What the US “Health Care Reform” Debate Did Not Address

Yves here. A comprehensive and sobering piece.

By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal

It looks like the bizarre process in the US Senate ostensibly to “repeal and replace Obamacare” (aka the Affordable Care Act, or ACA) may be ending, at least for now.  I can only hope that further discussion of health care reform will let sanity prevail, and start to address the major issues that have led to the massive dysfunction of US health care, but were not discussed during the latest kerfuffle (and not even discussed much in the real debate that preceded the introduction of the ACA.)

On Health Care Renewal we have discussed some of the issues that have received much less attention than the Senate process and the push by the Trump administration to get rid of Obamacare.  I submit the country needs to revisit these issues (and in some cases face them for the first time).

Health Care Dysfunction

Despite some protestations to the contrary (e.g., here), the US health care system has been plagued by dysfunction.  According to a recent Commonwealth Fund study, the US was ranked 11 out of 11 in health care quality, but 1 out of 11 in costs.  Traditionally, health care reform has targeted ongoing problems in the cost, accessibility and quality of health care.  The ACA notably seems to have improved access, but hardly addressed cost or quality.

Early on we noticed a number of factors that seemed enable increasing dysfunction, but were not much discussed.  These factors notably distorted how medical and health care decisions were made, leading to overuse of excessively expensive tests and treatments that provided minimal or no benefits to outweight their harms.

Threats to the Integrity of the Clinical Evidence Base

Evidence-based medicine advocates making decisions for individual patients based on critical review of the best evidence from clinical research to make decisions that will provide patients with the most benefits and the least harms.  However, the clinical evidence has been increasingly affected by manipulation of research studies, including aspects of their design, implementation, and analysis.  Such manipulation may benefit research sponsors, now often corporations who seek to sell products like drugs and devices and health care services.  Manipulation may be more likely when research is done by for-profit contract research organizastions(CROs) which may get more busines when they can produce results to fit the sponors’ interests. When research manipulation failed to produce results to sponsors’ liking, research studies could simply be suppressed or hidden.  The distorted research that was thus selectively produced was further enhanced by biased research dissemination, including ghost-written articles ghost-managed by for-profit medical education and communications companies (MECCs). Furthermore, manipulation and suppression of clinical research may be facilitated by health care professionals and academics conflicted by financial ties to research sponsors.  Clinical decision making based on evidence delibrately biased to favor particular products or services is liable to distortion, and the overuse of products and services that are excessively expensive, useless, and/or harmful.

Deceptive Marketing

The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing campaigns became ultimate examples of decpetive marketing.  Deceptive marketing was further enabled by the use of health care professionals paid as marketers by health care corporations, but disguised as unbiased key opinion leaders,another example of the perils of deliberate generation of  conflicts of interest affecting health care professionals and academics.  These extensive deceptive marketing efforts likely have induced again the overuse of products and services that are excessively expensive, useless, and/or harmful.

Distortion of Health Care Regulation Policy Making

Similarly, promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.

Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.

Bad Leadership and Governance

A major factor driving various distortions of medical and health care policy making which could have increased costs, decreased access, and threaten quality was bad leadership and governance of the organizations involved.

Health care leadership was often ill-informed.  More and more people leading non-profit, for-profit and government have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research. One could view recent legislative efforts to “repeal and replace Obamacare,” which largely shut out the input of health care professionals and health policy experts as a giant example of apparently deliberately ill-informed leadership.  Obviously health care and health policy decisions made by ill-informed people are likely to have detrimental effects on patients’ and the public’s health.

Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations’ health care mission, and/or health care professionals’ values.  The most recent example we have posted was a hospital CEO who allegedly over-ruled medical leadership to hire a surgeon despite reports that his patients died more frequently than expected, gamed reports of clinic utilization, and associated with organized crime (look here).

Health care leaders were driven by perverse incentives that prioritized financial goals over patient care.  Executives may received millions of dollars despite reports of poor clinical results or unethical behavior.  We have seen executives get raises after their companies made huge legal settlements of allegations of kickbacks or fraud.  The hospital executive mentioned above was receiving $1.7 million a year, plus perks like a car and driver.  Obviously, providing incentives that disregard patients’ and public health outcomes and unethical behavior can induce decisions that lead to excess costs, insufficient access, and poor health care quality.

