA was created on May 11, 1935, with the primary goal of promoting rural electrification. In the 1930s, the U.S. lagged significantly behind Europe in providing electricity to rural areas due to the unwillingness of power companies to serve farmsteads.”

            Sounds a lot like single payer for public utilities.

            Or is the argument that people with electrical meters banded together to form it?

          8. lolcar

            Small community-based coops are more likely to become reality.

            You mean like this :-

            DakotabornKansan says:
            May 13, 2013 at 10:05 am

            The rich already know that this change is occurring.

            Witness the spread of concierge medicine, where patients pay a fixed fee to their physician in return for specialized attention and round-the-clock service.

            My internist converted to a concierge medical practice several years ago. He limited his practice to 600 patients. Those unable to afford his $1,800-a-year retainer had to find another provider.

            Is concierge medicine (boutique or VIP medicine) the Anti-Obamacare?

            I wonder what kind of doctor and what standard of care a community-based co-op in a run-down post-industrial suburb of Cleveland could expect.

          9. Nathanael

            Lolcar: watch for change on the Mexican border. Compared to the non-system in the US, it’s becoming extremely attractive to cross the Mexican border to see competent, cheap doctors.

          10. Nathanael

            Goin’ South: there is quite literally no decent alternative ever identified to having a government. (There is one indecent alternative, which is constant war.) It certainly doesn’t need to be THIS state, but even co-ops have governments.

            The state is not optional. Corporations aren’t optional either (you can’t stop people from organizing them), but the current mega-corporations are optional, and the extremely corrupt “governance” structure for them is something we certainly don’t need.

            It’s not so much a question of “the State” or “Corporations” as it is a question of *how things are run*. There’s nothing wrong with either “the State” or “Corporations” which total governance reform couldn’t fix.

          11. Goin' South

            Initially misplaced my response to Lambert’s REA comment—

            The coops were locally organized, Lambert. The Feds didn’t organize a thing. Locals had to create the coops, then apply for the Fed loan money. They continued to run things afterward.

            Where I grew up, the electric coops were New Deal era, but a water coop funded by Fed loans was organized within my memory. Local citizens, who lived out in the country and depended on cystern water like my family, got together and organized a coop, applied for fed loan money and put in the system. The coop met annually, elected a board of local citizens and ran the coop.

            We’re really not so incapable of running our own affairs.

        2. Ray Phenicie

          Show me how a single payer system would work to address our broken health care system. I’d like the major issues addressed at the link below to be discussed in your analysis.
          http://www.nap.edu/html/quality_chasm/reportbrief.pdf
          this is a brief summary of the full report done by the Institute of Medicine.
          The full report is here
          http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx
          From the summary:
          ” if the system cannot consistently deliver today’s science and technology, it is even less prepared to respond to the extraordinary advances that surely will emerge during the coming decades. . . .
          There is a dearth of clinical programs with the multidisciplinary infrastructure required to provide the full complement of services needed by people with common chronic conditions . . .
          The health care delivery system also is poorly organized to meet the challenges at hand. The delivery of care often is overly complex and uncoordinated, requiring steps and patient “handoffs” that slow down care and decrease rather than improve safety.”

          Your suggestion for a single payer would not address quality issues that are discussed in the article above. Just to play devil’s advocate, what if the pediatrician’s manager was correct in that she was taking the wrong course of action? Do we know necessarily that physicians are always correct? I can inform you from painful experience that we do not. There are various skill sets need to be a successful physician and if a particular physician is not following best practices in that field, then what?
          How would a single payer system address the huge discrepencies that exist in qaulity of physician training? Just throwing billions and billions at the problem does not improve the quality of care.

          1. Lambert Strether

            The two issues are orthogonal; because the present health care system is far from perfect is no reason to deny health care for all as a matter of right.

            That said, by not implementing single payer, we’re leaving $400 billion a year of savings on the table; if there’s any money being thrown, it’s by for-profit rentiers who are looting the system. So take that $400 billion and use some of it for quality improvement instead of a vast medical insurance bureaucracy hell bent on profiting by denying care?

    2. Heron

      That’s basically how it works in Germany, though along with the public insurer there’s a treatment price-list that limits physician income to “only” being upper-middle class. A nice house, a comfrortable life, weekends at the golf club, but sadly no 2nd Ferrari.

    3. Dr Duh

      @mmckinl

      “What they, the providers, don’t like is that their ability to gouge, escape best practice and push ineffective even dangerous drugs would be severely curtailed.”

      spoken like someone who’s never walked an inch in my shoes. But hey, it’s a semi-free country, patronize your local crystal healer if you like.

      I very reluctantly supported Obama-care, inspite of the obvious implication for my pocketbook, on the basis of expanding access to care. Instead, it is turning into yet another looting opportunity. More strong work from The-More-Effective-of-Two-Evils(tm)

      Unfortunately, physician autonomy stands in the way of the looting, hence logic dictates it must be destroyed. Disgracefully, our professional societies have been coopted into helping lay the groundwork.

      The Shock Doctrine will be applied to medicine. We will end up with a true two tiered system. Where the proles get shuffled in and out of busy government funded (if not run) clinics, attended to by ‘midlevels’ whose limited education and training makes them dependent on cookbook medicine, while the rich get concierge medicine where the finest doctors are at their beck and call.

  3. sd

    It has become distressingly common for HMOs and other medical enterprises to have business-school trained managers putting factory-style production parameters on doctor visits. Outside of foreclosure mills, it’s hard to find similar approaches in other professions.

    Rest assured, the MBA has infected every industry. Case in point, movie studios in Hollywood tearing down sound stages to build offices for finance departments.

