US HEALTH CARE IS A PRODUCT - STUPID!

There is a paradox - USA is the world leader in medical research and has the highest standard of treatment of major disease, with kings and prime ministers flying in for care, while it scores lowest in multiple health care parameters, such as infant and maternal mortality, as compared to other high income nations, even though it outspends them astronomically. 

The situation has to have reached crisis levels when The Journal of American Medical Association, (JAMA), leads an online edition with a “Viewpoint - Salve Lucrum, (Hail Profit): The Existential Threat of Greed in US Health Care”, February 5, 2023. The American Medical Association, (AMA), is one of the most influential bodies in dictating the direction that health care takes and has a long history, for better or worse, in shaping health care and medical education in the USA.

On  February 7, President Biden in his State of Union address, while touting what his administration has achieved, encapsulated the health care crisis by rhetorically asking, “Will you have the money to pay your medical bills? Will you have to sell your house”. A day later an Emergency Department Physician in an opinion piece in the Washington Post wrote “Severely Understaffed Hospitals Shouldn’t Be Buying Super Bowl Ads”. The average cost of the latter, without production costs, is between six to seven million dollars. The thrust of his disgust was the juxtaposition of the obscene disregard the business industrial complex of health care has towards those who they rely on to “sell” their “product”, namely the medical profession.

  February had a synchronicity about this subject as an opinion piece in the New York Times  a week later echoed much of what Dr. Berwick Deputy Editor of JAMA had written in his "ViewPoint".  The Times writer indicated that a new generation of physicians were not going to just stand by and allow the profession to be engulfed by profit. 

The Journal of Internal Medicine published in the same February time frame, a research piece that detailed who were on the governing boards of the top twenty ranked hospitals in the US -  fifty - six percent were from the finance or business sector while fifteen percent had clinical training or were from the health sector.

Thus February 2023 heralded  the beginnings of a profession fighting to regain its mission. The activists claim that they are not mere purveyors of the product "Health Care" they are in the noble pursuit of caring and curing patients.

HOW AMERICANS OBTAIN HEALTH CARE COVERAGE

It is important in any discussion on health care finances to know the breakdown of where individuals obtain their coverage as there is no universal health care in America. Briefly about ninety percent of Americans have cover about half of whom are in government programs and the other half in private insurance companies.

Medicare is the government insurance program available for those over sixty - five years of age and has currently sixty million enrollees (It should be noted that half of Medicare recipients have enrolled in Medicare Advantage Plans which are managed by insurance companies, a situation which will be discussed in the body of this blog}; Medicaid covers over seventy million citizens and eligibility is based predominantly on income. {Although Medicaid is funded by the Federal Government it is administered by individual States} The Affordable Care Act, or Obama Care enrollment is seventeen million. The latter contained an important provision that expanded the eligibility for Medicaid and is responsible for the increased enrollment in the latter. 

There are twenty seven million uninsured individuals who are for practical purposes all non elderly. Of the three hundred and forty million covered Americans, one hundred and sixty six million, are with private insurance companies who now have to accept all patients, regardless of pre existing conditions as a result of the Obama Care legislation.

THE AMERICAN MEDICAL ASSOCIATION (AMA)

The AMA is the largest representative body of physicians in America. The AMA has dominated the profession for nearly two hundred years both educationally and legislatively.  It was behind the creation of the landmark Flexner Report in the early twentieth century which laid down the basis of medical education which is still in place to this day. Cynics maintain that the major reason for the AMA enlisting the Carnegie Foundation to pay a twenty - nine year old school teacher to formulate the template for medical education was to eliminate the medical schools, predominantly graduating poorer and black physicians. 

The AMA dictated fee schedules favoring surgical procedures over cognitive skills of doctors and specialization over generalism. This resulted in seventy percent of US MD’s being specialists and only thirty percent  being “primary care” providers, (PCPs). All the PCPs are not true generalists in the international sense because only a third of them are Family Physicians or General Practitioners and thus are able to be first contact doctors to all genders and their children. 