Health care leaders often had their own conflicts of interest.  For example, leaders of academic medicine frequently had financial relationships with corporations that sold health care products or services. In one study, approximately 60% of academic department chairs had such conflicts.  These included being consultants, paid key opinion leaders (as noted above), or even serving as corporate executives or members of boards of directors (e.g., see our first post on this phenomenon in 2006 here, and this articledocumenting the frequency of such conflicts.)   The latter conflict of interest is particularly concerning because directors of for-profit corporations are supposed to have unyielding loyalty to the interests of the corporation and its stockholders, although they are frequently accused of acting mainly as cronies of the top hired executives (see here and here).  Leaders who have such conflicts might be biased in favor of their corporate benefactors’ interests even when they conflicted with their institutions’ missions.

Moreover, we have found numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.  One would hardly expect corrupt leadership to put patients’ and the public’s health ahead of the leaders’ ongoing enrichment.

Health care leaders in the private sector (non-profit or for-profit) are supposed to operate under the governance of boards of trustees or boards of directors.  However, these boards may be populated by the leaders’ cronies, and fellow corporate executives, but often not by people who primarily represent the interests of patients or the public at large.  Such governance has proven to be opaque, fail to be accountable to patients and the public, and sometimes conflicted (e.g., non-profit trustees who are executives of for-profit health care corporations).  Such governance would be unlikely to restrain bad decision making driven by bad leadership.

Over-Arching Trends

Finally, bad health care leadership and governance has been enabled by series of over-arching trends.

Concentration of Power

Health care increasingly dominated by ever larger and more powerful organizations.  Such concentration of power may be facilitated by uninformed regulatory changes, and regulatory capture by private interests.  Concentration of power in industries outside of health care, which may culminate in the formation of oligopolies and even monopolies, historically has led to increased prices and hurt consumers and workers.  Concentration of power may well be a major factor in rising health care costs, and declining access and health care quality.

Abandonment of Health Care as a Calling

A US Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members, leading to the abandonment of traditional prohibitions on the commercial practice of medicine.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be “commercialized, nor treated as a commodity in trade.”  After then, it ceased trying to maintain this prohibition. Doctors were pushed to be businesspeople, and to give making money the same priority as upholding their oaths.  See posts  here and here.

Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations.  The physicians and other health care professionals they hire are thus providing care as corporate employees, resulting in the rise of the corporate physician.  These health care professionals may befurther torn between their oaths, and the dictates of their corporate managers.  When corporate imperatives to increase revenue prevail, no matter what, the outcome is likely to be worse patient care, higher costs, less access, and worse outcomes.

Perverse Incentives Put Money Ahead of Patients, Education and Research

We have extensively discussed the perverse incentives that seem to rule the leaders of health care. Financial incentives may be large enough to make leaders of health care organizations rich.  Even leaders of non-profit organizations such as academic medical centers and the parent universities of medical schools often make many millions of dollars a year in the US.  Incentives often prioritize financial results over patient care.  Some seem to originate from the shareholder value dogma promoted in business school, which de facto translates into putting current revenue ahead of all other considerations, including patient care, education and research (look here).   Health care leaders may become “value extractors” who put revenue, and the positive incentives they receive from enhancing revenue, ahead of all else (look here).  This may be a leading cause of mission-hostile management.

Cult of Leadership

Top leaders of health care organizations, be they non-profits or at least publicly held for-profit companies, used to be considered hired managers beholden to the organizations’ mission, its board, and its various constituencies.  However, such leaders, particularly CEOs, tend now to be regarded as  exalted beings, blessed with brilliance, if not true “visionaries,” deserving of ever increasing pay whatever their organizations’ performance.  This pheonomenon has been termed “CEO disease” (see this post).  Afflicted leaders tend to be protected from reality by their sycophantic subordinates, and thus to believe their own propaganda.  Leaders in these bubbles tend to make bad decisions, and put their self-interest ahead of patients’ and the public’s health.