    1. Heron

      MBAs really are like a virus. They tend to preference other business grads over people who actually understand what your business does for management positions, so once you hire one, it’s only a matter of time until a flock of those useless leeches invests your office, eating up resources with too-high salaries and producing with it an endless supply of bullshit memos.

    2. sierra7

      Cute! Real cute!!
      Too many businesses in the runup to 2008 financial crash had established, “financial centers” within their establishments, and had gotten very excited at the “profits” they accumulated, sometimes exceeding those of manufacturing (a) their product(s).
      And, we all know how that played out in ’08’09, and is still crippling the thinking about how to make money without bringing Armageddon to the whole global system.

      1. Newtownian

        I’m surprised they decided they made a mistake. I stumbled on a presentation recently by one of these plague rats commenting on R&D Downunder. His position was that all local R&D should be shut down because you can just buy in what you want when you need it more cost effectively. This China/Walmart approach to managing advanced economies is on the move sadly and there is no end in sight as these barbarians aren’t just at the gate, they control seat allocation and voting privileges at all the round tables even where they haven’t been crowned king.

    3. Hayek's Heelbiter

      Besides MBAs now in charge of making movies (notice recently that the new film in the multiplex seems to be exactly the same one that was there three months ago only with a different title), a few years ago, an MBA at a large multinational with which I am familiar went down his/her spreadsheet and noticed a facility that was costing the firm a tremendous amount of money but generating no revenue. Naturally, the company shut the facility down, thus saving themselvs said tremendous amount of money. Several months later, someone else (another MBA?) noticed that they had closed the research facility that had developed all their cash cow products. They tried to lasso back their scientists, but most of them had decamped. Nevertheless, I’m sure the MBAs still received enormous bonuses for their prudent fiscal management.

    4. Newtownian

      I totally agree and was puzzled by this assertion that you only find the managerial shonks in finance??!!! Management KPIs now infest every walk of life even beyond the corporate.

      Its rampant in universities and anyone visiting a multipartner legal practice needs to watch the clock because they charge you by the 5 min increment. Of course if they want something from you its bad faith all the way and a day’s work just to ring an hours fee on your behalf for expert services.

      The worst of it is now even school students are expected to develop ‘vision statements’ while school arts show travelling performers who are late to prekindergarten entertainment get castigated because they aren’t fitting into the crèche’s preset corporatized tasks for the day.

  4. kimsarah

    Time to say enough is enough
    Some things shouldn’t be privatized or corporatized, such as medicine, health care, education, police protection and prison operations, environmental protection and transportation. These are basic human and civil rights in a so-called advanced society such as ours, and what our taxes pay for.
    Health, safety and general welfare should not be for sale to the highest bidder. Yet, that’s what’s happening with schools, prisons, oil and gas pipelines, and hospitals.
    Our government is doing Wall Street’s bidding to supply its addiction to keep its worldwide ponzi game going.
    It’s time for intervention.
    Revolving-door politicians who do bidding for banksters rather than us must be called out and removed from office. There are enough of them that at least one in every state could be brought up for a recall by voters. It would boost voter turnout. Although the results may be similar to Scotty Walker in Wisconsin where big money pushed back, it would show the corrupt establishment that enough is enough.
    It would show Washington and Wall Street that their lying bullshit doesn’t work anymore.
    And that unlike today, there will be consequences.

  5. Bill

    bhikshuni -

    Thats the way it used to be ( And with teachers as well )
    The community hired and fired . Not a bureaucrat . Communities got lazy , communities got bigger . So we have the mess we live ( and die) with today . Don’t expect it to change . Live as healthy as you are able . Drop out of the system as best you can . I have a statin pushing doctor . His only answer is always another perscription for whatever. Statins cause me great joint discomfort . I quit taking them . My next question for the Doc is if he is getting gigged for my LDL not being where Ins. robbers demand it to be . Just another scam on the American people . Where is our liberator?

    1. LucyLulu

      Bill (and others),
      If the statins make your joints hurt, then tell your doctor and that you understand the risks of high cholesterol, and are choosing not to take any statins. He/she should understand that, and as long as knows you are making an informed choice, respect your decision. I haven’t always agreed with my physicians’ treatment plan and its never been a problem. They must inform you of what they consider to be any risks to your decision (because if they don’t, some people will sue if their arteries become clogged, and because it’s good practice anyways) but that’s all. He/she will likely explore other treatments as well, e.g. diet, if that hasn’t already been done.

      The cure should never be worse than the disease, and you ultimately decide which one is worse. You always have the right to refuse treatment. (Assuming you are adult, not suicidal or homicidal, and haven’t been ruled incompetent by court. Though if you leave the hospital AMA, your insurer will likely refuse to cover the bill.)

      1. aletheia33

        thank you, ll. i have been wondering about how to decline practitioners’ recommendations. controversy is growing over the standard approach to lowering heart disease risk. weston price claim we need the enzymes in animal fats. “healthy” soy products are so highly processed as to be nutritionally worthless or even bad for you. one usually has to educate one’s m.d.; specialists seem to be the worst, they live cookie cutter and do not seem capable of independent thought.

        i’m a complicated patient, paid OOP for many years, sought out alternative practitioners who helped my case when m.d.s had given up. every single other complicated patient i know has affirmed strongly to me that it is they, not any doctor, who have figured out their own diagnoses and what they have needed to do to get well or maintain best possible level of well-being. they say “WE have to educate THEM.”

        can anyone provide links to current research challenging the entrenched assumption that cholesterol numbers reliably indicate heart disease risk? an unconventionally minded m.d. i consulted told me it’s just not clear at this point whether this assumption is true or not, and as far as he can tell, the affirmation of it is mostly about selling drugs.

