The Stealthy, Ugly Growth of Corporatized Medicine

Yves here. We’ve written a great deal about Obamacare, since it epitomizes so much about what is wrong with contemporary America: the use of complexity to mask looting, the creation of two-tier systems, the crapification of the underlying service, which in this case is vitally important to society as a whole.

But Obamacare also needs to be recognized as a big step forward in a process that was already well underway, which is to convert the practice of medicine from a patient-oriented to a profit-driven exercise. This is perverse because medicine is so highly valued that medical practitioners almost always enjoy high status and at least decent incomes in most societies. And in societies undergoing breakdown, being a doctor is about the safest place to be, provided you can manage to avoid becoming aligned with the wrong warring faction.

But what is going on in the US is a type of under-the-radar enclosure movement. Doctors historically have been small businessmen, either operating solo or in a group practice. But big corporations see their profits as another revenue opportunity, and have become increasingly adept at making it so hard for them to operate independently that becoming part of the corporatized medicine apparatus looks like the least bad of the available options.

We warned last year that 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.

Doctors are already being told of the Brave New World that is about to be visited on them. One account came from Whole Health Chicago. 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 here’s what you as patient should 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 how are doctors being forced into this horrible position? The big one, as the update below states, is cost pressures. I guarantee one big source is the cost of dealing with insurers, both government and corporate. One culprit is Medicare, but I strongly suspect you see similar patterns with private insurance.

As a mere patient, I always paid for medical services and submitted for reimbursement. My claims would be processed, and only occasionally would they be haircut because the insurer thought the charges exceeded “ordinary and customary” prices (your humble blogger would generally contest these and would prevail over half the time). But about 4-5 years ago, Cigna suddenly ratcheted up its tricks for not paying me, including simply not processing the claim at all and hoping I wouldn’t notice (this still happens to about 20% of my submissions). I began having my doctors submit for reimbursement when I was seeing an in-network doctor to escape the hassle.

I have to imagine that insurers are making doctors spend even more on claims processing, as well as squeezing them on their contracted reimbursement rates, both as profitable exercises in and of themselves and to push more doctors into practicing out of hospitals, which further fattens insurer bottom lines. And why am I so confident insurers are helping to drive this bus? Again, from the Whole Health Chicago post:

As a test run, the insurance industry, large hospital systems, and government jointly created a healthcare delivery system called Accountable Care Organizations (ACOs). They’ve tried it with certain Medicare patients, liked what they saw in terms of both savings and patient surveys, and now ACOs will be the health care of the future. To cobble together an ACO, hospital management (or a very large medical group such as Northwestern or Advocate), speaking for its salaried physicians, contractually agrees to provide all health care (primary care, specialty referrals, hospitalizations, etc) for a certain patient population–say Medicare recipients, employees of a particular company, or members of a union. For this, the hospital is paid a very large sum annually from which to fund the health care of their enrollees.

And now we present more on how this grand scheme works in practice.

By JB McMunn, M.D.. Cross posted from Testosterone Pit

Over the past decade, Medicare fees have risen about 10% while the cost of running a medical practice has risen about 30%. It has become increasingly difficult to stay in business as a private practitioner. At the lower range of compensation – pediatricians, family doctors, internists – it has become almost impossible.

Many practices have stopped accepting Medicare or Medicaid, and some have opted out of third party payment altogether, electing to go to a concierge practice (flat fee for all services the doctor provides, usually paid monthly or annually) or just a straight cash-based fee-for-service model.

Another option is to work as an employee of a hospital. There are several advantages for the physician: a more secure and predictable level of income, none of the hassles that face a small business, such as personnel management, billing and collections, rent, equipment expenditures, maintenance, and so on. They have fixed hours, guaranteed vacation, a 401(k), health insurance, malpractice coverage, etc, and … higher income.

Higher income? Yup, but there’s a catch.

Physicians can receive a higher income when employed by a hospital because hospitals often receive higher payments than a private practice for the same service. For instance, a hospital can tack on a facility fee in addition to the physician fee, something a private practice cannot do. This can easily increase the fee by 70%. Thus, the hospital can afford to pay the physician more because they collect 70% more than the private office across the street just on the fee differential. Since the doctor also leverages the system with referrals for other services, they can also supplement physician salaries. If a doctor increases hospital revenues by $1,000,000 a year, do they mind paying her an extra $50,000 a year above the usual level of compensation?

Impact of Corporatized Medicine on Physicians and Care

Is it all rainbows and unicorns once a doctor goes to work for a hospital? What many doctors discover is that they are reduced to the status of livestock – that it’s all about production.

Probably the worst aspect of being a hospital employee instead of a private practitioner is the loss of autonomy. A doctor has a fiduciary obligation to the patient to do what’s best for the patient, not for the doctor. This not just a legal consideration; it’s pounded into physicians during their training (at least 7 years of indoctrination). Supermarkets, gas stations, airlines, and movie theaters have no such encumbrances.

While there are greedy doctors who exploit their patients, the vast majority of doctors, based on my 30-plus years of observation, do place their patients first. That’s one area where corporate people and medical people often bump heads.

The most significant problem with loss of autonomy is production pressure. The employed physicians are hired to draw patients into the larger system where they can be funneled into other hospital services. Many hospitals are quick to claim that there is no policy or contractual obligation to refer internally, but the physician who takes them at their word does so at his peril.

Compensation is usually linked at least in part to productivity, which can be measured in various ways, all of which have a final common pathway: money. There is intense pressure for the employed physician to use ancillary services such as blood work, x-rays, MRIs, physical therapy, etc and to refer to doctors either employed by the system or system-friendly. 

How has Corporatized Nedicine Worked Out So Far?

Some snippets from online physician discussions:

  • In the past we were very picky in who we had join our group. Now the hospital was in charge of recruiting, and they hired any old warm body they could find. They would show us CVs of candidates with red flags all over, and we said we would never even interview these people. The hospital would hire them. And of course it would be a disaster. We had a revolving door of anesthesiologists while the old core group tried to hold it together. The hospital made ridiculous demands, required expansion into unprofitable service lines and then constantly bitched at us that we were unproductive and underutilized. Meeting after meeting: “You need to be more productive.” They just never seemed to get it that we can only provide care to the patients that surgeons bring us. If the surgeons don’t have cases, we don’t have cases. [From an anesthesiologist. They can only do as many cases as surgeons bring them. It’s like blaming the truck driver for not delivering enough packages when the factory isn’t producing enough to deliver.]

  • The administrators and medical directors are always focused on where they stand on the corporate ladder and how they can get more leverage, not only over the doctors below them, but on their counterparts and their superiors. Large systems have all the loyalty, well meaning, and altruism demonstrated by a character from Game of Thrones. [Arguably, the main difference between a large hospital system and the Lannisters is that hospital systems have more money.]

  • I knew things were severely problematic when I was having a meeting with my bosses, and the head of the PCP division said, “We don’t understand why you’re not being a ‘team player’. We expect this to operate like the Coumadin clinic. We start them on the opioids, and you just take over prescribing, and the nurses monitor the urines!” At which point the business manager for my division pops in, before I can retort, to say, “Yeah we should be able to operate that way.” Needless to say, the professional bullying from the PCPs, the administrators, etc. to run both a pill mill and a needle jockey business was tremendous. I resisted the entire time, but god it wore me out. [From a pain specialist for a large multi-specialty group.]

  • We had a meeting with administration and the whole medical staff. They wanted to know why staff meetings were so poorly attended. (They didn’t used to be.) One brave soul spoke and said “It’s a waste of time for us to attend meetings where our opinions aren’t valued and our concerns aren’t addressed.” He was gone shortly thereafter.

  • I have watched employed physicians who do it ethically, at least in their viewpoint, and are only driven out. When the hospital system starts hurting for cash, it isn’t the CEO’s salary that will be examined, it is yours and your production value . . . The Admins . . .  refer to the independents as being “outside of the framework” which seems like a bureaucratic euphemism for not liking the lack of ability to direct and control their work.” [It’s amazing to me that they allow this independent physician to hear these conversations.]

  • One day, administration fired all the ER physicians and put in place an entire department of locums and tried to rebuild. It was a disaster. They couldn’t cover shifts, the competency level was horrendous. The hospital had 3 major law suits out of that ER in the first two months of this transition.

“Locums” is short for “locum tenens”, or a doctor who is hired for a short period of time to cover vacations or other temporary short-staffing situations. Doctors who do this type of work aren’t called “temps.” They are “locum tenens.” That’s Latin for “place holder” or in common parlance, “temp worker.” Doctors have learned that you can charge more when it’s in Latin or Greek. And it all follows the theme: a perfect storm of unhappy doctors, corporate-style medicine, and higher prices.

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  1. michael

    They make these products to make money and keep investors happy while ripping of the government in tax payer subsidies. The more people they medicate the more money they make it’s no different to the tobacco industry. I know some of these medications are important but their main motive is money. When poor people get sick they die simple as that,
    even if the drugs are there.

    1. Antifa

      In 2012, some pharmaceutical lobbyists slipped language into a bill outlawing the importation of personal amounts of medicine from overseas, giving US Customs the right to burn any package containing medicine worth less than $2500.

      Lacking the courage to enforce the law immediately, Congress directed the FDA to write up regulations as to how this is to be enforced, and those regulations are being given a 60-day public comment period right now. About 3 million Americans import generic medicines from Canada mostly, but also from other countries around the world.

      They import them because the quality is the same (indeed, sometimes it is a case of re-importing American-made drugs), but the price is 20% of American charges. The pharmaceutical companies want that money, but won’t get it. Most of those three million Americans can’t pay American prices. They will go without.

      1. mellon

        If the US allowed people to buy drugs from overseas, that would devalue the licensing rights.