Managerialism

Leadership of health care organizations by managers with no background in actual health care, public health, or biomedical science has been promoted by the doctrine of managerialism which holds that general management training is sufficient for leaders of  all organizations, regardless of their knowledge of the organizations’ fundamental mission.  Ill-informed management may result from leaders who have no background or training in actual health care.  Managers lacking understanding of or sympathy towards health care professionals’ values may be more likely to practice mission-hostile management.

Impunity Enabling Corrupt Leadership

Leaders of health care organizations increasingly have conflicts of interest, as noted above. Such conflicts may be risk factors for actual corruption (as defined by Transpaency International, the abuse of entrusted power for private gain).   Also as noted above, we have found numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, usually of corporate entities.  Corrupt leadership obviously can distort, if not ruin decision making, and channel large sums of money into private pockets.

In the US, nearly all cases involving corruption in large health care organizations are resolved by legal settlements.  Such settlements may include fines paid by the corporations, but not by any individuals.  Such fines are usually small compared to the revenue generated by the corrupt behavior, and may be regarded as costs of doing business.  Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements.  The former were originally meant to give young, non-violent first offenders a second chance (look here).  However, in most instances in which corruption became public, are no negative consequences ensue for the leaders of the organizations on whose watch corrupt behavior occurred, or who may have enabled, authorized, or directed the behaviors.  Since no individuals suffer negative consequences, the deterrent effect of such settlements on future corrupt behavior is likely to be nil.

Taboos

When we started Health Care Renewal, such issues as suppression and manipulation of research, and health care professionals’ conflicts of interests rarely appeared in the media or in medical and health care scholarly literature.  While these issues are now more often publicly discussed, most of the other topics listed above still rarely appear in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant.  For example, a survey by Transparency International showed that 43% of US resondents thought that American health care is corrupt.  It was covered by this blog, but not by any major US media outlet or medical or health care journal.  We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  As we noted above, the people who profit the most, those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.  But, if we cannot even discuss what is really wrong with health care, how are we going to fix it?

Real Health Care Reform

After the ACA became law, we noted that while it had some worthwhile provisions, it hardly addressed the concerns we had been raising to that point. Nonetheless, these deficiences were hardly raised by any of those advocating “repeal and replace.”

Now that perhaps more sober heads a are prevailing, maybe it is time to consider some of the real causes of health care dysfunction that true health care reform needs to address, no matter how much that distresses those who currently most p

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19 comments

  1. Bobby Gladd

    “Every misspent dollar in the U.S. health care system is part of somebody’s paycheck.” – Brent James, MD, M.Stat

  2. shinola

    Another example of the pernicious results of Milton Friedman’s “Maximize Shareholder Value” theology.

    Friedman to U.S. health care: Build a crappy system

  3. Tooearly

    healing from this malady will be generational work. I hope the author continues his passionate efforts to expose the details of how this pernicious rot at the heart of our health care nonsystem works and also elaborates on a way out of the mess

  4. Jeremy Grimm

    As I read the litany of sins in the Medical Industrial Complex I could hear echoes in the Education Industrial Complex — in the Science Mart … and other rotting institutions of our culture — what remains of it — eaten by Neoliberal Market formation. I should add that “Neoliberal Market formation” fails to identify the actors doing this eating — our Elite Classes hiding behind Corporate Masks, actualizing Corporate pillaging and destruction. And I remain convinced our Corporations constitute a new form of life bent on mindless actions yielding near term profits but promising the destruction of all we hold dear — even the planet we live upon.

    I sincerely hope our polity might begin to address the numerous horrors described in this post in a real health care debate. I have my own list of concerns about our Medical Industrial Complex — neither so comprehensive nor so astute as the list in this post. Related to the topic “the Abandonment of Health Care as a Calling” — the process for selecting candidates for Medical School does not select for the candidates best suited to become physicians and worse entices many promising Organic Chemists, Biochemists, and Geneticists away from their true callings. The constant hazing of Resident Doctors demeans them, threatens public health, and builds the doctors’ self-annoited god-mystique.