        1. Gregory Plotnikoff, MD

          Yes, check out “The Cholesterol Myth” by cardiologist Stephen Sinatra, MD.

          Also, for those who are concerned about their cholesterol numbers, check out the National Institutes of Health (NIH) risk calculator which can be found at:

          http://hp2010.nhlbihin.net/atpiii/calculator.asp

          The most important number is the reduction in absolute risk. For a huge number of people on statins, their absolute risk reduction over ten years is quite small. For many women, the Numbers Needed to Treat (NNT) over ten years to prevent one cardiac event can be in the hundreds.

          Given the known side effects of statins include diabetes and cognitive decline, the $20 for Dr. Sinatra’s book represents a huge ROI.

        2. Joe Rebholz

          Check out the Life Extension Foundation. They list 12 or more factors corelated to heart desease and they describe many supplements to counter these factors.

        3. Nathanael

          There is definite evidence that blood cholesterol numbers are linked to heart disease risk *in a very particular way*.

          Namely, if your LDL is very high, and your HDL is very low, you have an elevated risk of heart disease. The mechanism for this is understood: LDL deposits on the arteries.

          This is complicated by the fact that some people seem to have high naturally circulating levels, which may be harmless. If your LDL is rising sharply, due to diet, however, you definitely have a problem.

          The only thing which has a clear dietary link to really high LDL is eating lots and lots of saturated fat. So, I knew a guy who had sky-high LDL and had multiple heart attacks. His idea of food was lots of fatty beef and no vegetables. Yes, his cholesterol numbers indicated a problem.

          The trouble is that everyone has gone hog-wild and generalized far too much based on this collection of evidence. Most people don’t need statins and shouldn’t have ‘em, as the nice doctor above pointed out.

          If you have elevated LDL, reduce your saturated fat intake and make sure you’re eating a balanced diet. That’s the major conclusion of the “cholesterol” studies.

          1. Ms G

            What about sugar — that is supposed to give you high “bad” cholesterol too, right?

            P.S. Make sure you fast before going in for the blood screens for LDL, HDL, Tryglycerides, etc. Sounds silly, right? I wasn’t told to fast so my results were worthless. A friend of mine specifically asked 2 days before the tests if he should fast and the medical office person said “no.” True stories.

          2. Lidia

            In terms of sugar, my DH got diagnosed w/Type II diabetes. We dutifully went out and bought the glucose meter and $trip$. Turns out that the results can vary ±20%. What’s the point of obsessing about these numbers when we can’t even ascertain what they are to a useful degree?

          3. Nathanael

            “What about sugar — that is supposed to give you high “bad” cholesterol too, right?”

            Not established either way. Eat way too much sugar and you will get type II diabetes, though.

            Correct about fasting blood work. I’m astounded that someone who gave *bad information* regarding what blood work needed to be done fasting still has a medical license. That’s something doctors usually get right.

        4. LucyLulu

          I’ll add that when new studies come out that I think my doc might be interested in reading, I’ll either print them and bring them to my appt or fax them to his office with a note. That way if he hasn’t already seen them, he can read/skim them at his leisure, throw them out, whatever, or if needed, read them before our next appt. For over 20 years I got almost daily severe migraines and had a neuro who was willing to try the latest treatments being studied as I had tried every conventional and alternative treatment known to mankind with no relief. I would send him the articles backing up the latest options before my next appt. so we could talk about them as he was not a headache specialist. He told me didn’t even like treating headache patients, (though I was the exception, of course ;) ) but was actually quite good, and well-respected by the h/a specialist I occasionally saw at the closest very large medical center two hours away in Cincinnati.

          BTW, it was interesting indeed that after trying countless remedies, my migraines all but vanished the day my ex moved out. Go figure. If only I hadn’t hung on so long…… :D

  6. geof gray

    Medical Arms Race. I recently had a sinus procedure. Had to see the doc 4 or 5 times before the surgery. Each time–only days or week apart– they did a height, weight, blood presure, temp–these are items that make up the items in the Evaluation and Management Reimbursement Codes. Higher codes, which involve more Systems reviewed, pay higher amounts. It was pure make work, pure feather bedding to garner the higher reimburement. The cat and mouse game pits the medical corps against the payers–mindless procedures get justified. In the US many unnecessary procedures are routine carried out that in other countries are not never done, e.g. circumcision. Behind it all–maximizing reimbursement, not patient well being.

    1. LucyLulu

      My sister just had surgery and went to Duke, wanting the best surgeon in the land to perform her surgery. The afternoon of surgery she still hadn’t urinated which is not uncommon, anesthesia and catheterization sometimes make it initially difficult, though she said she didn’t feel full. They did an ultrasound to measure the volume of urine in her bladder. Apparently this must be the latest and best technology for assessing whether temporary catheterization is needed. Traditionally the nurse would palpate the lower abdomen for distention. Me thinks its ridiculous, an opportunity to pad the bill as the traditional nursing assessment isn’t a billable item. Perhaps the rationale is that nurses might occas. miss distention, esp. in obese patients. However my sister’s surgery was to correct increasing pain and vomiting after meals (90% pyloric obstruction 2* PUD – no malignancy, phew! Her docs had told her she surely had cancer, totally freaked her out, justifiably so, stomach cancer has terrible prognosis, and which I took issue with, but apparently she is okay with it all, thinks her original local doc who said he was optimistic that the problem was benign, didn’t look like cancer, did a biopsy which was negative, is the “bad” doc…….. go figure. But I digress.) which had caused a 30 pound weight loss on top of a baseline low BMI, so distention would be rather challenging to miss.

  7. Mark E. Smith (@fubarista)

    Properly prescribed pharmaceutical medications, prescribed by qualified physicians and taken exactly as prescribed, are one of the leading causes of death in the US. If fewer people have access to doctors, US life expectancy might rise to the level of less developed countries.