        Stopping that kind of thing is the reason the US is going around the world pressuring countries to sign free trade agreements like TPP, WTO/GATS, etc which effectively ban drug cost reduction strategies and ban new public health care.

        If they let one country do something which saves their people money and cuts into profit, they all would want to do it.

        Right now, PhRMA and USTR can sit in trade negotiations and point to the US and say “We don’t allow that in our country”, you shouldn’t allow it in yours.

        That’s why we don’t have affordable drugs or public health care. The middle class in Asia is far larger than in the US. That’s where the growth is. They don’t want the emergent developing countries to go the way of Europe and drive a hard bargain for drugs.

  2. LucyLulu

    In defense of Accountable Care Organizations, or ACO’s, the underlying rationale was that a large medical facility such as the Cleveland Clinic could provide patients comprehensive care for all their medical needs, avoid duplicative treatments and testing, improve collaboration, and theoretically remove the need for a third party payor. As the ACO’s gain experience, they would gain confidence in pricing the risk, and they would choose to self-insure. Physicians have taken oaths to “first do no harm”. Bowing to pressure by ordering unnecessary tests or procedures, almost all of which carry some level of risk, violates that oath. Physicians should be held “accountable” for being unwilling to compromise care.

    1. ambrit

      Dear Lucy Lulu;
      I know it was a typo, but your last sentence stands alone as a perfect encapsulation of the evils of the healthcare system in America. Physicians are being held accountable, by their corporate masters.

      1. Publius Democritus

        Everyone pretty much realizes by now that “Lucy Lulu” is either a shill, or someone so deluded that it’s unbelievable. Therefore deductive logic tells us, Lucy Lulu is a shill for anything corporate.

        1. ambrit

          I gather that you have the unenviable habit of shooting first and asking questions later. I will attest to the honesty and integrity of LucyLulu. We have “crossed swords” a time or two, but she has come away with her virtue intact every time. The track record of the commentator is the true measure of their worth. I have been known to stumble and commit the occasional gaucherie. So have we all.
          As to your essay in logic, well, deductive logic requires postulates to proceed from. When the postulates come in the form of character assassinations, the results attendant upon their use fall into the class of appeals to prejudice. As Detective Friday used to say; “The facts maam, just the facts.”

    2. Ray Phenicie

      The Cleveland Clinic has been providing very high quality care (higher than many hospital centers in the US) for several decades in its history. They are probably not the best example to give for setting an ACO as there providers were already successfully working towards and achieving the goals of what an ACO is supposed to be about. Setting up an ACO where high quality of care is not consistent throughout an organization may not be a good idea. If many providers in a group are not achieving high quality patient care scores-who are they going to compare themselves to except to go for standards outside the group. Then, once those goals are set up, who is going to train the practitioners, nurses, admins, janitors, and support staff?

    3. dw

      you do realize that the meme that doctors proscribe unneeded care, is basically a sham right? or do you work for a health care company?

      some but not all of this is done to actually pad income, cause it doesnt cost the doctor any thing to do proscribe unneeded tests.

    4. mellon

      Yes, Ive heard the insurers are setting up “Risk Sharing” contracts which doctors must sign along with the gag clauses that make it so doctors end up bearing the legal responsibility for the insurance company’s policies.

      ERISA Section 514 largely makes insurers impossible to sue.

      Since their business model relies on denying care and they have friends in Washington, as long as they keep pushing down the legal standard of care as they are doing, nobody will be able to say that any given insurer is any worse than the others. Sort of like politics. So their profits will continue to rise.

      Most Americans don’t know what good health care is anyway. They never can afford to travel.

  3. anon

    I am currently a 1st semester nursing student in a RN program, and I am horrified at the attitude about where the nursing prof. is said to be going. RN’s are to take the place of family physicians! by gaining education all way up to a doctorate. I interjected, “why not just become a doctor then.” which was ignored. The instructors are all bought into this move seeing it as a great opportunity for nurses. I see it as a degradation of healthcare. Those with money get specialized service from doctors, everyone else like the poor get a nurse with less education. What gets me is nurses have no organization to protect them like doctors. Nurse organizations are mandated to protect the public. So why do I want to bother being a nurse?

    1. LifelongLib

      I thought the idea was to allow nurses to handle “routine” cases, freeing physicians to handle the more unusual or complicated ones. Is this not right?

      1. Bart Fargo

        When you get down to it, there may be routine complaints but there is no such thing as a routine case.

    2. mellon

      They are creating an affordability crisis that only emergency measures like “harmonizing” eliminating quality standards and importing large numbers of contractors from other GATS countries will solve.

      Perhaps one of the reasons the FTA’s ban public healthcare is that you can’t use professional and efficient public healthcare jobs as bargaining chips in the world trade game.

  4. jjmacjohnson

    Doctor’s seem to be getting a taste of what lower paid workers have been getting for decades.

    1. Ken Nari

      “Doctor’s seem to be getting a taste of what lower paid workers have been getting for decades.”

      No joy in that. Doctors may be made uncomfortable under corporate rule, but it will be the “lower-paid workers” you speak of — meaning almost all of us — who will really suffer from conveyor-belt medicine and even more pill-pushing.

      “F-over thy physician and bestow his fee upon the dread disease.” –Shakespeare

      1. NotTimothyGeithner

        ACA was passed because the industry needed tax subsidies because consumers had reached their breaking point. The doctors and lower level administrators will be squeezed next.

        1. mellon

          Aren’t the tax subsidies supposed to be phased out over several years – as soon as they figure out what to charge long term.

          The FTAs ban “needs tested subsidies” – I think. The FTA-legal would be for poor people to get some kind of extremely low value product.

          Subsidies would be discrimination against corporations who might otherwise be able to sell the poor a cafeteria-style plan. People could pick diseases from a list of which ones they wanted to have covered. Some people might decide to pay extra for coverage of conditions that require hospitalization, other people might not because they wanted an affordable plan.


      2. Marcie

        I have an anesthesiologist acquaintance that thought the middleclass didn’t matter and that no one should get a hand out. I frequently reminded him that if you take out the middleclass there is no one left to buy products. He thought he was immune to the problem and didn’t care. He was definitely the type who believed, I’ve got mine and I could care less about anybody else. He who laughs last, laughs best is not going to solve the problem. I don’t want to laugh I want to fix the system.

        He also told me my illness was all in my head. Of course that was before I had all the labs showing gadolinium in multiple tissue samples and a differential of scleroderma, an often-times fatal disease. The lying, cheating medical doctors are saying I don’t have gadolinium poisoning. However, that is the real problem for me not the other seven diagnosed diseases I have. They were all caused by gadolinium being injected into me multiple times. And Omniscan and Magnevist, two of the worst gadolinium based contrasting agents are still on the market. But the ignorant patient population goes willingly into the machine that goes tap, tap and tap. We have serious problems in this country perhaps more serious than denial of treatment or overtreatment for profit and that is the intentional poisoning, maiming and killing of the patient population for profit. You take your life in your own hands when you go to one of these provider deniers. For sure if someone is liable for your injury you will be treated as less than human. The whole system is dysfunctional. I don’t have answers for any of it but I stay away from most doctors.

          1. Marcie

            Hi and thanks. Although I am disabled you should read some other stories on ProPublica’s Facebook Group. You will be shocked, guaranteed.

            I too hope you aren’t harmed. It will take years to figure out what gadolinium has done to us. It’s not on most people’s radar. It took me 10 years to figure out why I was sick and it was a former NY Times Reported that works for ProPublica and did an entire series on GE and Omniscan as well as all the gadolinium based contrasting agents. I must say I was slow to get it like most. Dr. Abraham is an expert in gadolinium toxicity. Here’s an interview with Dr. Abraham. He describes his study’s results that gadolinium passes the blood, brain barrier.


        1. mellon

          Did you have to go out of network to get a diagnosis? Ive heard a lot of scary stories about people who had to go several towns over and claim to be uninsured and pay cash to get an honest diagnosis. Class mixing- That’s what Obamacare is supposed to stop.

          People with the ACA plans will be segregated from the others so they wont be able to compare treatment.

    2. John Mc

      This comment smacks of the type of tit-for-tat mentality that if they only knew how it feels justification. Many upon many doctors do not pursue medicine for status or money. Indifferent labels and painting physicians with a broad brush is a poor response to the corporatization of all sectors of the American economy.

      When will blame and anger be directed at those parties most responsible?

      1. mellon

        The sock puppets online will just drown it out.

        >When will blame and anger be directed at those parties most responsible?

    3. Cynthia

      “Doctor’s seem to be getting a taste of what lower paid workers have been getting for decades.”

      The only way this will happen is if insurers, government as well as corporate, stop reimbursing large hospital chains at a much higher rate than they do private or freestanding clinics. If this were to happen, not only would hospitals be forced to significantly reduce high overhead costs, but more physicians would return to private practice where they can regain pay without sacrificing autonomy. It would be a win-win for patients and physicians, as well as other direct patient-care givers, but a huge loss to all the deadweight desk jockeys sitting in the back offices of hospitals.

      It was only about twenty years ago hospitals hired one manager for every physician on staff, now they have hired ten managers for every physician on staff. You can’t tell me that this is not one of the primary driver of high healthcare costs! Unnecessarily high healthcare costs at that. Needless to say, managers and other in the back office do next to nothing to improve patient outcome or reduce hospital stay.

  5. Middle Seaman

    As a patient one doesn’t have any knowledge of the doc/insurance machinations. Yet, the financial aspects of visits and treatment is fully open. Some insurance companies payments for regular doc visits went down to levels that the co-pay covers almost all of it. In reality, the insurance company all but stopped paying for visits; you and I pay for them. Many docs decided not to accept that insurance. Furthermore, physician with specialized knowledge or great reputation have stopped working with insurance companies. They charge the patient the full rate leaving the patient to fight a losing battle with the insurance.