    I am concerned by the way many doctors treat nurses and their support staff. As doctors are overpaid the nurses are grossly underpaid and mistreated by needlessly abitrary schedules solely focused on minimizing nursing costs while ignoring patient care and whatever life nurses might have away from work. What about the growing disparity between the profits of general practice and the profits of specialists? Doctors breed discontent in their own ranks. Why are doctors given such control and authority over the drugs used to treat patients? Most physicians study pharma for half a year — perhaps a year at most. They make easy prey for our Drug Industry.

    I severely condemn the present generation of medical doctors whose short-sighted quest for wealth undermines their Profession and will make it thrall to the Corporate Elite of the Medical Industrial Complex. Who benefits as the rising costs of Medical School and malpractice insurance and medical bookkeeping and accounting associated with medical insurance drive up the costs of becoming a doctor. Are doctors immune from becoming debt serfs like the rest of the population? Who will own and profit from holding their debt? Do doctors really believe their union is strong enough to fight changes to state controlled licensing of medical doctors? Those who can afford health care can already afford to travel abroad to obtain it. What will happen when travel to Cuba and its numerous well-trained Physicians becomes easier. What about H1-B visas for Physicians? Is that really an impossibility? Today’s doctors are paving the way for the capture of their profession and the reduction of an ancient calling to a commodity practiced by captive medical employees of the Medical Industrial Complex.

    1. Arizona Slim

      Speaking of travel to Cuba, anyone else remember Michael Moore’s movie, “Sicko”?

      Moore took a group of ailing 9/11 first responders to Havana. Reason: To get them the medical care that they couldn’t afford in this country.

      Not only did they get proper care, they were given a hero’s welcome by the Cuban people. In one scene, they went to a fire station and were greeted by firefighters standing at attention.

      Oh, about those H1Bs for doctors, Dean Baker (of Beat the Press fame) has been an advocate for years.

      1. JohnScarpaccio

        I cannot help but see H1Bs for doctors (or dentists) as a form of imperialism and theft. I’ve also read Baker’s proposals on this and the ways he attempts to also benefit the country of origin of the doctors but it just doesn’t feel right to me.

        The question Baker never seemed to address is why can we simply not have more Americans become doctors and dentists? The issue is not intelligence or capability, but instead the cost of education and training. But given that the federal government has infinite money, this is not a problem, the only issue becomes the time required to get the new recruits up and running.

        Of course Baker never seemed to be on board with the idea of the federal government possessing infinite dollars so this may be why he does not address it. His book, Rigged, certainly had some interesting solutions around the issue of copyrights and patents but even there it seemed to be flawed and incomplete due to his reluctance to accept the concept of infinite dollars.

        1. reslez

          Elites can import all the educated laborers they want, so they’re not going to spend any of their money educating the people here.

    2. reslez

      > I am concerned by the way many doctors treat nurses and their support staff.

      I knew a resident who referred to surgical techs as her “bitches”. Completely stomach-turning. And what patient would want to be treated by a doctor with that kind of attitude?

  5. PITA

    Appreciate the diligence and depth of coverage from Dr. Poses. Having once worked for a smaller community not-for-profit hospital that later was acquired by a large corporate entity, I saw first hand, albeit from the distance of a non-healthcare provider, the corruption of medical ethics by healthcare leaders. I left the hospital about 15 years ago. Several years later, the hospital was closed for business reasons (profits better elsewhere). The local community, especially that segment of people needing mental-health care, suffered greatly.

  6. Steve

    Our system is failing and the only solution I can see is a single payer system for all basic health care. With 17% to 18% of our economy being based on our current health care business model there are no quick or easy solutions. I think a good way to start and push the debate towards a single payer system is to gradually increase the segments of our society that are covered by Medicare. Extending Medicare coverage to all children from birth to 18 or 21 would be a good start. We should also be extending coverage in reverse to all seniors instead of raising the age limit we should be lowering it incrementally. One of the biggest problems with our system is the reality that Americans can never afford the level of health care they believe they deserve at the price they are willing to pay.