    Truly effective remedies are often a thousand times cheaper than harmful pharmaceuticals. Research on herbs, spices, and other natural cures can be done online for free. What I usually do is enter my symptom plus the words “natural cures” into a search engine, and look for sites where people talk about what worked for them. Most natural remedies have no side effects and are perfectly safe, which can’t be said for most pharmaceutical drugs.

    1. LucyLulu

      I respectfully say, “baloney”. “Natural” remedies are not necessarily ANY safer because they are natural. Heroin, cocaine, tobacco, morphine, curare, belladonna, scopolamine, quinine, digitalis, botox, ergotamine, and capsaicin are all examples of “natural” products which can have legitimate uses in medicine (maybe not heroin, though it does relieve pain, and AFAIK, not tobacco) but most definitely have a risk profile, including death at therapeutic doses or close to them for some. There are many more natural substances that have no use in traditional medicine that are outright toxic if ingested (hemlock for one).

      Furthermore “natural” remedies that are commercially sold have no monitoring for quality control. For example, a study was done of popular arthritis remedies that measured the actual quantity present vs stated quantity of “natural joint lubricants”. They found quantities that ranged from a very small percentage up to 110%, depending on the brand. These companies can make any claims they like. And some pharmaceutical products are exceedingly safe. It all depends on the individual product.

      I’m not saying that natural remedies are not sometimes useful. I believe they are. I’m only saying that their use warrants the same level of prudence. A drug is a drug, whether it is natural or synthetic in origin, and if the drug has an effect on the body, it most likely carries at least some level of risk.

      1. Nathanael

        “A drug is a drug, whether it is natural or synthetic in origin, and if the drug has an effect on the body, it most likely carries at least some level of risk.”

        Sure is.

        The problem at the moment is that in the “natural” realm, we have uncontrolled dosage and content, and in the “unnatural” realm, we have drugs promoted based on how profitable they are.

        Do enough research on the Internet and you can figure out what possible things you might want to try taking, very carefully. I found that vitamins are one of the most overlooked things out there. Vitamin deficiencies are very common in the US, and frequently unrecognized by doctors, because the standard RDAs and blood test levels are way too low for a lot of them.

        (This is relatively new research, the last few decades. The level of vitamin C needed to prevent scurvy, which is what defined the RDA, is not the optimal level — and similar things seem to be true for a bunch of other vitamins and minerals. Vitamin D, for instance, has a function in the immune system as well as in the bones, and if you only get the RDA — perhaps you never go out in the sun — your bones will be fine but your immune system won’t. You can overdose on a lot of vitamins, of course, so you have to research that too.)

    2. LucyLulu


      Mark Smith wrote: “Properly prescribed pharmaceutical medications, prescribed by qualified physicians and taken exactly as prescribed, are one of the leading causes of death in the US.”

      Source ?????

  8. DakotabornKansan

    Former pharmaceutical company executive new CEO of the American College of Cardiology:

    http://www.forbes.com/sites/larryhusten/2013/04/22/actelion-executive-to-head-american-college-of-cardiology/

    “Since when does a pharmaceutical executive become CEO of the American College of Cardiology (ACC)?” asks a board certified internist, cardiologist, and cardiac electrophysiologist.

    http://drwes.blogspot.com/2013/04/the-american-college-of-cardiology-gets.html

    “Seriously, what could possibly go wrong?”

    http://marilynmann.wordpress.com/2013/04/28/should-a-former-drug-company-executive-be-ceo-of-the-american-college-of-cardiology/

  9. Skeptic

    Short report from Canada.

    I am elderly and now use the public healthcare system more frequently than I used to do. Here also, you do get the cookie cutter atttitude, that is, if you do not fit the mold or ask too many questions, they do not want to deal with you.

    I had a slight heart attack two years back. I received good care generally. They did an angiogram but I refused stenting. The evidence on the huge angioplasty, stenting industry is that it does not work unless done quickly and the circumstances warrant it. That was not my case and I had lots of very proven and respectable research to prove it. I had to vigorously fight off the efforts to stent me.

    When I was discharged from the hospital there were negative comments from staff about my stent refusal and the discharging doctor was quite abrupt and dismissive. I was not given any followup referral to a cardiologist.

    So, having been semi-dumped outside the system, what to do? Fortunately, in this region, we had a highly respected MD who also practices integrative medicine, in other words, he does what works without prejudice. You even get to participate in decison making. I went to this doctor and have been doing so ever since. He is a godsend and very approachable and intellectually curious. I have to pay myself for most of his time with a small amount being paid by the public system.

    A lot of people think healthcare in Canada is free. It ain’t. First of all, you pay for it through your taxes. Secondly, it may not be of good quality and much of it is pharmaceutically based and also controlled by major corporations and business interests. For example, the angioplasty/stenting/cardio surgery interests run the heart disease industry here. Alternative treatments recommended by such eminent doctors as Pauling, Ornish, Esselstyn, Diehl, MacDougall, etc. are not offered.

    In the Financial World, you can only lose your money. In the Healthcare World, you can unnecessarily lose you life. It calls for double due diligence. Fortunately, my integrative doctor would agree totally with that statement.

      1. Jim Haygood

        Ditto. When customer discretion is taken out of the equation, the client is nothing but raw material to be ‘processed’ by the industry as it sees fit.

        I wasn’t born to be no field han’ on O’Bammey’s plantation.

        1. Goin' South

          They’re “patients,” not “customers.” Getting medical care, other than cosmetic surgery, is not like buying an iPad.