    Another patient burden, the deductible, grows every year. The ACA lower level plans also have enormous deductibles. In effect, high deductible and high co-pays relieve the insurance from paying much unless the patient requires expensive treatment.

    1. ambrit

      In other words, the ACA plans are overpriced Catastrophic Coverage plans. We’re paying out the colonoscopy management zone for access!

      1. run75441


        I rarely post here on this particular topic; but, Seaman did not give you much of a reference. The colonoscopy you refer to would come free of charge as it is classified as a preventative procedure. Silver plans today have an average deductible (Individual Market) of ~$2900 which is ~$700 cheaper than pre-PPACA, Bronze Plans have an average deductible of ~$5900. In any case with insurance, you do get the negotiated rate

        1. mellon

          Its good to see that poor people still wont be able to afford healthcare. And people buried in medical debt act exactly like they would if they were uninsured.

          But their debt will still keep rising, even if they stop going to the doctor!

          That way all the government subsidies can go to lowering the rates for the wealthy self employed. Its already happening!

        2. Yves Smith Post author

          No, no, the colonoscopy is free ONLY if it is a clean colonscopy and they find nothing. If they snip any polyps, you get charged for that, and those charges can be large.

          And most people are buying Bronze plans. Your deductible figures prove the point. Even a $2900 deductible for Silver is ridiculous. That is tantamount to a catastrophic policy.

      1. Yves Smith Post author

        Mine is $500 on an individual policy in high-priced New York City. I consider anything higher than that to be high.

  6. afisher

    There will never be a healthcare model that will make everyone happy. After spending >40 years in a healthcare profession, the field has become more complex both via diagnosis and treatment. One of the historical medical arguments: when you hear hoofbeats, do you think horses or zebras? How does one maintain a balance between cost and diagnosis, especially when you have Big Pharma saying that every symptom is now treatable by some expensive drug. in 2009 the NewYorker had a great article discussing this type of issue via Cost Conundrum:

    Think about that – we have now gone from treating to cure a disease to giving a Symptom a name – but only after some enterprising group have already created a treatment: horses / zebras.

    1. mellon


      Americans don’t take more expensive drugs. Actually, Americans take fewer drugs and more often than not we get older, off patent drugs.

      This is an interesting article about drug pricing in the US versus elsewhere.

      People in countries like France, Japan, and Western Europe in general get newer drugs at much lower cost. That because their countries set up their national health plans before the US pressured them into signing the US’s free trade agreements that ban them.

  7. Skeptic

    Congrats to NC for staying with Health issues. After all, all our problems exist because we are still alive. So, we must continue to do so to deal with the problems.

    As Healthcare becomes more degraded people will seek alternatives in some areas. See substitution effect. For instance, instead of angioplasty, stenting, bypass to treat heart disease, people will seek cheaper treatments like exercise, change of diet, chelation (proven). The treatments are there and mostly free (you might have to buy a book and some materials). All you have to do is read doctors like McDougall, Esselstyn, Ornish, Sinatra, etc. Many other health problems can be successfully treated alternatively and for, in the main, free. A lot of this on yootoobforboobs. Keep in mind also that, for some, health tourism is an available option. So, as they profitize health, they may be killing off the Health Goose.

    All this is similar to other sectors of the economy like Finance where people have started running for the exits. So, I only use their Finance, their “food”, their Healthcare, etc. when I must. I hope they starve and the alternatives flourish.

    1. Banger

      One of the reasons I opposed the ACA was that it would force all people into conventional medicine. While there are many good things in conventional medicine there is little regard for ultimate costs even though there’s been a good deal of science done that shows non-conventional approaches make sense. The funding for these approaches, however, is low and they cannot be properly evaluated at this time. I encourage people to experiment–healing is still a very mysterious thing. My step-daughter was recently healed by a spiritual healer from a chronic ailment, for example.

    2. Marcie

      I agree with you Skeptic. In regards to chelation you must be talking about the recent long-term study by the NIH that showed chelation worked.

      “Trial to Assess Chelation Therapy (TACT),1,708 heart attack patients were randomized to receive 40 infusions of a 500 mL chelation solution or a placebo infusion, with a second randomization to an oral vitamin and mineral regimen or an oral placebo. The chelation solution contained three grams of the synthetic amino acid ethylene diamine tetra-acetic (EDTA), seven grams of vitamin C, B-vitamins, electrolytes, a local anesthetic and heparin, an anti-clotting drug. The placebo infusion was salt water and a small amount of sugar.
      Researchers found that patients receiving the chelation solution had fewer serious cardiovascular events than the control group (26 percent vs. 30 percent). Cardiovascular events were defined as death, heart attack, stroke, coronary revascularization and hospitalization for angina.”

      They set out to prove that chelation therapy didn’t work and found the opposite. What I find astounding it that not one mainstream profession mentioned why it might have worked, after all we all carry around boat loads of toxic metals including lead, mercury, uranium, nickel, cadmium, cesium and aluminum and if you had an MRI gadolinium.

      I opine that it is because chelation has the ability to cure and therefore non profit generating. There is a pattern here. And what most don’t realize is it takes a lot of chelation therapy to get the metals out of you especially if you are someone like me that was injected 11 times with Omniscan, GE’s gadolinium based contrasting agent and once with Bayer’s product Magnevist. No I wasn’t sick prior to these MRI studies I allowed myself to be fear-mongered into getting annual MRIs for breast cancer risk due to my BRCA status. I don’t have cancer but I’m hoping chelation saves my life. But according to mainstream medicine there is no cure or treatment for nephrogenic systemic fibrosis the new man-made disease caused by gadolinium based contrasting agents. There is no money in it and it is best to let these people die.

    3. mellon

      Yes, as healthcare becomes more expensive, I suspect we’ll see a lot of people jumping out of ambulances while they are still in motion, or committing suicide so their families don’t get stuck with huge medical bills. Well, they can always serve as horrible examples. I bet that gets a smile out of the politicians.

      There was even that guy in Utah a few years ago who amputated his own arm with a Leatherman style tool.

      No wonder Europeans have almost stopped coming here.

  8. jackiebass63

    This is happening where I live. We had two hospitals and NY state forced them to merge. The result was that patients suffered because they no longer had a choice of where they would receive care. As part of the process independent doctors groups were forced to become employees of the hospital. I suspect they were told either do this or lose hospital privileges. Now if you are hospitalized you doctor doesn’t take care of you but you are assigned a staff doctor. The letter I got tried to gloss this over but the reality is that the patients care suffers. In our area health care is controlled by two corporations and both operate in the same way so you really have no choice of how you are cared for. It’s become like an assembly line process where patients are moved along the line at an ever increasing speed. Both systems claim to be nonprofit but the administrators make big bucks and the cost to the patients is going up up and away. I no longer feel like a patient but a number as part of the bottom line on a ledger.

    1. mellon

      The United States is waging a war against public healthcare around the world in the form of free trade agreements. So there was never any leeway as to what they could do in 2008, it was already predetermined. The 2008 victory presented a problem that they solved I’m sure by pretending to be in gridlock. They just had to make it look like they were failing to fix anything because of arguments. It had to look plausible.

  9. Clive

    Any system based on targets/measures which then feeds back into compensation (especially for managers) is automatically a looting-enabler.

    You set your comp or bonus on the outcome of some target/measure or other. All you have to do then is fraudulently tamper with the data. Voila ! An emminently scam-able system. The system is a prerequisite for the control fraud. No system, no fraud potentiality. You’re limited to much cruder thefts like actually taking money out the till or altering invoices. The system lends the required veneer of authorisation to the underlying bilking.

    I can almost guarantee that wherever you have a system (be it simple looking tick-boxing all the way through to complex IT solutions) under the guise of “monitoring outcomes”, someone somewhere is skimming by the means of adjusting the figures in their favour.

    1. nycTerrierist

      “The system lends the required veneer of authorisation to the underlying bilking.”

      Very nicely put. Sounds like education ‘reform’ as well.

    2. rxfxworld

      In no way to minimize the gravity of commodified medical care, as practiced corporatively, but the same issues apply to the notorious No Child’s Behind is Left aka Race to the Bottom. That time it was teachers all demonized and made to bear the brunt of poverty, dysfunctional families and diminished school budgets by grading schools/teachers based on tests for the kids. With a few exceptions, mostly in Scandinavian countries like Finland this destruction of professional classes is ongoing. It doesn’t matter whether the assault comers from left-wing authoritarianism or right-wing corporate syndicalism the first thing is to destroy the thinking classes and critical thinking generally. What was it Pastor Niemoller said: First they came for the Socialists, and I did not speak out–
      Because I was not a Socialist.

      Then they came for the Trade Unionists, and I did not speak out–
      Because I was not a Trade Unionist.

      Then they came for the Jews, and I did not speak out–
      Because I was not a Jew.

      Then they came for me–and there was no one left to speak for me.

  10. Adrian

    A lot of the momentum behind this stuff comes from the same private equity boys and financial engineers who are transforming every other part of the economy to fit with the new feudalism.

  11. armchair

    From the post, on anesthesiologists:
    “Meeting after meeting: “You need to be more productive.” They just never seemed to get it that we can only provide care to the patients that surgeons bring us. If the surgeons don’t have cases, we don’t have cases.”
    Okay, so a b-schooler sees this and comes up with a brilliant idea, ‘cold calling’. Get some big date on who’s buying glucosamine at Target, and then pass the phone numbers along to the anesthesiologists. Here’s a sample call script.
    “Hello Mrs Rickety. If you have sore knees, I’d love to set you up with Dr. Sawbones, so you can get a knee replacement. It be a privilege to put you under. Let’s go ahead and set you up with a consultation.”
    Productivity problem solved. Your welcome.

