The Commodification of Health Care
By Bernard Lown, MD
PNHP 2007 Newsletter
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Dr. Bernard Lown, MD, a cardiologist who invented defibrillation and many other innovations in cardiac care, is professor emeritus at the Harvard School of Public Health and Senior Physician at the Brigham and Women's Hospital, Boston. He was co-recipient of the Nobel Peace Prize 1985, on behalf of the International Physician for the Prevention of Nuclear War (IPPNW) which he co-founded.
Health care in America is in deep crisis. A public service has been transformed into a for-profit enterprise in which physicians are "health care providers," patients are consumers, and both subserve corporate interests. The effect has been to convert medicine into a business, deprofessionalize doctors and far worse, depersonalize patients.
In my lifetime in medicine, now spanning 50 years, I have witnessed a remarkable transformation. From a healing occupation dominated by professionals, medicine has increasingly become an industrial process run by technicians.
Underlying the breakdown of the health care system is a far deeper phenomenon - the onrushing marketization of all human transactions. The over all impact is to denature fundamental human values and tear apart the ties that nurture communal life. Yet no such profound developments are without opportunities to mobilize people on the basis of their most intimate undermined self-interest. What is happening within the medical system affords a profound education for the public on a much wider issue; the fundamental flaws of a market-driven consumer society.
In less than two decades, health care for a majority of American's was brought under control of what is called managed care, run by large insurance companies. The growth of fully privatized Health Maintenance Organizations (HMOs) was spectacular, increasing from 12% of those covered by private insurance in 1981, to 80% of the 200 million covered in 1999. The proffered rationale for the sweeping corporatization was the need to contain health care costs, founded on the belief is that only competitive, investor-owned organizations have the financial discipline to stem the inflation of health care expenditures.
Until the advent of HMO's, health costs were rising, on average about 11% annually - three or more times the rate of inflation. In 1995 American health expenditures for the first time surpassed $1 trillion dollars per year. In Massachusetts where I live, with a population of 6.1 million, total spending for health care last year was over $50 billion dollars. This exceeds the health budget of India and is nearly equal to that of China, the most populous nations on earth. Many establishment economists have maintained that the USA cannot afford to invest 16% of its gross national product (GNP) on health. The stated reason for governmental encouragement of the private sector is to contain such mounting costs.
However, no major social transformation results from a single cause. The change in health care could not have happened without a multiplicity of forces working together. In my view, these include: the medical scientific and technological revolution; an altered conception of the meaning of health; the attending changes in the doctor patient relationship; growing patient dissatisfaction with a depersonalized system; the demographic transformation brought about by an aging population; the huge profits to be made; and the insatiable appetite of corporate America.
The Scientific-Technologic Revolution
Colossal medical achievements characterize our era. People residing in industrialized nations no longer need fear succumbing, unexpectedly, to dreaded pestilence. The introduction of sulfanilamide, in the mid 1930's and penicillin during the last stages of WWII wrought a health care revolution and contributed to a demographic transition. Infectious disease, the leading cause of global fatality, could be contained. The most telling single statistic - embodying scientific advances - is the expansion of the human life span by an average of 25 years since the beginning of the 20th century. People not only live one third longer, but are far healthier, and their state of good health is maintained into ripe old age. According to the ancient Greeks, upon reaching the age of 50, one entered the senescent phase of life. At present, it is not unusual for a septuagenarian to continue gainful employment, partake of travel, sports and other vigorous activities.
Science has improved human life during all of its stages. The fetus can be monitored from near conception, prematurely delivered when in distress, and kept miraculously alive when weighing less than a kilo. Numerous congenital abnormalities no longer need shorten or disfigure life. Defective organs, be they hips, hearts or livers, when beyond repair, can be replaced. Many cancers can be restrained in their wanton proliferation, and a cure for many of the malignancies is in the offing. Coronary artery disease, the major cause of premature death in industrialized societies, is now being defanged as its pathogenesis is increasingly comprehended. I am optimistic that within the next decade this massive affliction will be controllable as well as largely preventable.
