Why 99 percent of health care should be angry


As Occupy Wall Street has gone from an obscure protest covered only on blogs and social media to a national phenomenon, the apparent parallels between the issues it is raising and the issues we have been raising in health care grows.

 A growing number of protesters are calling themselves the “99 Percenters,” referring to those who are not in the top 1% of earners.  The top 1% of income is clearly greater than $250,000 per year, and likely around $380,000 a year.

In health care, nearly all who are paid more than $380,000 per year are either proceduralists (some medical sub-specialist physicians, and some surgeons, again mainly sub-specialist), or managers and executives of health care organizations.

Health care’s 1%

We have been discussing since 2007 how the inequality among physicians’ incomes favoring those who do procedures over primary care and other “cognitive” physicians has been driven not by the market, but by regulatory capture.  The fees paid for all physicians services by Medicare, a fee schedule adopted without question or major changes by nearly all insurers, are set through the Resource Based Relative Value System (RBRVS) by the US Center for Medicare and Medicaid Services (CMS).  CMS, in turn, gets virtually all its input on these fees from the RBRVS Update Committee (RUC), a private committee of the American Medical Association (AMA), made up largely of proceduralists, whose deliberations are secret, and whose membership has been secret until recently.  See here for most recent posts.  Note that the CMS’ peculiar relationship with the RUC is now subject of a lawsuit that accuses this relationship of violating the Federal Advisory Committee Act.

The real top earners in health care, however, are not physicians, but executives of big corporations, non-profit and especially for profit.  We have discussed endlessly how huge their compensation may be, and how it seems unrelated to any aspect of their own or their organizations’ performance, especially not to how much they benefit patients’ or the public’s health.  Furthermore, we have noted how executives have prospered even when their management seems overtly hostile to the health care mission, when it leads to ethical missteps requiring legal settlements, or even guilty pleas or verdicts to criminal charges.

So health care’s “99 percenters” ought to be angry at the top 1%.

The power of finance

Furthermore, the Occupy Wall Street protesters are not merely upset with the upper 1%, but particularly outraged by those in the financial sector, which “with regulators and elected officials in collusion, inflated and profited from a credit bubble that burst, costing millions of Americans their jobs, incomes, savings and home equity.”  Then, “the initial outrage has been compounded by elected officials’ hunger for campaign cash from Wall Street, a toxic combination that reaffirmed the economic and political power of banks and bankers, while ordinary Americans suffer.  Extreme income inequality is the hallmark of a dysfunctional economy, dominated by a financial sector that is driven as much by speculation, gouging and government backing as by productive investment.”

In another report, the protesters “unite around a common theme: bankers are ripping off America.  Two secondary themes also emerge. One is that the super rich own the politicians.  The other is that the news media, almost across the board, view events through the eyes of the super rich.”

Finance’s links to health care

We have noted parallels between the effects of Wall Street and health care on the economy.  Furthermore, we have noted active ties among Wall Street and health care organizations. Top executives and board members of some of the financial firms most obviously responsible for the global economic collapse have served on boards of trustees of top medical schools and academic medical centers, and their parent universities.  The top leaders of medical schools, academic medical centers, and their parent universities have served on the boards of such financial firms.  There are also board interlocks among Wall Street firms and all sorts of health care corporations.  The corporate culture of Wall Street and health care have long overlapped.

We have further noted how the leadership of big health care organizations has deceptively influenced policy, particularly through stealth health policy advocacy.  Meanwhile, until the last few years, much of health care dysfunction has been anechoic.  Now the media is beginning to report some of the abuses.  Little about them appears, however, in the medical and health care literature that health care professionals are likely to trust more than news media.


We have frequently suggested that true health care reform requires reform of health care leadership and governance.  We need leaders who understand the health care context, uphold health care professionals’ values, and put patients first.  We do not need leaders who are ill-informed, incompetent, self-interested, conflicted, or corrupt.  We need governance that is accountable, honest, transparent, ethical, and again puts patients first.  Maybe to do that we will have to “occupy health care.”

In any case, it is time for health care’s “99 percenters” to stand up for their patients and the integrity of their values.

Roy Poses is an internal medicine physician who blogs at Health Care Renewal.

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