    1. Keenan

      RE: Cold Calling

      I’ve been receiving such semi-annual calls for several years from a local chiropractic office offering free spinal evaluations. Even telling them “don’t call me, I’ll call you if I ever think I may need you” hasn’t yet stopped it. Time to use words like harassment or file a complaint with the FCC, but does that agency do anything more than claim to serve the public.

  12. Jim Haygood

    ‘Over the past decade, Medicare fees have risen about 10% while the cost of running a medical practice has risen about 30%.’

    Yes. So Medicare services are provided at close to cost, resulting in price discrimination against private payers, most egregiously the uninsured who are charged absurdly high ‘rack rates.’

    Meanwhile, despite lowballed Medicare compensation, the program is still deeply underfunded. How have our KongressKlowns responded? Why, by enacting a law in 1997 that requires further cuts to physician reimbursement, and then suspending it on an annual ad hoc basis, 17 years in a row. This year it was done by voice vote with only handful of members present, and many complaining afterward that they weren’t even notified. Impressive, huh?

    When 535 people (perhaps ‘lifeforms’ would be more accurate) are in charge of other peoples’ money, nobody is in charge. If you think corporatized medicine is bad, just wait till Big Gov (the nation’s largest corporate entity) runs it.

    1. Katniss Everdeen

      This is such a stupid argument. “… just wait till Big Gov (the nation’s largest corporate entity) runs it. And I’m sick of hearing it.

      The Canadian government “runs” healthcare. So do the Swiss, German, British, French, Swedish and Belgian governments. And on and on. And you know what? All of these “governments” get better results for more people at a lower cost.

      So it’s not “government” per se that can’t (or won’t) “run” healthcare. It’s THIS government. The government of the United States of America.

      And why would that be do you think? Could it be that it is populated by too many people who are “convinced” that “government IS the problem” yet keep running for re-election and remaining part of it?

      Apparently they’re not so sure that government will prove to be as incompetent as they claim. So they hang around to keep throwing sand in the gears just so that they are proven right.

      If you want a machine to work, you don’t hire a machinist who keeps whackin’ it with a hammer and then tells you, “See, I told you it was broken and would never work.”

      1. Clive

        Yes, spot on Katniss

        Here is the UK, while the NHS is certainly not a panacea, I’ll take it over the US Health “care” system in general — and Obamacare in particular — any day of the week. And even in private practice, I’d encourage anyone who needs non-urgent treatment to investigate the costs of a bit of UK-bound health tourism vs. domestic US equivalent treatment. Even adding in flight costs, I’ve a strong suspicion you’d be in the money and the treatment would be no worse (and arguably better, especially at the white glove health facilities which match any international standard. And they’re prepared to haggle too.) Germany is probably even better value, and if you’re prepared to go to Eastern Europe, 50%+ savings are possible.

        All this is of course in an “uninsured” context. But even with insurance, from what I’ve seen of the Obamacare deductibles / co-pays, it might still pay.

        1. mellon

          I hope you realize that the US is waging war on the UK’s public healthcare, as well as public healthcare elsewhere in the world! The things that re being done in our name via the free trade agreements are truly horrid.

          The US as well as the UK, signed, and the US is pushing, everywhere, free trade agreements (FTAs) which largely ban any new public healthcare, and attempt to tear up existing public health systems by using a so called ratchet effect- mandatory incremental privatization rules, that’s why the NHS is being gradually privatized.

          These rules are brutal, but they are all so dense and difficult to understand that for the most part only experts understand them.

          So they have fooled Americans into not mounting any kind of opposition to this because we still think improvment “may” come without a house cleaning and complete re-evaluation of all FTAs (and US laws) concerning healthcare.

          The huge special interests, who want to export the US healthcare model elsewhere, are very skillfully manipulating the online world and there seems to be a sort of genteman’s agreement to not discuss the free trade agreements – or single payer healthcare, in the US mass media. I think that there must be a similar agreement in the UK to not discuss the real reasons for privatizations there, for similar reasons.

          You might do a search for the writings of Allyson Pollock in the UK, she has written extensively on the US’s and the FTAs attack on the NHS and UK public healthcare and the reasons its happening.

          Here are some random links which might be helpful:

          Trading Health Care Away? GATS, Public Services and Privatisation (If the link doesnt work, Google on the name)

          The special interests are spending lots of money on pro-level PR which operates very deviously..

          Here in the US, they spam the blogs with armies of sock-puppets who pretend to be Libertarians who are against public healthcare. In 2009, I don’t know if this is still true, but I heard (from a friend who has spent most of his life in the advertising business- he was part of the tobacco industry campaign against smoking regs, so he knows these people) they were spending $700k a day on guerrilla PR activities, mostly online activism, to get Obamacare passed and public healthcare pushed out of the public mind by drowning online discussions about it in noise.

          For more on the FTAs impact on healthcare in the US, and elsewhere- basically most of the developed world, start with the WTO services agreement, which is the worst of them all.

          For a very good, brief introduction to a number of the core issues, even if you dont live in the NAFTA nations, I recommend this paper on NAFTA, especially pages 8 and 9, which serve as a good into to investor-state concept. (which is part of all the FTAs- they attempt to do an end run around democracy.)

          I would also recommend reading the paper above on GATS and Public Service Systems. Also, a Canadian NGO, Policy Alternatives has a great many excellent publications on the FTA war on public healthcare. One that is particularly relevant for both US and UK readers is Putting Health First. But I would also search using something like – (on Google) “ filetype:pdf GATS” (without quotes – or other term”

      2. Jim Haygood

        ‘Apparently they’re not so sure that government will prove to be as incompetent as they claim.’

        One word, Katniss: Obamacare.

        Need I say more?

        1. Oregoncharles

          Intentional misdirection. The problem with Obamacare is that it fastens the (private, profit-driven) insurance companies around our necks. And further corporatizes medical practice, as the article indicates.

        2. Lambert Strether

          Because markets. It’s ObamaCare’s insistence at retaining the wholly parasitic health insurance industry that’ the source of its system complexity which, in turn, was the source of it technical failures (and coverage failures as well).

          If I may say, you need to work on that “big gummint” reflex. It comes down to fitness for purpose (and nature of purpose (e.g. ginning up wars)) more than size as such.

        3. Propertius

          But “Obamacare” (really “Fowlercare” or “Baucuscare”) is just legally mandated private insurance. How does that demonstrate that government can’t provide health care?

  13. Juneau

    Going from working for a large corporate healthcare entity to working alone, I have seen insurance rates cut by 40 percent simply for going from “group” to “solo” status. Those who can afford to “do it right” (maybe those without kids or a mortgage or 3 divorces to pay for) feel like dopes. Colleagues who put themselves first survive. Those who made sacrifices, provide free care to indigent patients, accept insurance, etc…..are now the low tier low status docs who work 60 plus hours to make overhead and stay afloat. At least that is what I do. Some patients are understandably unsympathetic and hostile on this issue, others are very understanding and try to work with the physician. I guarantee more docs will leave practice ASAP. I see no way to fight this system, the changes have been underway for at least 20 years. People who see docs getting what they deserve have yet to see their care has been transferred to MBA’s…….no offense to good MBA’s……Still, expect doctors to start taking regular lunch hours and time off on the weekends and they will turn their phones off on vacations….the perks of being a salaried employee after all. Just not the usual standard for the healthcare professions.

    1. orthomama

      Like Juneau, I have nearly 20 years in the healthcare biz – but as an orthodontist. The “changes have been underway for at least 20 years” is dead on accurate. About that time, our annual meetings went from providing only patient centered continuing ed (CE) to including marketing and practice promotion centered (CE). Initially, med/dental offices embraced the move from profession to business. But at the end of that slippery slope, we find the MBA’s claiming their right to “run” the business, with docs relegated to worker bees. What baffles those of us who are growing long in the tooth is the readiness with which young docs embrace their new role of employee. New graduates appear to readily accept the corporate propaganda about “the work / life balance” accompanying a corporate job, as if private practice is a gulag – yet talk little about losing the vitally important doctor-patient relationship that is non-existent in corporate offices (at least for dentistry).
      While I fear that medicine has gone past the point of no return, dentistry is tipping on the edge. PE and other “investors” have aggressively pushed into the dental biz, in violation of state dental laws. While I will be the first to say that the dental biz needs to embrace changes that will make dental care more affordable for our patients, I’m quite confident that corporatization of dentistry will only result in the “crapification” of dental care.
      Yves, thank you for maintaining focus on the corporatization of medicine – and please consider looking into dentistry.

      1. Lambert Strether

        Dental anecdote: When I worked in the cube I had dental, so I went to the in-network dentist to have my teeth looked at. The (rather assembly line-like) exam concluded with some kinda whole head-scan X-ray that showed my back teeth sprouting out of the bone at weird angles, so they recommended a number of extractions. That sounded like major surgery to me, and I had no pain, so I didn’t do it, but did have a cavity filled.

        So a year later I’m out of the cube, and little bits start falling off their filling (which had had a sharp edge on it, for some reason). It being the depression, I ignore the little bits that keep falling off… Until this year when I got to Thailand and had my teeth fixed in the Land of Cheap, Excellent, And Above All Pain-Free Dentistry. The Thai dentists do the whole-head scan too, and the photo looks nothing like the photo the assembly line dentist took, of which I have a very vivid memory. I wouldn’t put it past those clowns to fake the photo so they could bill for the surgery. After all, the evidence is going to be ripped out of the patient’s head, right?

