The ongoing battle for the soul of health care

The key change in medicine that has caused a escalation of costs, a decline in the quality of care, and an increasing shortage of physicians is the shift toward an exclusively business contract with society at the expense of the social contract.

To differentiate the business contract from the social contract I will use the following example. One afternoon I see my neighbor hard at work changing her tire. If I offer to help my neighbor without expecting any material reward then I am operating under a social contract. By helping my neighbor, I am strengthening the social bonds of the community.

However, if I walk over to my neighbor and tell her that I will help her with her tire but it will cost her $20, then I am acting under a business contract. My offer may be accepted, but I am not strengthening the social bonds of the community.

Every organization has to balance the business contract and the social contract aspects of their work. Physicians and health care organizations are no exceptions to this. Historically, in medicine, the social contract took precedence. One treated patients and made allowances for those who could not afford the usual fee for care.

In the past decades, several forces have driven the practice of medicine toward an overwhelming preponderance of the business contract at the expense of the social contract.

One of these was the establishment of the relative value unit (RVU) pricing system which rewarded doing things to patients more than talking to patients, and it rewarded speed. Generally the development of the social contract requires spending time communicating with a person and that is impossible to when patients are being seen as if they are on an assembly line. By rewarding the rapid performance of procedures, physicians who had more of a business contract orientation were able to make vastly more money than those who had more of a social contract model. With money comes power, and therefore those who subscribed to the business contract model were able to push the health care system in that direction.

Another factor in the loss of the social contract is the use of lawsuits to settle malpractice claims. While there can be debate about the monetary cost of malpractice litigation, there is no doubt about the cost to the social contract. Lawsuits destroy the social contract. Even the threat of litigation pushes health care providers toward a business contract model. And the more the business contract model is used, the more likely patients are to use lawsuits as a way of rectifying perceived wrongs. A destructive feedback cycle is set up.

As those pushing health care toward a business contract model gained power, the organizations they served became increasingly focused on providing health care solely as a way to make profit. These corporations purchased physician practices, turning physicians into employees and eliminating their ability to choose to follow a social contract model. The company’s goal is to maximize the amount of revenue it can generate and that means forcing the physician to see the maximum number of patients per day or be fired. These corporations also have manipulated laws and markets to make it hard for physicians who want to follow more of a social contract model to survive. The current goal of corporate health care is to use everything, including doctors, as a resource to increase profit.

Note that it doesn’t matter if a system is socialist, capitalist, non-profit or whatever. The key is on how the social contract and business contracts are balanced. A business organization can still maintain a social contract with its community or with society by being less greedy for profit.

This emphasis on the business contract model is the poison in the health care system. Yes, physicians can make excellent salaries. But, in order to make such a salary the physician is forced to engage in practices that are less and less logical or even helpful for patients. They are forced by their employer to treat patients as widgets, as objects to run tests on, or as orifices to stick probes and pills into, all to make more money for the corporation. Furthermore, there are fewer and fewer ways to opt out of the system, i.e. return to a social contract with patients, and survive economically.

Imagine that you run a photography business in which you get paid for taking and printing photos of people. You contract with your customers to produce photos that they enjoy. Now the government starts to pass laws regulating how you take photos and print them. This would be frustrating, but you would work to find ways to cope and people who wanted photos would come to you.

Now imagine that a big company is buying up photography shops. They offer you an opportunity to work for them. They will handle all the financial aspects, all the paperwork, and they will be able to pay you far more than you could make on your own. There is just one catch: If you work for them then 75% of the photos you take and print will be pornography. Why? They make more money on porn. Of course you can refuse to use your photographic skills to create porn. But what if there is no other option? Would you become a porn producer, or leave the photography business? What if you had a family who depended on you for food, clothing, shelter, and medical care? And if you do take the job then you either harden your heart and lose your soul, or you get depressed and perhaps suicidal.

This is the situation many doctors, and other health care providers, find themselves in. They want a strong social contract with their community and it is becoming impossible for them to achieve that. This conflict between the social contract model and the business contract model is a battle for the soul of health care. Physicians and other health care providers need to fight back against the business interests that have subverted the social contract. And when we fight, we need to make it clear to others and ourselves what we are fighting for: The return to the primacy of the social contract between the healer and the one who seeks healing.

Joseph P. Arpaia is a psychiatrist and co-author of Real Meditation in Minutes a Day: Enhancing Your Performance, Relationships, Spirituality, and Health.  He can be reached at his self-titled site, Joseph P Arpaia, MD.

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  • ninguem

    Kevin are you on this story?

    Here’s the deal. We are getting to the point where we are graduating more physicians, than we have postgraduate positions to train them.

    We’re just about at the tipping point, right now.

    A medical degree, without residency training, is a useless piece of paper, one that cost the student eight years of life and hard work, and upwards of a quarter-million-dollars debt.

    Right now, it’s 412 medical school graduates unable to find training. Not clear if that’s including the osteopathic graduates or not. If they didn’t count the osteopathic graduates, likely that number is significantly worse.