But science is not all pluses. Three essential adverse consequences will be touched upon. First is the presumption of medicine as merely a science, reducing human beings into biomedical models with physicians serving as superspecialized technologists; second is the short shrifting of social and psychological factors as playing a role in disease; and third is the distancing of doctor from patient and patient from doctor.
Science Contributes to Abandoning Healing
The practice of medicine has increasingly shifted to a scientific paradigm which approaches the patient as a biomedical being. Medical students are selected based on their achievements in pre-medical science course, not their affinity for the humanities nor their readiness to serve people. The medical school curriculum responds to the promises of science by progressively diminishing training in interpersonal relations. Little time is devoted to mastering history-taking or acquiring skill in the physical examination. Training is focused on proficiency in science and gaining competence in a host of technologies and procedures. Students are inculcated with a reductionist medical model in which human beings are presented as complex biochemical factories. A sick person is merely a repository of malfunctioning organs or deranged regulatory systems that respond to some technical fix. Within this construct, the doctor, as exacting scientist, uses sophisticated instruments and advanced methods to engage in an exciting act of discovery.
The fact that doctors are trained largely in tertiary care hospitals, veritable emporia of cutting edge technologies, further conditions the young with a mindset favoring the technical. This is reinforced by their teachers, future role models, who are almost exclusively highly trained specialists. Bedside teaching rounds are largely replaced with chart rounds and examining computer print-outs of the latest laboratory data. On rounds, attending physicians evince scant interest in the sick patient and instead fixate on the biochemical, molecular or genetic derangements. The focus of teaching necessarily shifts from an holistic approach dealing with an ailing person to the dysfunctional organ. Human interactive skills are deemed outmoded and are minimally cultivated. The patient is increasingly referred to not by name but by the deranged organ as the liver, kidney, heart patient or whatever ails.
What in olden times could only be exposed by pathologists during a post mortem examination, can now be imaged speedily, accurately and safely. No structure is hidden from view. Young doctors glory in being scientists with a commitment to master these sophisticated instruments and complex methodologies. The trainee physician quickly learns that compared with the sharp images provided by ultrasonography, MRI, CT, endoscopy, and angiography, a patient's history is flabby, confused, and subjective. Being deskilled in bedside medicine, young doctors have but little choice in dealing with patients except to rely on sophisticated medical gadgetry. There is no consideration of the prohibitive economic costs of immediately resorting to expensive technologies and bypassing the patient who is the ultimate repository of relevant information.
Contributing to the popularity of specialization is that early in their careers doctors learn that ascent on the academic ladder is for those who master these elegant technologies, not for those who evince interest in afflicted human beings.
This trend is reinforced and accelerated by the billions of dollars poured by the government into medical research. The physician most gifted in obtaining grant funding is promoted in academe. Advance is unthinkable without a thick bibliography and success in obtaining grant support. Prestige no longer belongs to a beloved family physician nor to an astute bedside clinician, but is the prize for those who breach the scientific frontier.
Not only contemporary philosophic notions of illness, but powerful economic incentives reinforce these views. The shift from a patient-focused health care system to one based on disease, relates to lucrative fiscal rewards for the practitioners of scientific based medicine. Reimbursement is greatest for the specialists who are captains of complex and invasive technologies; cardiologists foremost among these. Society places a far higher premium on using technology than on listening or counseling. A doctor earns more from performing a procedure requiring a single hour than from an entire day spent communicating with patients. The following fact is illustrative. In 1982 U.S cardiologists earned $127,000 annually. By 1987, their income had nearly doubled to $225,000 coincident with the introduction of coronary angioplasty, which is pursued with ideological fervor though supported by scant evidence that it prolongs life or protects against a heart attack.