        1. jrs

          They are also recommending excessive and unnecessary x-rays. The x-ray tech said to me when I complained about having to get x-rays again: only get the minimal x-rays – it’s all you really need – don’t get the full set they want, you don’t need it. And then the problem besides wasting money is excessive radiation exposure. Yes the problems with our medical system run MUCH deeper than unaffordability (and this was dentistry which is probably less corrupt than medicine as I actually pay out of pocket).

        2. Denise

          If you want to go out of the country for dental work, how do you find the dentist? I’ve been trying to find this out for a long time.

          1. Nathanael

            Hard problem — you need someone with foreign language skills, obviously. Very valuable to speak Spanish like a native.

            1. Nathanael

              For Thailand, they’re actually advertising to Americans, so it shouldn’t be as hard.

      2. McMike

        Ooh, don’t get me going. The up-selling, and costly pre-emptions of theoretical risks, and let’s-create-a-problem-so-we-can-fix-it is already well underway in dentistry.

        I’ve had old fillings that were “upgraded” by a different dentist to some new type of filling (not fully covered by insurance), that then later needed to be redone by yet another dentists because they were failing.

        I got the “I don’t like the look of that filling, it if fails, it will blah blah blah… so we ought to take just go ahead and the tooth out and do a crown.” No thank you.

        Already had one “might as well go ahead and do a crown” preemption, damn gums have never been the same, and base is sensitive as hell.

        They have this thing now where they preemptively spray the kids teeth with some damn plastic sealcoat. Might as well dip them in liquid pvc.

        Saw one dentists who on the first visit did a full evaluation then told me all the ways they could beautify my smile. Except I was in for a toothache.

        I understand that they don’t just do “braces” anymore. Now there are pre-braces and retainer thingies and essentially what used to be a twelve month ordeal is become a lifetime revenue stream of hardware.

  14. Rob Levine

    My ex was a psychiatrist at a hospital/clinic in the Twin Cities that used the so-called “production model” for reimbursement and payment. They were given an hour for an intake interview, and 20 minutes for a “med check” after that. If seeing a patient took longer than that the doc didn’t get any more pay. The system literally pits the doctor’s salary against the patient’s health. Another friend who is a psychiatrist said it’s practically malpractice to assume you can gather enough info in one hour to prescribe these powerful drugs.

    1. Denise

      When I was a patient in Kaiser Permanente, I was warned very sternly that if they gave me an appointment with a psychiatrist to get medication prescribed, I was UNDER NO CIRCUMSTANCES to try to discuss anything other than medication with him or her. This point was made to me twice.

      I thought this was so weird that despite the fact that I was paying $900/month to Kaiser, I continued seeing my outside psychiatrist on my own dime.

  15. NotTimothyGeithner

    Politically, big pharma, hmo’s, and insurance have been using doctors as front people for decades, and doctors have been complicit and reliable GOP goons* on top of that for years. Having the doctors wear there corporate logo will end that aspect of emotional blackmail.

    *I’m sure democratic strategERists privately supported ACA as a means of clawing mds away from the GOP.

  16. Banger

    The medical profession is partly to blame for this situation. Medical training specifically trains doctors to not connect emotionally to their patients or to allow all their senses to take in the patient. As a youth, I saw a physician who graduated from Harvard Medical School in 1918. He told me that his training was more holistic than it was (we spoke about this in the early 70s) in contemporary times. He could see, at a glance, what was wrong with a patient, he didn’t need tests–he saw this through demeanor, color, smell, tone of voice and so on and knowing the personality and life-situation of his patients. He was much respected and active and practiced into his eighties. He did not ignore labs but he did not believe in them the way doctors do today–they only look at labs, for the most part.

    So, it’s no surprise that doctors who take a view of healing as having to do with numbers that they should not be caught in a web of the Spreadsheet Culture of MBAs, who are like a plague of locusts eating up the land–it is they who tell the oligarchs that TINA to their policies. If you assume numbers as being god-like then everything will turn into numbers.

    1. Ken Nari

      “Medical training specifically trains doctors to not connect emotionally to their patients…”

      As so often these days, U.S. News and World Report is at the root of the problem. Since there’s no way to measure the quality of doctors a school turns out, the ratings depend on the average GPAs and MCAT scores of students.

      Virtually all med schools profess to seek out well-rounded students with a firm grounding in the humanities, but the reality is med school admission favors numbers-bots, not people-oriented students.

      I think there’s a real desire in the medical community to change this, and most med schools seem to be able to accept a few “non-traditional” applicants without greatly damaging their ratings. A few even, like Virginia Commonwealth, go all out to attract the kind of student who is well-rounded, compassionate and more than an MCAT score, but they are in the minority.

      Everyone knows U.S. News and World Reports’ ratings of everything are bogus but, the U.S. being the U.S., everyone still goes along, accepts the completely non-scientific fallacy of reification and pretends numbers can be assigned to qualities that can’t be measured.

      1. washunate

        And if the government didn’t subsidize the higher ed industry, med schools would have to create value that could stand on its own. The US News rankings is one of the symptoms of an educational system with way too much capacity and pricing power.

        1. bob

          That’s not discussed enough. Most doctors are trained by the state. I know a former russian, now ortho surgeon who trained at the VA. Raging tea-bagger. “I don’t want my tax dollars to go to giving addicts needles in San Fransisco”

          Median pay for orthos- over 350k a year. I don’t want my tax dollars to go to douchebags.

    2. Jim in SC

      In Chinese medicine, they take the pulse and examine the tongue and these are their primary diagnostic tools. They spend their first year in Traditional Chinese Medicine school learning how to take the pulse, which of course is something more complex and holistic than simply measuring how many beats per minute your heart is going. Tongue diagnosis is pretty complicated: I’ve seen Chinese books with hundreds of tongue photos in my acupuncturist’s office. My mother, who is ninety one, goes twice a month for ‘maintenance.’ The cost is low, less than $1500 a year, as we pay the price we started with nearly ten years ago. Her physical health has improved dramatically during that time. Among other things, a shoulder problem for which an orthopaedist had recommended a shoulder replacement has been cured. I wanted her to keep going to the acupuncturist because, in the days before she started using a walker, I could tell that she was putting less pressure on my hand as we left the acupuncturist than when we arrived. It was obvious every visit. In addition, we pay $1500 a year to participate in her PCP’s concierge medicine practice. I can’t say enough good things about that. So we’re paying a total of less than $3,000 a year on extras that wouldn’t be covered by Medicare, but we think we’re getting a lot for it, which is more than many can say about their health care.

      1. Jim in SC

        Improvement with acupuncture is not necessarily fast. A certain amount of faith is necessary, because you’ve got to keep coming. Sometimes they get just the right spots and sometimes they don’t. My mom’s shoulder took a few months to respond, and there were several relapses, but today it doesn’t even pop anymore.

        Maintenance protocols for older people are very similar, mostly a few points on the leg. Some acupuncturists, such as Miriam Lee, believe that a ten needle protocol (five on each side) treats most of what ails you. There are ways to stimulate points besides needles, if needles bother you.

  17. Katniss Everdeen

    This article illustrates one of the seldom discussed but essential aspects of the tyranny of the 1%–the complicity of the 20% just below them–the “Judas steers.” Without their cooperation and expertise, all the 1% has is a plan.

    These are the “practitioners” who willingly trade their “integrity” for influence and power and money. These are the ones who can rationalize the betrayal of their colleagues and their principles and their patients. In this case, it is the AMA which could simply say, “NO, medicine cannot and should not be practiced in this way.”

    But they don’t. They are enablers. They use their position to set “standards” and make rules that permit and promote the crapification implementation. And they are richly rewarded for their selling out.

    And what of the older doctors, the ones who can’t quite wrap their ethical heads around the new paradigm? Better to be bought out and retire, to be replaced by a new crop of “medical technocrats” who don’t know any other system and for whom no such “ethical” conflicts exist.

    Americans need to realize that there are no Marcus Welbys or Ben Caseys or Dr. Kildares any more, and interact with this new system with their eyes wide open. If they have to interact with it at all.

    1. bob

      “Better to be bought out and retire,”

      That’s it right there. Sell your souls to the health industrial complex and retire elsewhere.

    2. Propertius

      it is the AMA which could simply say, “NO, medicine cannot and should not be practiced in this way.”

      But only about 15% of practicing physicians even belong to the AMA. It’s not like the AMA is any kind of official certification or licensing body – it’s primarily a lobbying organization for a minority of practitioners.

      1. jrs

        How do they have so much lobbying power then? Who funds the AMA? Maybe physicians need to create a better more representative lobbying body if the AMA is not respresenting them (they are in a better position to pull off solidarity than most of us – more bargaining power). Maybe they should.

        1. rxfxworld

          For any representative body to act for doctors there exist strict legal limits. For example much of this steady deterioration in medical care began in the 80’s with advent of HMOs. Drs. who might have been opposed to group practice were legally prohibited by ERISA Employee Retirement Income Security Act of 1974 From forming a collective bargaining agency, i.e a union. The AMA is not a union but a lobbying group which used to be filled with GP’s. Though its politics have been generally conservative, reflective of most doctors views it was not consistently so. While in 1965 AMA opposed creation of medicare, in 1937 AMA opposed, but was ignored on the criminalization of marijuana. A significant percentage of AMA members and non-affiliated Drs. favored and still do singler-payer over the mess that Obamacare is and the boondoggle it is for corporate medicine–this last is oxymoronic. While corporations have been endowed with personhood by SCOTUS, and they are immortal by law, they have no heart and no conscience. Zombies do not practice medicine.

          1. LifelongLib

            Well, in the mid 60’s a physician friend of mine who worked for Group Health in Seattle was prohibited from joining the AMA because the latter considered Group Health “socialistic”.