          Capitalism fundamentally disrupts the doctor/patient relationship. The crazy American system, with these MBAs and insurance bean counters interposing themselves along with the drug peddlers, maximizes the misery along with the profit.

          Primary care needs to be community-based, organized as a coop, and run by a combination of the workers and the community that’s served. People who want to own three houses while playing 18 holes every afternoon need to find another profession other than healing.

          1. AbyNormal

            Goin’South…your slammin! (prime ex why i read nc daily)

            Behind this mask there is more than just flesh. Beneath this mask there is an idea… and ideas are bulletproof.
            v for vendetta

            1. Lambert Strether

              So fund them with single payer, eh? Works for the REA….

              UPDATE AbyNormal… I looked at that PDF. It’s about “Community Health Centers” and if the word “co-operative” appears in it, I can’t find it. So we’re still looking at a paucity of relevant examples. Except for the statist REA example, helpfully supplied by Goin’ South.

          2. AbyNormal

            before i fall down a wormhole i can’t come out of…MT uses this service http://communitysharesusa.org/ which seems to deviate from the spirit of community coop (or im miss reading)

            i want to understand the ins/outs…i don’t trust corps not to ease into this w/tax write-off etc

          3. Goin' South

            Re: Lambert’s comment re: REA—

            Actually, that’s exactly what happened. The Feds provided loan monies (or guarantees?), but the coops were locally run and organized. Where I grew up, the electric ones were organized well before I was born, but one to provide water was organized in the 60s. No Fed organized it; local citizens did. The Feds just helped provide the original capital to build the system, done as a loan, with perhaps a partial grant included. The local coop then charged its members enough to amortize the loan and provide for upkeep and operating costs.

          4. Paul Tioxon

            Robert Caro explains how he understood what made LBJ who he was and why the people of the Texas Hill Country loved him and FDR, because he brought them electricity. If you want to have any idea of what it was like for Americans in rural poverty, in mind numbing isolation, in the total dark at night, in soundless night without radio, in the far removed distance of ranches, in the sickening, back breaking work of hauling water for laundry and hauling wet laundry and the young women who saw in the broken bodies of their mothers, by the age of 40, their exact fate. You need to hear this history. Rural Electrification Coops did and still bring light into the darkness, and communication from the outside world and keep the health wrecking labor of simple, personal hygiene, such as clean clothes, from becoming a death sentence.

            http://www.youtube.com/watch?v=YLEe5DB-vbY

            https://www.nrucfc.coop/

            The above link should be required for all the dreamers, the complainers and others just seeking a ray of hope to cope. Billions are spent to keep the electricity running in the remote areas of this vast continent. The grid is own and operated by and for the member co-operatives.

      2. John

        Really? Like millions of us have a choice here.

        Paying outragous monthly premiums and can’t afford to go to the doctors because of the deductiables.

        It’s nothing but extortion money. It most certainly doesn’t equal choice or health care.

      3. lolcar

        This has nothing to do with single-payer per se. There is no conceivable medical funding regime that could prevent surgeons cheerleading for surgical interventions, or a significant proportion of doctors taking a “What do you know, I’m the doctor here” attitude to patients who refuse their advice. The funding question and the medical culture question are two separate things.

        1. JEHR

          As far as the Skeptic’s report goes, I would say that your choice of doctor rather than the single payer system has more to do with deficiences in the Canadian system. There is a shortage of doctors in the smaller, poorer provinces and our premier is trying to reduce payments to doctors to save money and they are reacting very angrily at that proposed measure.

          I hoped that I would die before my doctor retired but, unfortunately, she retired before I died which became unfortunate for me as the new doctor is too young, too hyper and too interested in maximizing her control. It’s hard for us older patients to “train” a new doctor so late in life!

      4. Nathanael

        Goin’ South: the Canadian’s comment PROVES that single-payer is the solution.

        Yes, it’s a two-tiered system. The single-payer system provides a baseline, guaranteeing that you won’t be bankrupted by fraudulent medical bills and dealing with the majority of cases. Then, when you need additional care, you pay cash to a different doctor who actually posts his prices, without dealing with the insurance companies.

        Something similar happens in Britain. I’d be extremely happy with either the British or Canadian system. Here, it is hard even to find doctors who take cash…

    1. Lambert Strether

      In the aggregate, Canadian health care outcomes are far better than ours. So are costs. That is true for us vis a vis every other single payer system (heck, every other system in the “industrial” world). Adding… If you want to talk policy, and if the numbers really are available, that’s what you look at.

      That said, the neo-liberal virus is infecting everything.

      If there’s a more cooperative “Farmer’s Market” version of health care anywhere in Canada, that might be better. Single payer, as a back end system, should certainly pay for it — exactly, to carry the metaphor through, as SNAP money goes to organic farmers through Farmer’s Markets.

    2. LAS

      I have seen this in US hospitals in New York City. Older patients are sometimes treated by medical staff as if they were nuts for refusing treatment, when actually they’re making a wise decision. Treatments and procedures are not cures and it is perfectly rational to refuse them. Particularly as procedures compound, risks compound. But doctors at big hospitals have drunk the koolaid and are largely glorified, posing sales persons and they hardly even know it. Some patients who have been around the block – they know it.

      1. JerseyJeffersonian

        The behavior you are seeing in the form of scorn heaped upon those who are leery about receiving complex, often invasive surgical interventions and procedures may also be driven by what KIND of medical institution they find themselves in. If it is a TEACHING hospital, the young doctors don’t learn the procedures and interventions by NOT DOING THEM. They may have a vested interest in pushing them on their patients. Not a pecuniary interest perhaps, yet a very real one, nonetheless.