    1. Anonymous

      Single payer ain’t gonna work when we have such a short supply of doctors that specialists (and they’re all specialists nowadays) pull in 300k++

  7. Tyronius

    11th of 11 in patient outcomes, yet 1st of 11 in cost?

    This is yet another example of the systematic capture of our institutions and professions by corporate interests who are incentivized by profits rather than outcomes.

    I suspect we will continue to get such substandard results in the medical industry and elsewhere until and unless we can put an end to the stranglehold campaign contribution ‘donations’ have on our political system.

    Citizens United is wrecking everything our country was once world renowned and respected for.

  8. mtnwoman

    Great essay that cuts to the core.

    I’ve been in the medical trenches for 30+ years. I saw and experienced a lot of this on a personal basis. Fortunately, I’m in solo, cash-only practice (see Ideal Medical Practice) just so I can do more straight up medicine without the annonying interference of the Medical Industrial Complex.

  9. kramer

    I think much of these shenanigans would not happen if we had a very high income tax rate on very high incomes. When the pile of loot becomes huge, peoples’ moral sensibilities and fear of punishment are overwhelmed.

  10. roxan

    Before we can have single payer we must have free or heavily subsidized medical schools. All the various medically related professions are very expensive. Nurses were often trained for free by hospitals even in the 1980s. Now, you could easily graduate with $100,000 in debt! Even nurse’s aides, who usually make minimum wage, are now forced to go to school. Twenty years ago, they were also trained for free–a whole two weeks of training–which is all anyone needs in order to learn how to move a patient and make a bed.

  11. Kris Alman

    As pointed out, “evidence-based medicine” in the United States is tainted by conflicts of interest. Not so for Cochrane.
    http://www.cochrane.org/about-us
    http://www.cochrane.org/about-us/our-name

    Consider mammography. How many doctors take the time to dissuade a woman without risk factors to not get one done.

    Yesterday our son asked my husband, a radiologist, his opinion about a video, The Little Known Truth About Mammograms. This comes from the series of Adam Ruins Everything on truTV.
    https://www.youtube.com/watch?v=Ni9TQHOsHUQ&feature=youtu.be

    My husband admitted the challenges of chasing false positives. Susan B. Komen Foundations has rightly been accused of overselling mammograms.
    http://www.huffingtonpost.com/2012/08/03/susan-g-komen-overselling-mammograms_n_1738428.html

    I stopped getting mammograms because I was sick and tired of the call backs for “dense” breasts. While I did not fear the return visits, it was a hassle. For the average patient, it would be costly for this “diagnostic,” rather than preventive, mammogram.

    From Cochrane:
    http://www.cochrane.org/CD001877/BREASTCA_screening-for-breast-cancer-with-mammography

    The studies which provided the most reliable information showed that screening did not reduce breast cancer mortality. Studies that were potentially more biased (less carefully done) found that screening reduced breast cancer mortality. However, screening will result in some women getting a cancer diagnosis even though their cancer would not have led to death or sickness. Currently, it is not possible to tell which women these are, and they are therefore likely to have breasts or lumps removed and to receive radiotherapy unnecessarily. If we assume that screening reduces breast cancer mortality by 15% after 13 years of follow-up and that overdiagnosis and overtreatment is at 30%, it means that for every 2000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings.

  12. Wade Riddick

    This is inevitable when you privatize public goods. It turns into extortion for profit. Privatized war means endless war. If you’re a military contractor making a profit going to war then why would you win or lose the war? You’ll be out of money. Similarly, if you make a profit running a private prison, you want more prisoners (“customers”) and thus a higher crime rate. If you make a profit treating sickness, you want more sickness. We tried privatizing fire departments once, a long time ago. Entire cities burned down.

    Entire lives are burning to the ground in the “healthcare” industry for pretty much the same reason. Like fire, disease spreads. This creates more “customers.” It would be nice if Poses began his arguments with a few irrefutable moral claims on public goods. When you trot out the actual laws of supply and demand, it’s no longer easy for these charlatans to hide behind pseudo-economic babble to justify their frauds.

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