  18. Carolinian

    Don’t doctors have themselves and their pressure group the AMA to blame for much of this? The AMA has historically opposed more rational systems that might put a dent in physician incomes. When you make money your goal it’s only a matter of time before the real money boys come in and take over.

    I’m sure most young people still go into this difficult profession for idealistic reasons. But they also want to become rich. My mother once worked in a local college’s chemistry department and heard this constantly from pre-med students. Money can corrupt, and when it comes to medicine there’s a lot of it on the table.

    1. bob

      The AMA is the only union that no one wants to knee cap.

      At the same time, I think they are ripe for change within. The rank and file are getting completely screwed by the MBA’s on top. GP’s, the most numerous, are responsible for everything. The specialists can’t even be bothered with making a bedside appearance when the patient is conscious.

      Complications after surgery? “Call your GP. I have a tee-time.” Slap.

  19. ambrit

    I have hypertension, and have been slowly weaning myself off of the drugs I was “introduced” to ten years ago. (C’mon kid! The first one’s free!) The first ones to go were the statins. (It turns out that there is no compelling evidence linking overall cholesterol levels with heart disease. HDL levels and triglyceride levels are better indicators.) I’m now working on the beta blockers. (Phyllis says she will be very happy when I stop carvedilol, due to an “unfortunate” side effect of that drug.) It’s a work in regress if you will.
    The system described in the piece, metricized production, bears an uncanny resemblance to what has been going on in Big Boxx Retail. As I can attest from personal experience, this system leads to steady deterioration in all spheres of endeavour. I am soon to leave retail for a while. Simply put, I burned out. Thus, I will become one of the Great Uninsured Underclass again. COBRA is a joke, and ACA is a sick joke. I’m looking for a great Revival in Christian Science. Prayer is about the last thing left for all us downtrodden masses.

  20. Holly

    It’s interesting is no one seems to care about the monopoly that large medical systems have on regional healthcare. (Take a look at Charlotte NC region – also a big banking area – maybe they are taking hints from BA?)

    Have seen coders instructed to figure out how to upcode (charge a higher level of service) for UTI’s. Then instruct MD’s/PA’s how exactly they are to document to get higher reimbursement. (Normally level 2 but now a level 5 – lot more money.)

    Little concern about quality of care – Mgmt gives lip service to “quality of care” but that is all it is. If a high income producing doctor gets complaints they keep ’em and find a way to quiet the critics. Good doctors that are low producers, do not get the same support.

    1. Katniss Everdeen

      When you have a monopoly, the last thing you have to worry about is “quality.”

      Take it or leave it. I guess that’s the “healthcare” “choice” everybody keeps talking about.

      1. bob

        William Binney, of NSA whistle blowing fame, actually did just that. He used some NSA tech to look at medicare fraud. That program was immediately shut down and de-funded.

  21. Kimberley

    How long will we continue to ignore the reality that patients in the US are paying a premium for care that is clearly subpar

    Healthcare reform won’t have a significant impact until two things happen: 1) individuals invest time and effort into understanding the relationship between the cost of their care and the quality they receive and 2) we, as a society, can actually have an honest discussion about what constitutes superior clinical care. Hint: standardized evidence-based medicine is not the enemy.

    Rushing towards universal healthcare is just one option – there are others. In fact, this notion that independent physician practices are dead is way overrated. Check out the Surgery Center of Oklahoma. It looks a lot different from the traditional physician practice … and that’s the point.

  22. Vatch

    This is genuinely scary. This is a big incentive to take care of one’s health, but everyone gets sick or injured eventually. In the meantime, don’t smoke, don’t drink much alcohol, get some exercise, eat your fruits and veggies, avoid trans-fats, wash your hands before eating, and wear sunscreen if you spend much time in bright sunlight. All things we should be doing anyway, but the corruption of the U.S. medical and insurance industries really, really makes it important for people to take as much control of their health as possible.

    1. Benedict@Large

      No matter what you do, unless you die instantly, you will need medical care. When that happens, you will find a system geared to extracting your wealth down to the last penny as quickly as they can and for as little effort as they can. Once this is done, you will be abandoned. Because money.

      We are told that this is called FREEDOM, but the only freedom here is the freedom for the looters to loot.

  23. Rahul

    Hello all,
    I was lucky to read the book “Free to Choose” by Milton Friedman. It explains the disadvantages of socialized services especially by the government in the name of security and equality. Education is a prime example of what would happen if you socialize great indespensible services. I believe eduation, health are primed for socialization as freedom has already been. Assuming the medicine socialization is complete by 2020 and doctors are the new teachers. The rich always go to private schools even after paying for public education. There by don’t question the standards of public education. There by eliminating themselves on questioning how your money is spent. Have we become irresponsible with the money that you made or worked so hard for? May be its not hard work! huh I guess the problem lies and depends on how money is made, if you are are paid more than what you are worth, you are more likely to spend with out accountability.
    Coming to Doctors becoming the new teachers:
    1) Salaries are going to uniform and you would n’t know who is a good doctor and who is a bad doctor unless the later kills few unprivliged homosapiens.
    2) When you take away the gift and rewards to become the best doctor, Why should I?
    3) I was wondering when would sports become socialized. I would really love to see Lebron James get paid as the worst guy on NBA bench is paid.
    I don’t think the guy on the bench would like it either —
    Any ways any one suggest me a good book about socialized medicine in england, canada and socialized education in America?
    Please tighten your seat belts, I thought it would take us for ever to get where England was. Too bad its coming and its fast.

    1. Yves Smith Post author

      Can you read? This is not “socialized medicine”. The HMO, which is the early prototype for this sort of thing, was invented and promoted by private companies. And it is the private insurers who are in the drivers’ seat now.

      1. mellon

        Yves. The right pretends that Obamacare is a liberal program! Most progressives were sold on Obama and Obamacare, by a massive disinformation campaign on the bigger lefty blogs. Their massive astroturf campaign was able to spin it that Obama was a liberal when of course he was a neo-liberal.

  24. DocHolliday

    I work for a large, staff-model HMO in the mental health field. The primary method the company uses to make money in psychiatry is by systemically and strategically understaffing. This results in the individual provider having to triage a small, inadequate set of resources to a large set of patients. The result is that everybody gets a little something, but nobody gets what they really need or what is even appropriate. The profit from this strategy goes to the MDs, who own the company, so you don’t hear them complain too loudly, even though they are very poorly treated as well. When non-MD staff complain, we are told we are “not team players,” etc. There has been an increasing pressure from non-clinical administrators to maximize productivity and give the illusion of quality. What is being lost is any meaningful countervailing force to maximize quality patient care. All the drivers in the system go in one direction: less care/more profit.

  25. washunate

    Yves, this is a great intro and article.

    “But big corporations see their profits as another revenue opportunity, and have become increasingly adept at making it so hard for them to operate independently that becoming part of the corporatized medicine apparatus looks like the least bad of the available options.”

    I would just continue to emphasize that it’s not corporations that make life difficult for small businesses. It is the government. Public policy has been pushing for the concentration of healthcare provision for many years. That trend of centralization is a core element of the authoritarianism behind everything from the national security state to the legal system.

      1. washunate

        That’s the rub. I guess it depends on the meaning of the word own. You can go down that rabbit hole quite awhile. Defining government is perhaps the fundamental difficulty :)

        Corporations are creations of the state. If the state wasn’t the actor with the power, then rich people wouldn’t need to buy off political leaders in the first place.

        1. Vatch

          Corporations are legal fictions, and as such, are creations of the state, but billionaires really exist, and they don’t depend on the state for their existence.

          1. Nathanael

            Without the state, corporate executives would create their own power. By hiring mercenaries, like Blackwater/Xe/Academi, for example.

            1. Vatch

              Thank you! They did things like that during the Gilded Age. For example, the Pinkerton “detectives”. They also created their own mini-states in the form of company towns.

  26. Vatch

    Washunate said:

    I would just continue to emphasize that it’s not corporations that make life difficult for small businesses. It is the government.

    It’s not an exclusive disjunction, big corporations or the government. Both the government and big corporations make life difficult for small businesses. The government is owned by big corporations and billionaires.

    1. Lambert Strether

      This is Gramsci’s idea that “the state” and “civil society” are in essence academic distinctions meant to scope the object of study. In fact, they’re two aspects of one thing: The ruling class (which I’d identify as the 1% of the 1%). The 20% Judas Goats that Katniss refers to can and to function in either environment. The “gummit” on the right reifies the state, treats an abstraction as a real thing; similarly “corporations” on the left reify civil society, treating, again, an abstraction as a real thing. Hence the sterile debates between the two. But Soylent Green is people, controlling real resources….

  27. Kimberley

    Healthcare reform won’t have a significant impact until two things happen: 1) individuals invest time and effort into understanding the relationship between the cost of their care and the quality they receive and 2) we, as a society, can actually have an honest discussion about what constitutes superior clinical care. Hint: standardized evidence-based medicine is not the enemy.

    Rushing towards universal healthcare is just one option – there are others. In fact, this notion that independent physician practices are dead is way overrated. Check out the Surgery Center of Oklahoma. It looks a lot different from the traditional physician practice … and that’s the point.

      1. Kimberley

        I’m not buying your promotion of “Eminence Based Medicine” — repeating suboptimal clinical decisions with increasing confidence over an impressive number of years. (source: BMJ, Vol 1 Sept2001)

  28. ep3

    Every time i see my doctor he complains about Obamacare. My doctor is very well known in my area. He works in a private practice still with a few other doctors. i have private insurance. I see the statements from the carrier where the doctor has charged $60 for the office visit, i have paid my $30 co-pay and the insurer lists “pymt of $30, less network discount of $24”. So my doctor got $36 to take care of me (cover his bills, pay his staff, etc). Please note that when I didn’t have insurance, he charged me $36 for a visit.