The AMA acting as a trade union on behalf of doctors fought for well over a century against the formation of Government sponsored care even opposing the formation of Medicare in the nineteen sixties conducting a massive costly campaign. When Health Maintenance Organizations were thought to be the panacea of all the health care ills, the AMA challenged the doctors’ rights to advertise their association with those bodies only to lose their dictatorial edict in the Supreme Court. 

It was round about the twenty first century that the AMA finally found religion. In 2007 they launched a campaign to be “The Voice For The Uninsured”. A year later they formally apologized for their earlier exclusion of African American physicians as office bearers and made a concerted effort to rectify that practice. A few years later they backed President Obama’s efforts to overhaul the public health care system including the belief in universal coverage.

In short the AMA have a lot to answer for. They are a wealthy organization with a large lobbying budget so their role in rectifying the current mess is important. Although they no longer have the membership of the majority of the profession they still have over two hundred thousand card carrying members. So this unabashed lead article is far more significant than the coverage it has been given. JAMA is their main academic and policy journal but they have several others thus reaching a large audience. 

“THE EXISTENTIAL THREAT OF GREED IN US HEALTH CARE” - JAMA FEBRUARY 5 2023

All this discussion must take cognizance of the fact that the cost of health care in the US is nearly eighteen percent of GDP, over four trillion dollars a year or one in every six dollars spent. The US GDP percentage is fifty percent higher than those of other high income nations. For example, a country such as France spends less than half the sum in dollars per citizen as compared to the USA. (Thirteen thousand dollars per citizen versus about six thousand). 

The “stratospheric” drug prices, even those that have long been on the market, are highlighted in the editorial. “Eye popping” prices are legion as there is no price regulation legislation. (Biden has modest legislation that begins in 2025). The fact that often the research behind the newest drugs has been executed with government money is not acknowledged or priced in. A constant criticism is that the cost of the self same pharmaceuticals, that are the products of American research, is far higher in the USA than in other countries. The companies basing their pricing on “what the individual markets will bear”.

 The central implication of the JAMA “ViewPoint” is the danger that the business industrial model will come to totally dominate health care. A strategy not yet debated in the public arena is the exploitation of insurance companies of the Medicare Advantage, (MA), Program. Viewers of television should have wondered why they are being overwhelmed by advertisements offering expanded coverage at a very low cost. The MA ;program was brought into being to give Medicare enrollees an opportunity to have managed care by private insurance companies at a low cost. The venture has mushroomed to cover fifty percent of those qualifying for Medicare. The insurance companies have gamed the system to the extent that it will cost the Government six hundred billion more dollars over the next eight years had the beneficiaries remained in the original Medicare program. This surely should answer those who argue that if the private sector were to solely manage health care, costs would be lower!

Hospitals are also in the business of printing money. An example quoted is a charge by one of the most prestigious University Hospitals in the country. They charged seventy three thousand dollars for two infusions of a prostate cancer drug, the price of which in the UK is two hundred and sixty dollars a treatment. 

Non profit institutions are closing hospitals in poorer areas and opening them in more affluent suburbs. There are currently six hundred and twenty one rural hospitals under threat of closure.  Exacerbating this problem are eleven Republican controlled states refusing to accept moneys to increase Medicaid enrollment available under the Obama Affordable Health Care Act. They believe no money is better than that afforded to them by Obama Care. The rural hospitals could be remunerated for many of their patients who cannot afford payment and consequently would be able to remain open.

The JAMA policy piece continues, “Profit may have its place in motivating innovation and quality … but kleptocapitalist behaviors hurt patients, governmental programs,… these behaviors … pose an existential threat to a sustainable, compassionate and equitable health care system…..” 

The "ViewPoint" also alluded to the impact on individuals, “.. 41% of US adults bear medical debts. One in eight individuals owe more than ten thousand dollars… In Massachusetts, forty six percent of adults say they skip care because of costs. As of 2021, 56% of all debt collections in the USA are for medical bills……”.

It should be noted that since the publication of this article the US Consumer Financial Protection Bureau has published a report that found that Americans carrying medical debt has dropped by about eighteen percent bringing the indebted to about twenty percent. The reason they believe is a result of Obama Care which added millions to the insurance rolls both government and private.

