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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