        Yet, the patient may be capable of assessing the degree of potential “harm” associated with the procedure (remember that Hippocratic Oath? Is it now just another “goddamned piece of paper” like the Constitution?) They may be considering the loss in quality of life potentially associated with the procedure. Don’t they have the perfect right to assess the cost/benefit ratio themselves? If the patient is not non mens compos, they certainly do, as one has the right to refuse medical treatment.

    3. LyleJames

      I have lived under both the American and the Canadian health care systems. I live in the U.S. now but continue to see how Canada’s single-payer system works by observing the care my 93-year-old mother-in-law receives. The contrast is ridiculous. The care I and my mother-in-law have received was at least as good as I esperience in the U.S. — without the absurd amount of paperwork, without the absurd cost of drugs, most of all, without the nightmarish possibility of bankruptcy hanging over your head should you the unlucky enough to become really sick. No one in the American system can understand the peace-of-mind citizens experience when they have a government that believes ensuring a citizen’s health is a moral oblgiation.

      1. Ms G

        The piece of mind is huge. I’ve now witnesses the effect of the artificial stresses caused by the costs, bureaucracy, unexpected “surprises”, and so on, on my elderly parents and friends’ elderly parents, who are already frail and vulnerable. It is not a metaphor to say that our “system” is really, really bad for people’s health, and for the elderly in particular. (And mind you, I’m referring to men and women who were already on Medicare.)

        It is an unconsionable disgrace, what we have.

        It is also true that all sorts of off-the-radar things are being done at CMS to reduce Medicare — slashing reimbursement costs, re-jiggering CPT codes (with the helpful assistance of the American Medical Association and their “RUV” committee).

        If we succeed in getting a Congressional win for Single Payer through Medicare for All, there will be a lot of work ahead to undo the undoings that have been going on at the Medicare level. (Think the obscure regulatory actions taken by Fed, Treasury, SEC, OCC, et al. in re the separation of commercial and investment banks that had turned Glass Steagall into swiss cheese by the time the Rubin-Clinton-Weil public coup de grace was administered).

    4. McKillop

      My own experience with doctors and the system in Ontario differs.
      I have a few health ‘deficiencies’ that have been helped by several doctors -specialists all but for the main g.p. Because my income is low, I’ve paid no money for the care and those who do pay, I think, have a cap of $900.00 per year in Ontario. As well, after paying $100.00 per year, many of my prescribed drugs are paid for as I’m over 65 years old. These drugs include expensive ‘biologics’ that cost $2,000.00 per month.
      My doctors, an internist who treats my rheumatoid arthritis, an opthalmologist for both cataracts and macular degeneration, a dermatologist and , infrequently, an orthopaedic surgeon and anesthetist, have all provided stellar treatment, including referrals to others to confirm their diagnoses.
      My only complaint, aside from general complaints boring innocents who still inquire about my health, is that my g.p., having conducted numerous digital examinations of my prostrate, has neither asked me out to dinner nor called me the next morning (although silence might be preferable, yeh?).
      From what I’ve heard from people in the United States I consider myself blessed that my orthopaedic surgeon performs 400+ surgeries per year, that my opthalmologist is both ambidextrous and expert, as well as modest, -despite high praise given by other doctors- and that all have both patience and a sense of humour in response to my questions.
      People complain that the internist’s appointments are _always_ late but he has never rushed me through an app’t. and, when I go home at 6:00, after waiting to get to my 3:00 o’clock app’t., he still has a patient or two to examine before he gets to leave.
      Many of the problems of healthcare delivery in Ontario, I think, comes from the denigration single-payer gets from the U.S.A. and it’s ideology. Not to mention people whining because they are charged for hospital parking and other costs that infringe on their ability to buy a coffee and do-
      nut at Timmies.

      P.S. Once, the internist’s patients were kept waiting because another patient had been so inconsiderate as to die during the visit. When I consider how much I cost the system -ahh, let’s not go there!

  10. Larry Mulcahy

    I think this is why physcians are joining into ever larger private practices. My orthepedic surgeon was part of a huge group in suburban Boston that was basically a minature hospital. The only thing they lacked were operating rooms. This group of an unknown amount of doctors then has a large number of patients to negotiate payments with insurers and in fact got into a major kerfuffle with Blue Cross over rates. The physicians dropped Blue Cross and within a month Blue Cross met their demands. At the same time, I see what this article is talking about with Steward Health Care. A private equity venture that took over several faltering Catholic hospitals in New England and is trying to micromanage physisians to the tee, including real time video monitoring of their practice of medicine with criticism and feed back. It seems that if physicians and the AMA wake up to this, they’ll be able to beat it back, but I’m not sure they’re very aware of it.

  11. clarence swinney

    BUDGET BRIEFER
    2014 BUDGET
    EXPENDITURES-(3777 Billion)
    Social Security-Unemployment-Labor-33%
    Medicare-Health Care—25%
    Military—17%
    Interest 5%
    Vet Benefits-4%
    Transportation—4%
    Food-Agriculture—4%
    Housing-2%
    Education- 2%
    Energy % Environment-1%
    International Affairs-1%
    Service-1%
    Government 1%

    REVENUE—(3033 Billlion)
    Individual Income Tax-46%
    Payroll Tax—34%
    Corporate—11%
    Misc 5%
    Excise—3%
    Custom duties—1%

    Deficit-744 Billion—(2008 Budget last one under 1000B Deficit)
    Recall fuss over Bush not budgeting two wars? 20143 Budget does not include Afghan War funding
    Why cannot we pay our way with a 14,000B Income and 3777 outlays? Simple. Most of Income is at top and they have power ($$$$) to control Congress. Yes! They pay Most but lesser part (%) of income.
    Source:OMB.GOV

    1. sierra7

      Funny, but I don’t see any lines denoting, “Killing People Unnecessarily Around the World for Their Natural Resources”, or, “Black Budgets”, etc., etc.,……..

