That the United States spends the most on health care is unsurprising.
What’s questionable is paying so much for the worst health care system amongst high-income countries and being far behind many countries that could not be considered high-income by any stretch of the imagination.
Other than doing brilliantly at mammograms and seasonal flu vaccines, the U.S. is found appalling. Not just Canada and Mexico, but when the likes of Chile, Saudi Arabia, India and Dominica are ahead of us, and we are in league with Slovenia and Lithuania, it is time to blush. What gives? Corruption. Or, to put it in “morbidity and mortality conference” jargon: Corruption causing system failure.
Fixing the system is imperative.
It is not particularly egregious if one ends up choosing an inept plumber. It can be fatal, innocently choosing a bad doctor. There are laws of the land, bylaws of health care facilities and a code of ethics for its practitioners. All read principled and high-minded. Yet, the practitioners from the top down are compromised or survive by “see, hear and speak no evil.”
Integrity is frequently checked at the door. The problem arises out of an unnatural arrangement. The cat is expected to protect the mice. And, the mice, the cheese. The pharmaceutical and “health insurance companies must turn a good profit for themselves and their investors, which conflicts with their raison d’etre. It necessitates diverting health care dollars, doled out as profits and bonuses.
While just in the recent past, it was unconscionable not to prescribe copious amounts of pain medication at the whim of the patients (thus, enriching the pharma industry, never mind the addiction epidemic that destroyed lives). The current fad is to boot outpatients from hospitals as fast as possible (because they recover better at home!). It helps the industry’s cause to deny necessary procedures or delay them by ensnaring physicians in interminable processes to justify their treatment.
Imagine a surgeon fileting patients indiscriminately, causing complications and alarm. There are mechanisms available to check his (it usually is a “his”) mayhem. Except, doing so will deprive the hospital of the significant monetary gains from those misadventures in the guise of surgery. If you were an “astute” businessperson, which of the following steps makes sense? Following a modus operandi that a) will generate million(s); b) manage to just break even; c) leads to soaking in red.
Choosing “a” makes one a good hospital administrator, endears one in the eyes of the financial beneficiaries, and results in generous bonuses for the “fiscally prudent.”
As a fiscally prudent administrator, why would one kill the goose that lays the golden eggs? Far better to employ those quality control measures to show on paper that all is well — or use them to upend those who rock the boat and endanger the windfall.
If you choose “b,” your performance from a business perspective is lackluster, and expect to be replaced by a star. The star may be a CMO or CEO who blatantly demands — at the peril of livelihood or financial setback to the hapless physician — that patients be kept and referred within the particular hospital system, even to the patients’ detriment. So much for Stark laws! If you chose c), you are out the door.
The problems of discrimination and cronyism are rife in U.S. health care. We do not see it because we search for villains with horns on their heads. We don’t see the good neighbor, the great dad, the generous friend or the brilliant aunt.
We see the kindly doctor who treats our mother’s heart condition, and not that he refers patients to his friend who he knows is decidedly incompetent. We don’t see that he indiscriminately performs tests and procedures that serve no purpose other than to enrich him. He is also confident about getting away with it because he and his friends always have. He also does the hospital’s bidding by pulling in line or ostracizing colleagues who stood up for their patient’s welfare. Yet, his own family would be referred to the ostracized!
There is nothing really to prevent birds of a feather from flocking together, be they the well-entrenched old boys’ clubs, soft-spoken and polite in the deep south. Or it’s first-generation immigrants in the Midwest who have surreptitiously taken over the hospital in numeric strength, causing the original natives to largely flee. Medical ghettos are thus created, espousing tactics more in line with the mafia. If there were any “good” left amongst the physicians or administrators, they would adopt that old saying, “If you can’t beat them, join them.”
So, what is a principled physician to do? If you attempt to bell the cat, the cat eats you. The answer, in some ways, is straightforward.
Defang the cat.
For starters, expel insurance companies from the stock market to remove at least one perverse incentive. Just as advertising cigarettes is banned, disallow pharma from touting their wares to the public as if they were candy.
Other than perhaps the German army of WWII, there is no army in the world where the privates command the generals. Nor are the crucial logistical and administrative aspects outsourced to civilian MBAs so that the generals and soldiers can do what they are meant to do — fight.
They devise their own logistics and methods, getting the requisite education and training to do so. If anything is contracted out, the contractors are accountable to their clients, not turned into bosses.
Therefore, something is wrong with a system when highly qualified physicians are managed by high school graduates or those with less-than-stellar credentials.
Why complain when those who are from the finance and assembly line tradition run health care exactly like that? Given the opportunity, they would have done exactly the same to the military. Similar to the latter, health care should promote from its own ranks the most competent and able physicians and nurses with unquestioned integrity, who are untainted.
If we study good health care models, the physicians are at the helm and in crucial roles rather than in token leadership positions. The prevalent system generally enables physicians who are morally weak, chameleonic in integrity and servile to the non-medical administrators to be incorporated into the administration.
If led by those intent on feathering their caps and undermining their colleagues and profession, we can only be led further into the abyss. Administrators collecting bonuses for making a profit should be outlawed in medicine. With great power comes great responsibility.
In health care, that should mean that if a physician is found guilty of malpractice and the hospital is found lacking in checking it, the heads of the CMO, CEO and associates must roll alongside the unsavory physician. They automatically go if seen retaliating against a nurse, physician or employee attempting to protect the patient and do the right thing.
During such moments, suddenly, the administration protests their innocence due to their lack of medical background. Or they scapegoat the doctor or nurse. Just a few bootings in such circumstances will wonderfully fortify wavering integrities.
Just as the state grants licenses to practice, the state or a transparently autonomous body should handle privileges at any hospital, independent of the hospitals but with provisos reflecting their particular goals.
We are dealing with mere humans, so not just self-interest but conscious and unconscious biases prevail. Why else would blinded music auditions cause the percentage of female musicians to rise from 6 percent to 21 percent in highly-ranked national symphony orchestras?
Peer-review companies as a business are no better than the health insurance and pharmaceutical companies. He who pays the piper calls the tune, and so, peer-review companies commonly do the hospitals’ bidding in whitewashing unnecessary complications. Imagine a judicial system where one side could pay off the judge? Do away with any peer-review model where there is money to be made.
When it comes to our wealth, the system works well enough. We need not fear that someone might run away with the contents of our bank account. When it comes to our health, for many, it is the luck of the draw between good treatment, being injured by someone’s greed or ending emphatically dead — even as sickness and demise make possessing all the wealth in the world meaningless!
As amply demonstrated here in the U.S., throwing a lot of money at health care is not the solution. All it does is create a free-for-all to make hay while the sun shines. The few who walk the straight and narrow stick out like a sore thumb. Once, we had the best health care in the world. Today, it is in dire straits. The ship will sink if we don’t change course.
The author is an anonymous physician.
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