The JAMA article ends by outlining plans for action and a plea for those in control to right the ship. The editorial alludes to the demoralizing effect this business industrialization of medicine  has had on health care providers, a situation that was underlined in the Washington Post Opinion Piece. 

EARLIER ATTEMPTS AT HEALTH CARE REFORM

For a very brief period there was a glimmer of hope in the 1990’s with the Hillary Clinton plan for health reform. The President, her husband Bill Clinton, had run on providing a universal health care plan. Central to the plan was to be the role of employers. The plan hit a mountain of opposition led by Republicans, libertarians, big business and the insurance industry. For a host of reasons, including Ms Clinton’s handling of her Task Force and the secrecy of its workings, it went nowhere. The AMA leadership was generally supportive but faced a rebellion from some of its high roller membership. It would not be till Obama’s Affordable Health Care Act of 2010 that there would be any major relief for the "consumer". President Biden has also put into effect further reforms. 

In the 1990’s the First Lady, Hillary Clinton, had recognized that costs would never be controlled nor health care indicators improved unless there was universal access to providers - acknowledging that the major feature that differentiated the US system from other high finance countries was the number of general practitioners/ family physicians. 

THE BUSINESS INDUSTRIAL MODEL TAKES HOLD OF HEALTH CARE FROM THE 1990’S 

Round about the same time that the AMA was finding religion - namely that it needed to come to terms with the fact that it had a social responsibility - the business model of health care was busily taking off. Whereas the major money makers in the latter half of the twentieth century had been the physicians in the surgical specialties such as ophthalmology, orthopedics and cardiac surgery, where some providers were raking in millions a year, the hospital administrators and health care CEOs took over as the major money earners in spades. 

There was consolidation of all aspects of health care - hospitals, health care providers, insurance companies and pharmacies in various combinations. Profit and non profit companies were formed or expanded. For the providers in health care the outcome was irrelevant whether the company was for profit or not. Within a few decades the number of physicians in private practice dropped to twenty - six percent. In 2021 there were a hundred and thirty - five thousand corporate owned medical practices in addition to physicians that the hospitals employed directly. The number of midlevel managers mushroomed as each billing item was categorized and maximized. Twenty - five percent of hospital expenses went to administration which was double that of Canada. 

The health organizations themselves had armies of bureaucrats headed by highly paid CEO’s. The CEO’s of the seven largest  for profit health care companies in 2021 cumulatively earned two hundred and eighty three million dollars. The non profit health organizations CEOs earned multiples more, by comparison to other non profit entities. At least ten such executives earned over seven million dollars a year, headed by the CEO of Kaiser Permanente who garnered eighteen million per annum.

So the health care organizations are in big business and they are selling a product called “health” or more aptly “disease”. The personnel that are “selling” their product are for the most part physicians or nurses who have as their agenda ministering to the ill.  Jay H. Ell personally witnessed a Family Physician being fired because he was not seeing the requisite number of patients per day. Likewise, nurses were being sent home and losing pay because there weren’t enough admitted patients “to justify” them being there. Conversely nurses were having to manage far more patients than previously so as to cut down expenditure. 

Now perhaps the aforementioned articles can be seen in context. 

SO WHY ARE AMERICANS NOT GETTING THEIR BANG FOR ALL THESE BIG BUCKS?

In a comparative study of eleven high income countries the USA was ranked last in four of five parameters. (Commonwealth Fund Organization - “Mirror Mirror 2021: Reflecting Poorly”).

The four measurements were access to care, administrative efficiency, equity and health care outcomes. In a fifth parameter which involved preventive screening USA was ranked second 

The study noted four features that distinguished top performing countries such as Netherlands, Norway and Australia - Universal coverage and removal of cost barriers, investment in primary care systems to ensure high value services are equitably available in all common items to all people, reduction in administrative burdens that divert time, effort and spending from health improvement efforts and investment in social services especially for children and working age adults. (It reads like a synopsis of what ails the American Health Care System).

Added to the USA health care woes is the burnout of physicians, notably those that are in the front line for access to care - first and foremost being the Emergency Physicians,

ACCESS TO CARE

There are three portals of entry for health care - Primary Care Practices, Emergency Rooms and Immediate or Urgent Care facilities.