    In the past, the unmatched students were a couple types. They were bad apples, not bad enough to throw out, they were good enough to graduate, but no one wanted them for various reasons. Some were qualified students, but set their hopes on the very high-end competitive specialties, neurosurgery or plastics or derm, or ortho, and they.were perfectly good, but not good enough.

    There are new schools being opened right now. The established schools are expanding. That “412 unmatched graduates” number is guaranteed to get bigger. Much bigger.

  • DeceasedMD1

    This is a nice piece. But at some point all the understanding of the problem is not enough. We need to use our outrage in some way to fight back.

    • Arby

      I understand what you are saying. However, I appreciate this article for giving a big picture overview to an issue where it is easy to get lost in the weeds of each particular pain point.

      For patients, I think this type of dialogue is more understandable to us than some of the other ways to engage them that have been debated here.

      • DeceasedMD1

        oh I agree. For everyone. It was an article we can all relate to and feel understood as to how , well “pornographic” (author’s words”) the problem is.

  • Arby

    Welcome! I’m glad to see your article here.

  • Patient Kit

    It is possible to run a business ethically with a strong code of corporate social responsibility and still make a good profit. It is not a given, written in stone, that in order to be successful, everything — employees, customers (or, in healthcare, patients), community, environment, etc — must be sacrificed in order to maximize the bottom line at all costs. If the US healthcare system is going to remain, at it’s core, a Big Business, then we need to organize a push for more corporate social responsibility and reward those companies that are truly committed to that. Businesses need to make a fair, good profit in order to thrive. They don’t need to make the maximum profit possible at the expense of everything else. Despite what some would have us believe, greed is not good.

    • guest

      I think it is harder to do that than you might think, as the businesses without a strong code of social responsibility tend to be able to compete more successfully for business than those with a strong ethical compass.

      When the less-ethical businesses are more successful, and gain market share, they are able to drive the less successful businesses out of competition.

      • Patient Kit

        Agreed. Believe me, I’m under no illusion that it would be easy. In my previous job, I worked for years on a fair amount of corporate social responsibility campaigns and issues. And it is never easy to challenge something powerful or to engage and keep the public engaged in a campaign for change. It’s hard work. But it can be done. And it’s worth doing.

        My main point is that we don’t have to assume and accept that business has to be as exploitive and ruthless as it too often is these days. Of course, my personal preference would be for the US healthcare system to move away from being a pure profit-driven big business. But if it is going to be dominated by big business, we could try to make it better within that model.

        One thing is sure — any efforts by doctors and patients to change our healthcare system that diverts any of the money from those who make and control the money now , will not be easy. But what’s the alternative? Just throw our hands up and do nothing? That’s a big part of the reason why things have gotten so bad.

  • Thomas D Guastavino

    I have been a photographer for over 25 years. For years people brought me the photos to be processed. Some of my clients paid me for each photo, others had contacts with me where we both freely agreed upon how many photos I would provide at what price. I was even able to provide some services for free. Some clients were dissatisfied with my work, but for then most part the ability to freely choose your photographer was the best quality and cost control measure.
    One day a contact client showed up that became so large and powerful that it had the power to dictate policy. Soon I, and my fellow photographers, who were to complacent and fearful to say anything, were told how many hours we were to work, how much we were to paid, and setting the standards of quality for our work. Soon clients were showing up as often as they wished and we had to by law process as many photos as they had even if we were not paid at all. These clients even had their own police force, threatening us if there was even a hint that we not providing the highest quality photo processing available.
    Naturally, such a system cannot go on. There were numerous attempts to try and counteract what was happening but to no avail. Once you replace a system based on mutual voluntary association with one where an outside third party with its own motivations dictates the rules, that system is doomed. One can only guess what will rise from the ashes.

  • DeceasedMD1

    How did the docs react in the meeting? Why do you think they did not react? But I agree it is a lost cause at this point but the turning point was exactly the 90′s. thanks. you nailed that one.

    • Stefani D

      As I recall, they were impervious to any ‘outside’ pressure….they really thought that no one outside the medical community would dare challenge established medical practice. Which, in my case, was reminiscent of a meeting I had with the Chairman of Medicine at a medical school affiliated with the hospital in which I worked. I remember it well because as the Director of Critical Care Nursing at a large academic center in NYC I was charged with bringing the message of the impending prospective payment system to the faculty so they could, if they wanted, integrated it into the student training. When I told the Chair about the new DRG fixed rate system, he said (and yes, I remember the words vividly), “Little girl, they wouldn’t do that to us – its just a little turbulence to stir up the natives.” That’s a direct quote. That same arrogance has permeated the established medical community….just look what’s going on with the ABIM call for re-credentialing!

      • DeceasedMD1

        wow thank you for sharing that. that sort of arrogance is amazing! Even if it came sown to economics, one would think MD’s would fight back let alone now the regulations that are killing medicine. there is no one left to think. just procedures sold. What a rude thing to say. bet you wish you could go back and ask him to rethink what he said! LOL

        • Stefani D

          I am still active in the hospital industry as a consultant and I’m delighted to report that the young physicians starting practice seem to be more open minded and recognize the benefits of working as part of a team…so I’m hopeful that the future of healthcare will be more patient-centric and much safer.

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