The cure for ailing health care lies in returning to ethical traditions, prioritizing patient care over profits, holding physicians accountable, and reforming existing oversight bodies and professional organizations. The ailing health care is curable. To be made whole again, it requires obvious but drastic steps. The crux of the problem is that medicine largely abandoned its own traditions and time-tested modus operandi in favor of the seemingly efficient and shiny methodology of the business/merchant community. Human beings are not commodities. Disease is not an experience to be handled by techniques of the hospitality industry. Nor is it on par with buying items, e.g., clothes. The skill and compassion of a practitioner matter and will shine through, regardless of a cure, complication, life, or death. It is this sustained bona fide ethic that builds durable reputations and ultimately proves profitable, rather than gimmicks, latest business fads, or artificial and potentially exploitative productivity measurement tools.
The etiology of health care’s indigestion includes insurance, administration, physicians (yes!), alongside patients themselves, professional organizations, and a lack of genuine oversight and accountability. Let’s address each.
Insurance companies generating revenue in the stock market to spend on health care is genius. It isn’t because it is unchecked. The remedy may be to categorize health-related stocks where a substantial portion of revenue must be obligatorily spent on enabling patients to obtain good health care. This portion should be substantial and protected from encroachment by expenses, e.g., administrative costs, salaries, dividends, bonuses, etc. Insurance companies “save” money by gaming the system and create a chain reaction, where hospitals and physicians counter with their own games. Rather than making health care affordable, insurance companies are the main perpetrators underlying its crisis. Treatments become mainstream or out of vogue, depending upon the payout or lack thereof. The insurance system creates a perverse incentive for the surgeon (and hospitals) to perform excessive operations instead of the one needed. Conversely, a general practitioner or a facility may find it far more rewarding to check the quality measure boxes accepted by insurance companies, farm out patient care to employed, relatively unsupervised PAs and NPs at business locations all over town, to the detriment of real patient care. Such entities usually are no strangers to litigation, where they may cause enough inconvenience for insurance companies to be usually left alone and benefit from dubious treatment claims. The squeaky wheel gets greased to the detriment of bona fide patient care.
The best and most suitable person to lead a hospital or health care organization is a capable, well-rounded doctor or nurse with practical experience in general and specialized health care and integrity and abundant empathy. It is not someone whose training is from the sales or assembly line tradition. Nor a physician who has pivoted to administration because of his/her ineptitude in practice. Health care is hierarchical like the military or the church. It too is best run by its own, steeped in its peculiar customs that have withstood the test of time. It makes a difference to such organizations whether they are led by Alexander (the Great) or Alexander VI. Counterintuitive as it may seem, prioritizing profit over care eventually is the undoing. Despite the best of intentions, the lack of lived experience as a physician/nurse causes non-physician/non-nurse administrators to make decisions that prove poor. It is tantamount to a military historian believing his vast knowledge in the subject renders him capable of commanding the army during war. Individuals or entities without a bona fide medical background usually enter health care with the objective of making money by practicing the techniques of the extractive economy, thereby depleting to death the very system that enriches them.
Physicians are the sun of the solar system that is health care. They make and break it. Therefore, they must stand up for their patients unfailingly and heed their conscience frequently. They must be held to a high standard. This is not a demand for perfection, rather for competence, empathy, humility, and integrity. Any physician found wanting and deliberately harming a patient for personal gain should be summarily banished from practicing forever. A physician’s unique status must also be acknowledged by recognizing their autonomy and better compensation. The same holds true for nurses. Quality does not come for naught. As things stand, those who are most crucial are squeezed evermore, while those who are parasites on the system are well rewarded.
A patient cannot be faulted for being unable to separate the grain from the chaff. It is their right to expect that a physician is qualified to treat. Matters of health, life, and death should not rest on the luck of the draw. Conversely, patients are losers when they approach treatment as they would goods and wares and conflate health service with the hospitality industry. Sound health care occurs when there is a social contract whereby physicians treat to the best of their abilities, are transparent, and patients recognize that the physician is going over and above to restore health. They also recognize that an untoward outcome can be an act of God, not malintent or malpractice. When one approaches treatment with the air of someone looking to litigate an unfortunate occurrence, it may lead to a self-fulfilling prophecy. Ambulance chasers also harm themselves, for they may inadvertently reap the consequences of a depleted system, as patients.
In practical terms, the only protection the patient has against bad medicine is a physician’s conscience. It is inadequate. While well-intended accountability tools are in place, e.g., morbidity and mortality (M&M) conferences, peer review, etc., as is their wont, humans have distorted them for purposes other than intended. Those who lead such bodies frequently suffer from dubious ethics and integrity. Rather than tools to learn from errors and improve patient care, they can be means of scapegoating and sweeping malpractice under the rug. They also shield otherwise bad physicians who generate significant revenue for the hospitals. Case in point, Christopher Duntsch of Texas, who mauled and killed in the guise of neurosurgery, and more than one hospital looked the other way. Why would a facility look into excessive surgery if it generates far more revenue than the straightforward (or no) surgery? JCAHO reviews and certifies hospitals. It draws subscriptions from the accredited hospital and has in its employ members from the hospital industry. JCAHO is conflicted because it is expected to bite the hand that feeds it. It shows in the number of hospitals de-certified.
Peer review is a commercial enterprise where hospitals may engage companies, frequently cognizant of the type of decisions they make. The peer review companies do what’s necessary to remain viable. Proper accountability requires that as much as possible, the process is truly blinded. The members of oversight bodies need to be independent of the organization or industry. They may be retired health care nurses, physicians, and laypersons of proven integrity, unbiased, and with the objective of improving health care and protecting patients. The confidentiality granted to M&M and similar review bodies must be subject to effective audits, to gauge if they serve their intended purpose.
Health care is burdened by dinosaurs in the garb of professional organizations, e.g., AMA. Their primary purpose appears to be bilking their members to benefit those at the helm and support the organizations’ burgeoning and redundant bureaucracy. Medical specialties are balkanized evermore, and their requisite certification and re-certifications create new revenue streams. Unnecessary CME requirements are generated with physicians compelled to take (and pay for) them, where the body of information may be completely irrelevant to the particular practitioner. They monetize physician data, even to the detriment of the physicians and regardless of whether or not a physician is the organization’s member or has consented to such data usage. It may be time to curtail or disband these behemoth, top-heavy organizations with overarching agendas. Perhaps physicians are better served by a union properly fighting their corner? Similar to driving and medical licenses, the qualifications and suitability to practice could be under the purview of a state (or federal) body? The same goes for granting privileges at hospitals or clinics. The current system can encourage monopolies or informal guilds whereby qualified physicians may be shut out, e.g., by creating conditions in the hospital bylaws that are very easy to change or insurmountable, depending upon what suits the administration or the entrenched physicians. Open and fair competition raises standards and weeds out the incompetent and the unsavory.
The suggestions above are doable. Remedy is possible for what ails health care.
Shah-Naz H. Khan is a neurosurgeon.