By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, Nov. 8, 2013 Physicians tend to be a conservative group, in the sense that we’re cautious when it comes to new ideas. For example I find myself very reluctant to prescribe medications that have been on the market for only a few months or a short year or two, no matter what benefit their manufacturer’s claim they offer. Caution seems a better practice when it comes to our patients, especially if hundreds of millions have used a traditional treatment without harm, while the new medication in question is so slickly advertised.
Over the last couple of years, medicine as a profession has stood on the shore of a kind of health-systems continental drift. As a profession, we doctors have tried to keep doing what we have been doing, perhaps with a belief that our coastal province will eventually come (back) under our individual control.
It is almost as if we would so prefer to embrace a sedimentary but predictable process, a layering of generations of responsibility within our profession, measured in geological time, that we are loathe to try to decipher our own experience.
Beneath the surface, the continent of medical care is being subsumed into the continent of corporate power and profit. A few aspects of what we can do for patients have been uplifted, but most have been subsumed and driven deep underground or else sheared in half or even pulverized into pieces. The impact of these changes upon caring for patients comes not over a geological epoch but over a short decade or two. It is a worldwide process that now touches nearly every physician and nurse in the United States. While a few physicians have taken the opportunity to do well, rather than good, most of us head to work with the motivation that we can improve the health, and thus entire lives, of other human beings. If there are a few who have cashed in on business schemes and then gone on, for example to CEO work, those doctors remain the exception, not the rule, in our profession. Most of us head early to the office or clinic or hospital, and often keep extra hours at our work.
Physicians see the work of our profession as a call to service to humanity. Corporate executives in the giant health care enterprises that dominate our country see us quite differently. They see us not so much in a profession, but in a “position.”
These corporate “positions” are roles defined by the needs of the institution and its financial viability, not the talents, dedication or human qualities of individual caregivers. Similarly, patients are seen not for their needs but for the revenue stream they will provide. The plate tectonics metaphor makes sense to me because underneath it all, deep underground, lies a great collision of human values.
Will corporate medicine succeed in “profitizing” the caregiving relationship? Dr. Julian Tudor Hart, the great British physician, put forward a thesis that the doctor-patient relationship is a productive partnership. Together we work toward a product that has great value to ourselves personally as well as the society as a whole, the health of an individual. This fundamental character of caregiving may be seen as a human enterprise, but clearly it does not and cannot lend itself to the immediate extraction of profit.
This contradiction is a problem for corporations. It is even more of a problem for patients. And it is a problem for the profession of medicine. The effort to extract a profit from the doctor-patient relationship amounts to an effort to end it as a productive partnership and re-establish it as an adversarial money-driven contest.
The cause of profiteering from the care of human beings has been pushed further along by the Affordable Care Act. A new wave of corporate health care investment and conglomeration has been unleashed. In turn, we find a new escalation of user fees, co-pays, co-insurance, high deductibles, in-network fees and out-of-network fees. And with these a tangle of unintelligible rules and fees the prevalence of underinsurance – the phenomenon of having health insurance that doesn’t cover our health needs – is growing.
To capture revenue, health care corporations add administrators, finance experts, deal-makers and supervisors in a mushrooming byzantine bureaucracy. Patients simply try to hold on to their bank accounts. And physicians now begin to see a struggle to hold on to our profession. True to our conservative nature, and skeptical of the changes afoot, physicians want to get back to caregiving. The patients want the same. I believe we physicians need to partner with our patients, not only in the exam room, the operating room and at the bedside.
With earth-shaking changes altering the landscape of health care, to protect our hard-earned ability to provide truly expert care to our patients, the most conservative thing medicine as a profession can do is to start from the health needs of our patients – as individuals and as a population. We must partner with our patients to demand that our democracy provide its people with a health system without user fees, publicly pre-paid, so that every patient’s necessary care is freely available – for each and all.
Dr. Andrew Coates practices internal medicine in Upstate New York. He is president of Physicians for a National Health Program.
You can listen to Dr. Coates’ radio broadcast here: http://wamc.org/post/coates-corporate-influence-medicine
By Andrew D. Coates, M.D., F.A.C.P.