      That’s what’s killing our tax paying money….(and the corrupt politicians that administer those monies!)

    2. Nathanael

      Clarence — that is an extremely misleading set of numbers because the Iraq and Afghan wars are “off budget”. So raise that military number from 17% to more like 34%….

  12. DakotabornKansan

    The rich already know that this change is occurring.

    Witness the spread of concierge medicine, where patients pay a fixed fee to their physician in return for specialized attention and round-the-clock service.

    My internist converted to a concierge medical practice several years ago. He limited his practice to 600 patients. Those unable to afford his $1,800-a-year retainer had to find another provider.

    Is concierge medicine (boutique or VIP medicine) the Anti-Obamacare?

  13. petridish

    What’s really impressive (and not in a good way) is that articles like this need to be written at all, let alone taken seriously. Sorry, Yves, but it must be said.

    What part of FOR PROFIT do Americans not understand? How anyone in this country can still believe that the medical care system is about keeping people healthy is a mystery.

    The only reason “patients” (customers, actually) are involved at all is that the medical profiteers haven’t yet figured out how to bypass them and go straight to the profit. But it looks as if they’re getting a handle on that one.

    Obamacare forces you to pay into the system and you will be summarily dismissed from said system if you dare to step off the conveyor belt. Of course, you will continue to be required to pay the man anyway.

    Will everyone please wake the bleep up? Once they have outlived their profit usefulness, throw-away people will be thrown away. That is the way the system was designed to work.

  14. gozounlimited

    Corporate control of the weather has eluded you and corporate control of medicine has just dawned on you? A little sloooooooow………

  15. LAS

    My only beef with this essay is that it is not a question of “will happen”, but it already has happened.

  16. Duncan Hare

    You are desribing to some extent General Practice in the UK. General Practitoners (Primary Care Doctors) are paid a fixed amount for every patient on their list.

    It works well. Better than the “fee for service” proactice in the US. The outcome in the UK are better than the US.

    The alternative of “billable hours” is a dreadful system. Check you legal bills, the accounting overhead is huge.

    1. Yves Smith Post author

      I think you might be misreading the post.

      The reason for the desire of corporatized practices to prefer healthy and largely compliant patients is:

      1. They won’t waste doctor time arguing

      2. It is assumed they will get better if they follow orders, which is an assumption that breaks down if you have people who have complicated conditions (and frankly I think breaks down even with simple stuff. Notice the “taking mammograms and stains” on the Good Patient list. I’ve ranted about what a crap test mammograms before but why they continue to be used [big installed base of equipment at radiologists + lots of false positives, when the med system likes overtreatment. But they don’t tell you is they are bad at identifying the fast-moving cancers that will kill you. And you can see the objections to statins and the more general issue that cholesterol levels aren’t really that great as an indicator of heart disease risk.

      These practices anticipate increased participation based on outcomes, so they want to select a sample that will give them that

      3. The simple procedures focus apparently leads to the highest ratio of billable procedures per time spent. That’s not explicit but is clearly the assumption. May be due to the cost of fighting insurance companies over coding for multiple ailments in a single visit.

      In other words, there has been no retreat from fee for service medicine in the US except at the high end, in concierge practices.

      1. Nathanael

        The “healthy and compliant” patients will figure out *very* quickly (within a few years) that they’re wasting their money.

        After all, if they’re healthy, they don’t need doctors. And as soon as they get sick, the doctors suddenly turn out to be useless… and people DO talk to each other about useless doctors.

        This corporatized medicine scheme is terrible, but it’s also self-destructive.

  17. Andrea

    One of the problems with health care in the US (and other countries, like Switzerland) is that docs – but note not nurses, just to keep it simple, limited to those 2 categories – have the status of ‘independents’, and are paid according to patients seen / minutes spent, hours worked / medical actions undertaken / prescriptions made up / operations carried out, etc. that is various strange metrics and combinations of metrics that measure their activity.

    Naturally, the docs don’t set the rubrics themselves, so they are not ‘independents’ but caught up in highly complex systems that aim to control them, usually by insurance Cos (for profit) and by the State (ideally, and in many countries, against waste, for best practices, and like the insurance Cos. keeping doc income under control.) Reciprocally, what is charged to the patient and/or his insurance is perfectly arbitrary.

    In (roughly) single payer systems (there are no pure ones left), and in the ideal case, ‘prices’ – arbitrary also – are fixed through negotiation and are stable, that stability is important for all the actors, and the patient does not bear the brunt of ‘expensive’ visits/emergencies/procedures, as compared to the ‘lighter’ maladies, issues, prevention, etc. Docs are given somewhat more decisionary power and more leeway (e.g. doc who has 30 terminal cancer patients can prescribe x,y,z. Other doc cannot..) but only when the system is well in place and runs smoothly.

    (I’m aware that many docs in the world work for a fixed wage.)

    Imagine how plumbers would act if they could charge for 23.5% of their bill in function of the number of tools they used? Or if dealing with bathrooms afforded higher bills than dealing with kitchens? First off, their prices would rise immediately, as they would need at least a good video cam and a half-time secretary.

    Anyway, this is all terribly complicated, and I am not arguing here either for a more libertarian system, or for more state control, so called single payer or the like. It all depends on cultural matters, and the other systems around health care (e.g. taxes.) Although the argument for ‘docs on salary’ is implicit I guess.

  18. Doug Terpstra

    These private insurance racketeers, whose primary mission is to deny care to maximize profit are clearly the ultimate “death panels” — not the hollow specters that Sarah Palin inflated to scare us away from single-payer, Medicare-for-all.