  29. Jack Singler

    I thought a healthy LDL was under 200? Who changed it to under 100? Could it be Crestor with its new commercial that subtly suggests a healthy LDL should be under 100, or perhaps Pfizer, (which tried the same thing back in the early 2000’s), that admits everyone should be on a statin, whether it helps or not? Where is the outrage, Doctors? Profit above patient, and treat the symptom (with highly profitable pills), while ignoring the cause, this is the path corporate health care has chosen. To improve care, my HMO recently installed a drive-thru; the first window is check-in and co-pay, the second window is diagnosis with the PA/RN (maybe MD), and the third window is pharmacy/gift shop/fries. The old system, of going in the building, was so similar to this new drive-thru system, that I really don’t see any difference. I think this drive-thru idea will catch on soon.

    1. Yves Smith Post author

      No, 200 is total cholesterol. LDL was 130, recently lowered to 100 to help statin-pushers. My impression is a lot of doctors are not falling in line with the new guidelines.

      1. lee

        That has been my experience lately. I stopped taking statins some years ago because I either experienced or imagined I was experiencing indications of some of the serious potential side effects associated with these drugs. Although I am congenitally predisposed to low HDL and high triglycerides my doctor pointed out that my heart and arteries are looking good for a guy my age.

        I wish some of the money that’s going toward curing my nonexistent cholesterol problem could be spent on finding a way to get my immune system to quit attacking my central nervous system. Fucking systems just can’t get along with each other!

  30. impermanence

    The notion that you can fix, repair, and replace 320M people’s body parts is completely absurd. This is a system primarily designed to produce enormous corporate profits.

    The only solution is an actual health care system where you place efforts and resources into maintaining health.

    I have been a physician for over thirty years and people would not believe how incredibly corrupt this system is. As always, it is the leadership [of the professions] who have been paid-off for delivering the masses [of doctors] to the gallows.

    I made less last year than I did in my third year of practice. Health care has become much like financial services where they pay you for making money for them. It is truly pathetic.

    1. Banger

      I’ve heard this from many physicians over the years–there are quite a lot of you–you need to sustain each other through organizing or just hanging out and giving out hugs.

    2. susan the other

      It seems to me that American doctors have a good passport to go to other countries and practice. Although your income would be much lower, so would your cost of living and you would still have the satisfaction of actually helping and curing people. Health care in the United States is a lost cause.

  31. Erwin

    I don’t know why he should be surprised. In conjunction, AMA certified doctors and insurance companies have systematically worked to eliminate competition for the last 80+ years. Now the only way to keep the gravy train running for the insurance companies and hospitals is to squeeze the doctors and nurses. Don’t be surprised when all those not towing the corporate line are shocked with how low their pay goes. And after that will be those that DO tow the corporate line!!! And worse is that despite all the so-called advances, the level of iatrogenic deaths is as high as ever (north of 750k per year in the US). Enjoy the world you’ve actively worked to bring about!

  32. theinhibitor

    The way I see it, we humans are coming to a crossroads: on one road we see the advancement of our civilization and technology, and on another we see gluttony and ignorance. Apparently, it seems to me that gluttony is winning.

    I never understood how “economists” can’t see that if you start corporatizing everything, you essentially demotivate society as a whole, as well as create a branch of people that are happy making money off of other people’s hard work. Its all take and no give. What do insurance companies do that benefits the medical industry? ABSOLUTELY NOTHING. But people say “but how could we afford surgery X and pill Y?”, and it’s these people that unfortunately just dont see the larger picture. Without insurance companies, medical costs would go WAYYYYYY down.

  33. Gabriel

    How about we prohibit profit in the health care industry?

    In other words, only non-profit charters would be allowed.

    1. jrs

      sounds good if it was true non-profits, only somehow Kaiser is considered “non-profit” at this point (psst non-profit status is being abused … shhhh don’t tell anyone …)

      1. bob

        That non-profit moniker protects them from anti-trust laws, apparently. I called both the state AG and the feds about this with respect to a local Health insurance non-profit who was claiming profits of over 100 million a year, and paying their execs, including a retired CEO over 5 million a year.

        “they are non-profits, they aren’t subject to anti-trust legislation”

        What about fraud? Non-profits making millions. Sign me up.

  34. jrs

    What is the AMA’s position on single payer/universal healthcare though? I mean yes the ACA is in many ways worse than what it replaced. But do doctors have a favorite solution for good affordable medical care for the masses?

    1. bob

      “What is the AMA’s position on single payer/universal healthcare though”

      They were the first group invited to DC to help “organize” the ACA. What do you think their position is?

      They were also in DC, designing the ACA, while the financial world was melting down. “Get the AMA set, then worry about the banks.”

      1. Propertius

        Again, AMA membership accounts for only about 15% of practicing US physicians. It’s not as though the AMA’s talking points are representative.

        1. bob

          What’s it not representative of? The AMA was first in the door to set the stage for the ACA. The question was about the AMA.

          What am I missing? How is the AMA not representative of the AMA?

    2. jrs

      basically the only reason the ACA had ANY support among the public, rotten bargain that it was, is that many people couldn’t get insurance at all (due to preexisting conditions etc..) and medical insurance had already become prohibitively expensive so many others couldn’t get it because they didn’t have the money. So the system already didn’t work … If doctors wanted to address this it’s been years in the making …

    3. Benedict@Large

      “What is the AMA’s position on single payer/universal healthcare though”

      Universal single payer was first introduced in Washington in the late 1940s. For the first half century of the effort to pass that legislation, it was the AMA that was the lead lobbyist against it.

      Now doctors are losing their practices as Wall Street takes over. They dug their own grave.

  35. Ernesto Lyon

    Compulsory Medical Care
    By Clarence Darrow

    “The efforts of the medical profession in the United States to control the treatment of human ailments is not due to its love of humanity. It is due to its love of its job – which job it proposes to monopolize. It has been carrying on a vigorous campaign all over the country against new methods and schools of healing because it wants the business, and insists that nobody shall live or die without its services.

    “Whether it cures more or fewer people than the schools which do not use medicine, or whether it cures anybody, are debatable questions which I shall not attempt to discuss. I stand for everyone’s right to regulate his own life so long as it doesn’t infringe on other people’s rights to do the same; and if a man wants to live and die without the aid of the medical profession, he should be permitted to do so. If he hasn’t that right it is pretty hard to tell what rights he should have.

    “Now I would have no quarrel with the medical profession if they would leave me alone. I am willing that they should advertise their wares, but I object to being forced to patronize them. They have specifics to prevent one from getting almost every disease, yet not one of them can explain how prevention is brought about – nor can he prove that it does prevent. They are not content to vaccinate those who apply to them, but they ask the State to compel everybody to be vaccinated. I might as well ask the State to compel everybody to hire me to try their cases!

    “Sometime if they keep on, and they will keep on if the people give them a chance, they will be able to vaccinate us for everything and we shall be compelled to submit. I have watched this medical profession for a long time, and it bears watching. I know that there is not a single thing affecting human life that they will not lay their hands on if we give them the chance.”

    – Clarence Darrow

  36. TheraP

    There’s another tie-in to the profit-driven medical system. And that is research on drugs. Just last week, on Good Friday afternoon, no less, my spouse received a phone-call from a top researcher in a specialty department where he is being seen (by another physician we really like).

    Although my spouse has previously indicated that he does not want to take part in research studies, the big-wig specialist (he made a point of his seniority to our well-liked doc) put on the pressure for said spouse to participate in one or another research study for medication. Now I should add that we’d already been apprised of such possibilities and our own doc had agreed that these meds in trials, indeed, had bad side-effects. But the big-wig tried to insist to the spouse that “You have a serious diagnosis and it’s going to get worse. And this one drug is already approved in Europe.” (Hmmm… then why did the European nephew who’s in the same specialty not recommend such a drug – as soon as last Spring when the diagnosis was made? Why didn’t his Father convey such a dire warning when he visited us last Fall?)

    Needless to say, we are not going to be conned. But all too many will be! And this one drug can cost up to $2500 a month! And all it hopes to do is lower one “value” in a bevy of tests for this disease. A value which is measurable via testing, apparently, but not via subjective experience. (Or indeed longevity!) With side-effects so bad you need monthly monitoring for liver enzymes, stomach problems, dizziness, fatigue and so forth.

    It’s a very sad day when you need to protect yourself AGAINST medicine and medical providers. And I say this as a retired clinical psychologist, who tried to practice ethically, got out of managed care networks for that reason, and am mightily glad I don’t need to practice now – under the strong arm of healthcare as a business, rather than a calling.

  37. anon1776

    Some revelations from a physician:
    1. the AMA is an insurance affiliate, just like AARP. Only 15% of docs belong. Its goal is to sell products (insurances) and collect royalties on the coding system all medicaine uses.
    2. medical care in the US is just fine and better than most places. Please stop with the longevity studies without accounting for tobacco, gun violence and drug related problems (violence, HIV).
    3. the overwhelming number of physicians are good at what they do and are on your side.
    4. If Washington wanted to lower costs, it would set drug prices, just as they set EVERY OTHER MEDICAL PROCEDURE PRICE.
    5. The ACA is a direct subsidy of the Insurance Industry. Nothing more
    6. Real physicians don’t rename diseases: renaming breast carcinoma in situ doesn’t make less of a problem if you have it;
    7. In the UK, a patient and his physician should consider if a digital rectal exam is indicated! Then again, the rate of death for prostate cancer is significantly higher in the UK than the US (check the NHS guidelines on the web)
    8. physician fees have basically stayed the same for 15 years and are a small piece of the healthcare pie. Our government and insurance industry needed to stomp on them because they do fight for their patients. Can’t have that, can we?
    9. A brand name drug maker can pay off a generic maker to not make a drug- legally!
    10. Most physicians believe the American public have deserted their physicians and would rather rely on magazine articles and TV doctors for their health advice. well good for you. For me, I’ll pay my doc and heed his or her advice. They are the most caring and best educated among us. I am not going to squander my relationships. Will you?