In the USA access to care is a huge problem, because only thirty percent of the physicians are in “Primary Care”, thirteen percent being generalists. "Mid level" practitioners, nurse practitioners and physician assistants have been added but have made no discernible dent in the problem.

 If you want an old fashioned primary care service where you will have a practitioner respond to you timeously there are so called "concierge" practices, where the patient pays anything up to two thousand per annum just to join.

 As there is not universal health coverage where can the uninsured or poorly paid government insured go? There is only one service that by law that has to accept and evaluate any person who presents for treatment and that is the Emergency Department. At the best of times this service is stressed out by the very nature of the job definition and by being overwhelmed by anyone pitching up. The Covid pandemic resulted in many ER physicians opting out.  Wait times under normal circumstances for any non life threatening presentation can be between four and ten hours. There are six thousand ER departments in the US.

In order to cope with lack of access the number crunchers in the systems created “Immediate Care” or “Urgent Care” clinics for paying or insured “customers”.There are approximately five thousand in the USA. 

Jay H. Ell has practiced in all three of these first contact situations. The ideal non emergent situation is the primary care practice. In the latter context the patient’s history is known, as well as her behavior and if the practitioner is a generalist she may well be managing the whole family. Where there is easy access management can often be time based and the patient can be asked to return if the condition worsens for example. It is much easier to assess the problem in that milieu. 

The Emergency Room is a “specialist” care situation, the problem has to be sorted out there and then. There is disease or there isn’t. It is either urgent even life threatening or it isn’t.  Litigation adds to the stress with nearly every ER physician having had to face litigation. It is far from the ideal situation to manage anyone or everyone who seeks care.

Practicing care in an Urgent Care clinic is extremely difficult because the patient has made the decision that her problem does not require emergent care and or it is not serious. Unless it is a painful throat how on earth does she know? The practitioner who does not know the patient from a bar of soap is working on a primary care model where supposedly she has to see x number of patients per hour. Jay H.Ell found this model which is essential under the  current circumstances, the most taxing, often coming across patients who had to be bundled into an ambulance and referred to the ER.

So much maligned Hillary was right thirty years ago and it is not too late to prioritize medical students going into Primary Care. Jay H. Ell attended a meeting where she  addressed academics and student leaders. When she was challenged that withholding grants for students who wanted to go into specialties was discrimination, allowing only the rich to go into the more lucrative professions, she simply countered that the objective was to serve communities not meet the needs of those going into medicine.

AT THE END OF THE DAY

Biden when asking rhetorically, “Will you have the money to pay your medical bills? Will you have to sell your house?’ , was recalling a situation he personally experienced with his son Beau who had been diagnosed with brain cancer and had no medical coverage. Obama either lent or gave Biden the money.

Just to quote one of the solutions offered in the JAMA article,“Salve Lucrem” (Hail Profit): The Existential Threat of Greed in US Health Care”:   - …Health care professionals in all disciplines need to become noisier about the conflict unchecked greed and the duty to heal. Extortionate drug prices, exploitation of market consolidation, coding games, excessive executive compensation and promulgation of unnecessary care ought not to be met with silence. Silence is assent. One word of caution - there is safety in numbers - individual activists can just be picked off and eliminated.

The AMA are finally on the right side of history. 

The impact of Obama Care is still multiplying. Maybe the politicians of those Republican States who believe no healthcare is superior to Obamacare will start caring when they are left without rural hospitals. 

None of this situation detracts from the remarkable progress the Medical Profession has made in combating disease and the dedication of health care professionals to their patients. Studies that show anger towards the costs of health care invariably indicate that participants are very satisfied with the care executed by “their” doctors. 

While companies are managing health care as a product to be advertised bought and sold like any other in the market place, those that “sell” the product for them are still in the business of caring and curing. 

Finally, just maybe, the “free market” will work the way their apologists maintain and the insurance companies, pharmaceutical companies and hospitals will compete with complete transparency and bring the price of high quality health care down.  

For the meantime US Health Care is Just a Product - Stupid