    Of course we already have corporate control of medicine, but in an extortion racket to end all rackets, Obamacare now forces all Americans to buy from these death-panel profiteers — even while Obama simultaneously schemes to gut Medicare (and Social Security) as we know it. Again, this is not an innocent case of incompetence, inexperience, or ignorance; it is calculated, premeditated malice.

  19. Joel3000

    The vaccination obsession of the American healthcare system ( we vaccinate far more than any other country) makes more sense: it’s a predictable ticket item. They have so many kids in each age bracket and x% will get vaccinated, which brings in a predictable reimbursement. Ideally the vaccinations prevent more expensive, unpredictable treatments down the line.

    It’s good for the docs and insurance cos, but how many shots is too many?

    We don’t know – there are no funds to research that question.

  20. clarence swinney

    PRESIDENT PROPOSALS
    Reduce deficits by over $4 Trillion over ten years by 2.25-to-1 ratio spend cuts to new taxes.
    $666 Billion over ten years for infrastructure repairs.
    Universal access to prekindergarten education funded by new taxes on tobacco
    Repeal automatic cuts by sequestration.
    Reduce agriculture subsidies for wealthy farm owners
    Stop individuals from receiving both unemployment and disability payments
    Raise Medicare premiums for wealthy retirees.
    Negotiate lower drug prices for Medicare patients.
    Limit tax deductions and loopholes for the top 2 percent of income earners
    (how about Bush Tax Cuts?)
    Make permanent tax credits for low income earners via American Opportunity Tax Credit, Earned Income Tax Credit and Child Tax Credit.
    Proposes closing some corporate tax loopholes and lowering corporate tax rates.
    How about cutting Defense?
    How about Means Testing Social Security and Medicare. Why should my multi-millionaire pals get them?

    1. Nathanael

      Means-testing is a bad idea. For political reasons. If your multi-millionaire pals are the only people who don’t get Social Security, *they will put their political weight behind eliminating it*.

      No, what we need is public services which everyone can get, regardless of wealth — free at the point of use. That and progressive taxation.

  21. PQS

    HMMM….unaccountable Bidness Types telling everyone in the field what to do and how to do it and ignoring any protests or evidence of better ways to do it. Threats and retaliation for non-compliance. This sounds familiar…oh year, it’s what’s happening in our schools all day every day!

    This is not just a healthcare disease. It’s a corporate culture, bottom line disease.

  22. ChrisPacific

    The whole model of for-profit insurance based healthcare as the primary (in most cases only) care model for an advanced society is simply insane. One of the primary duties of society is to look after its most vulnerable citizens. The US health care model is a complete abdication of that responsibility.

    To give just one example, consider those poor women in Cleveland. I have been reading news articles discussing the difficulty of rehabilitation after an experience like that, and the need for extensive counselling and therapy programs. Who would pay for that under the US healthcare model? The women have been locked in basements and presumed dead for 10 years (through no fault of their own) so they certainly won’t have had any opportunity to buy insurance. Under what argument should we as a society not pay for their rehabilitation, if they have no means of doing so themselves? Any system that does not cover this scenario fails on grounds of basic human decency.

    1. LucyLulu

      Couldn’t agree more. It’s the seamier side of capitalism, the self-centered focus glorified by folks such as Ayn Rand. Learning how to share, give as well as receive, is a life-long lesson that should be instilled by the time one is in kindergarten. We’ve become a nation of “takers” and I’m not referring to recipients of public assistance, but those who don’t recognize their resources have resulted from having reaped the benefits of society, and are unwilling to pay it forward to those behind them.

  23. gillyrosh

    Re: the non-compliant, we really are in love with this notion of throwaway people aren’t we?

  24. anon y'mouse

    does anyone realize or care that the Worker’s Compensation system currently functions much like this? their goal is to limit costs and eventual liabilities, so they deliberately shunt you to doctors who will be complicit in all of the activities mentioned in this article: denying care (or even testing) that seems appropriate, stuffing pills in your gullet until you’re “feeling okay,” trying to get you into physical therapy before they even know what your condition is (which can exacerbate your as-yet-undiagnosed condition), constantly finding in favor of a diagnosis that limits the company’s payout, etc.

    all of this, while alternately forcing you to see a managing physician every month (the coordinator of all of this pro-medical-billing but anti-health mayhem) who doesn’t want to see you or answer your questions, merely wants to refer you to another specialist so he can “pass the buck” or claim he did his due diligence, won’t take seriously the reports of the specialists he did see, believes he knows what the problem is but won’t tell you, won’t go to bat with the insurance company even though he has mentioned “other tests” that could determine your condition (then won’t tell you what those tests are), isn’t worried that it has been 18 months and you still don’t know what you have (leading to the “you should’ve been able to go back to work by now” insinuations of psychological origin or malingering), and who participates with the insurance company against your interests while billing them for what passes for an ‘adequate enough’ job until they are ready for the expiration date on your case to go by.

    and you, as the patient, are trapped in all of this, and if you want to keep seeing the wage compensation checks (which are measly, and forced you to sign up on SNAP because of them going back over the previous -x- amount of time, and you work in an industry that has seasonally fluctuation, and naturally they chose the absolute lowest rate of pay during that time to compensate you with) you can’t walk way.

    initially, you had your own choice of doctor but the WC insurance company fought him so vehemently over every request for tests that he gave up in frustration and sent you on to one of their mandated (vetted for collusion) doctors. you can’t work, and yet ever other month the insurance company or your doctor (or both) are scheming to send you back to work even though you still don’t know what you have (result from on the job injury) or why it won’t go away, and the doctors will tell you nothing.

    all of the above was second-hand, but witnessed by me.

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