    1. Nathanael

      The majority of physicians are being employed by these corporate conglomerates and are being *forced* to perform bad medicine.

      For me, I’ll do my research into my illnesses independently. Because I know my doctor won’t do his research; he’s only permitted to spend 15 minutes on me and doesn’t get paid for doing the research!

      1. mellon

        >Because I know my doctor won’t do his research; he’s only permitted to spend 15 minutes on me and doesn’t get paid for doing the research!

        You must be in another country. Here in the United States under managed care, doctors are being pressured to see more patients. They now only spend an average of 6 to 8 minutes with each patient.

  38. William

    It’s interesting that the article doesn’t say much about the patients, who are supplying the ailing bodies and minds for the medical-industrial complex to exploit. However, it can be surmised from reading the article that the patients and their ailments are being used as commodities.

  39. Propertius

    [Arguably, the main difference between a large hospital system and the Lannisters is that hospital systems have more money.]

    And, of course, a Lannister always pays his debts.

  40. AltoBerto

    The Athenian Stranger – Plato’s Laws
    “Did you ever observe that there are two classes of patients in states, slaves and freemen; and the slave doctors run about and cure the slaves, or wait for them in the dispensaries-practitioners of this sort never talk to their patients individually, or let them talk about their own individual complaints? The slave doctor prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a tyrant, he rushes off with equal assurance to some other servant who is ill; and so he relieves the master of the house of the care of his invalid slaves. But the other doctor, who is a freeman, attends and practises upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure. Now which is the better way of proceeding in a physician and in a trainer? Is he the better who accomplishes his ends in a double way, or he who works in one way, and that the ruder and inferior?”

  41. kaj

    MD means doctor of medicine, that is, there is a medicine, (yes a cure, can you believe it!) for all that ails you, it wont hurt you, it will help you is what they say.

    This whole column is spent feeling sorry for the physicians aka SOBs, fleecing bastards, when their knowledge is really based very little real knowledge;;; a lot of Ph.D.s could become physicians if they wanted to. Physicians become physicians not because they truly care for people but because of future assurance of high income — that is all they care about.

    About 50 years ago, I was shocked to hear that physician won’t divulge the test results of a positive pap-smear to a patient till she had paid her lab bill. He was sued and I did not follow up on the story. A friend underwent a bypass surgery about 15 years ago and it turned out that he had been scared into it by a young surgeon who told him that he might die when stents might have done the trick. It turns out that the surgeon was the lowest member of the cardiology group’s totem-pole and needed healthy patients to do multi-vessel bypass surgery and my friend under-went a 5 vessel bypass: his cardiologist told him that 2 arteries needed replacement. A Harvard trained opthalmologist robbed another friend of an eye! Never seems to end.
    These bastards are over-worked because they chase money and social prestige, that is all. That is their Nirvana. Harvard health letter and the Mayo Clinic’s health letter both now emphasize exercise, good and balanced nutrition (less animal protein, lots of vegetables, esp. greens) and recently fresh (un/under polluted air). Talk to an internist about these things and they will chase you out of the office. Feel sorry for their predicament, Never.
    This country needs a reasonably well-funded, non-politically touchable system like the British Health Care system, where the Physicians are employees like most of us.

    I worked for Medicare and Medicaid policy and saw costs escalate with physicians cheating and misdiagnosing into wild the blue yonder. I am sick of these thugs and their big-Pharma buddies and the hospital chains.

  42. Gabriel

    What we’re looking at here at its root is greed – also known a the more-revenue-and-more-profit virus. I see it in many places. I see it when I go to the dentist, to get my car looked at, when I visit a physician, and so on. How can I sell you more, how can I charge more for this service, how can I spend less time with you?

    Since we are mostly a service economy it’s tough to avoid getting bit by the greed virus. And it’s not realistic to blame “them,” the other guy – because most of us in some way rely on the money obtained by the virus. Our jobs often depend on our firm making more money and more profit – as do our 401Ks in our pensions.

    And unfortunately once greed in one sector of the economy takes hold, it produces revenue and profit pressures in other economic sectors – and the greed spiral takes off. Greed in one place pushes other spots in the economy to also seek more profits and revenues.

    So for me the question is how how do we diminish greed or stop it in our economy. Government used to be one way to control greed, but not stop it, but government today sees its job as propping up business and jobs. Short of a traumatic event like a general war or another great depression, how can we stop greed? Are there more gentle ways to diminish or stop it?

    A more difficult prior question is – do we want to stop mounting greed in our country? Do we even see the connection between outsized greed in some industries and the resultant problems?

  43. OMF

    The common thread here, as in so many industries and professions, has been the takeover of an occupation by a parasitic and incompetent administrative layer.

  44. Reify

    A brief screed on Healthcare: What About Nurses, Social Workers, Chaplains and others whose services are “bundled” into hospital bills, who can not bill insurance companies per unit of service?

    If we consider the healthcare system to be our patient and come to the conclusion that the patient has cancer,- what do we do? Currently, on the front lines of Healthcare, especially hospitals,
    the “answer” is to resect (remove) healthy muscle tissue, i.e. nurses, and others,** though this is NOT where the cancer is.
    If you read nursing management journals these days they are full of “languaging” which is lifted right out of Japanese automobile manufacturing management lingo from the 70’s, later picked up by Jack Welch et al. Never mind that the Japanese themselves did not (and do not) use this approach to healthcare and have a single payer system.
    Briefly, the “scientific” mechanism hospital nursing departments are thus subjected to is “benchmarking” as to what staffing should be, comparing one’s hospital to hospitals somewhere, (Bangladesh?), and “ruthlessly” staffing to match that level of “nursing hours per patient”.

    What follows inevitably is a lower nurse to patient ratio,
    and the predictable result of riskier care,
    as fewer staff move at higher speed
    trying to “keep all the balls in the air”.

    The crazy making double bind is enhanced with a new top down vigilant tone against overtime, mistakes.
    (This last shift undermines a long standing culture of collegial, open, problem solving analysis of process to detect patterns of mistakes and thus vulnerability in the system to error. The emphasis begins to feel like a shift toward blaming, scrupulously avoided in the past.)

    Meanwhile the most demanding patient remains the computer where the Electronic Health Record co-opts the nurse as an extension of the Risk Management department. There, more charting screens are added when the Committee in the Cloud thinks of something else that could go wrong but screens (forms to fill out) are never removed. EHR is becoming the “Hotel California” of healthcare as constituencies formed of those dissociated from the actual process of providing care, programmers and administrators, HMO controllers, push their demands forward irrespective of the impact on the finite time of the actual care providers.

    **Actual holistic providers are devalued and/or depopulated. Social Workers have had their ranks diminished and are relegated to the narrow task of discharge planning. In order to break their ties of expertise and care for their historic clientele, say Labor and Delivery, and enhance their focus on their new, narrower job descriptions, hospitals have moved all their social workers to departments they are unfamiliar with. Hospices downsize the number of chaplains, “because anyone can provide beside counseling.” Old hands experienced with leading staff through painful debriefings after sentinel events are let go because anyone could do that. Not “value added.” And on and on.

    Completing the picture is the imposition of condescending doggerel as to what nurses and other caregivers should think, with attempts to reframe, rein in, any skepticism about the impact of these changes on patient care. In this inductive environment one’s response is merely indicative of whether or not one is “disengaged”, or working to help the team “win.” All nursing activity needs to be “value added,” including relationship with the patient. Such an environment quickly stifles dialogue.

    Middle managers, having drunk of the Kool Aid, have forgotten how to think for themselves, lost in the semantic cul-de-sacs of their new vocabulary, with their minds concentrated on job security by the periodic purges, relabeling and consolidating of their positions.

    This will all culminate with the announced, predictable return of the nursing shortage timed perfectly to coincide with the Baby Boomer demographic bulge moving into the time of maximal need for care and the denouement of the infernal HMO/ACA/ACO $$ machine. As to the other marginalized disciplines I have mentioned where excellent job performance cannot be immediately connected to a “billable moment” they will be relegated to a tenuous future indeed. Their heed of the call to do their chosen work will be what guides them to provide care in spite of the systems they work in. Respect them for this.

  45. impermanence

    The lesson here is that the every institution eventually morphs into the same ugly beast. The good news is that people are being forced into taking responsibility for their own health care.

    Proper diet, adequate exercise, and mental/emotional equilibrium is the formula for good heath, a prescription that has been known for thousands of years. Practice/maintain this balance and you will enjoy the best life you can.

    1. Lambert Strether

      “People” are not being forced into taking responsibility for their health care. Bodies are being force-fed into a machine designed to extract the maximum amount of money from them. If there’s a healthy outcome, that’s a random side effect.

      1. impermanence

        As people can no longer afford traditional health care, indeed, they are being “forced” into taking care of themselves.

        In the end, the individual must take responsibility for themselves. To become dependent on institutions, “to save ones sweet ass,” is as ignorant as it is illusory.

        Although a single-payer national health care system is certainly preferable to a corporate-controlled system, the answer does not lie there.

        1. Nathanael

          Oh, you have to be dependent on institutions. No lone individual has a chance.

          Right now, it seems like we have to build our own institutions, since the existing ones are mostly rotten and corrupt. Time to organize, as the communists and trade unionists say…

        2. mellon

          Many Americans have been doing that for years. They just thought it would be different now. But they should have realized, the system is corrupt to the core.

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