The enormous appeal for specialization skews the distribution of doctors. Unlike any other country, 70 per cent of practicing physicians in the U.S are specialists. Another lesson of the American experience is that a medical care system skewed towards science-based, curative medicine entrusted to highly trained specialists, costs grows astronomically and health care is increasingly rationed along class lines.
Scientific medicine that ignores the ailing human being has additional negatives. It leads to the medicalization of people and thereby warps the social fabric in numerous ways. Government funding of medical research requires an enthusiastic public. Every medical center dependent on such government largesse has a public relation staff generating a continuous Niagara of information about this or that scientific break-through or medical miracle. The bottom line message to the public has been that scientific medicine has a potential cure for all that ails. The massive medical industrial complex in the USA, now far larger than the military, further contributes to the hype since it needs to cultivate an ever growing number of customers for its expensive wares. It enfilades the media with stories about health and the value of its commercial products. Pharmaceutical conglomerates, major players in this game, currently advertise directly to the public - to the tune of $2.7 billion in 2001. In a complete reversal of norms of medical practice, these advertisements urge people to recommend a particular drug to their doctors. In fact, patients may be among the first to learn the merits, but rarely the limitations, of a newly released drug.
As Ivan Illich predicted in Medical Nemesis, medicine has expanded into almost all facets of human existence. Brought into the domain of medicine are an array of "proto illnesses" - conditions that do not cause symptoms or impair life in any way but are prognosticators of potential illness far in the future - are brought into medicine. Among this ever-mounting list are such conditions as high blood pressure, elevated blood sugar, cholesterol levels, osteoporosis, colonic polyps, heart murmurs, carotid artery narrowing, memory loss, sun exposure, and the list is constantly expanding. As scientific insight advances one may reasonably anticipate the emergence of a whole gamut of tests predictive of potential disease. Furthermore, it is certain that risk factors for future illness will be recognized ever earlier in life - soon, at birth, in utero, and with genetic mapping even before conception.
A recent study highlights the problem with this approach. At the National Institute of Health, 1000 healthy asymptomatic individuals had brain screening with magnetic resonance imaging. Of these, 18% demonstrated incidental abnormal findings and three were found to have unsuspected brain tumors. Should then the entire population be screened, and why only the brain? The negatives of such sweeping dominance of medical science are evident. Everyone is tied umbilically from birth to the medical establishment, resulting in an unceasing preoccupation with the struggle of surviving rather than with the challenge of creative living.
I harbor even deeper misgivings about the biomedical model and the current dominant scientific paradigm in medicine. This model, rooted in Cartesian dualism, is now under serious philosophical challenge. Science is fundamentally reductionist; it orients to probabilities not certainties, it searches the very depth to focus on genes and molecules, on electrons and subatomic particles. Defining a complex amalgam - such as an individual - is beyond its purview. But the practice of medicine ultimately is focused on the individual.
The biomedical model is additionally challenged by the theories of chaos and complexity. These theories question the basis of determinism as the explanation for cause and effect. They suggest that small, barely perceptible initial conditions of a system can result in disproportionately large changes in the same system over time, and emphasize the limitations of a reductionist approach in describing natural phenomena. The implications are that some systems are unpredictable and will remain so. Traditional science cannot accurately predict the trajectory of complex systems such as people. Physicians face a sea of uncertainty in dealing with a particular human being, confronting a system with an infinitude of interacting variables shaped by familial, cultural, social, and economic factors, condimented with conditioned responses and inundated with subconscious mental content-- virtual memories of the night. The extant medical scientific vocabulary is dismissive of these "unknowables," communicating a largely irrelevant and nonexistent degree of determinism.
For physicians and patients, the building blocks of communication are metaphors and narratives, the ancient tools for comprehending the world. They enable coping with the subjective and the unmeasurable; the prevalent depression among the elderly; the grief of the bereaved; the suffering of those with terminal illness; or the despair of a mother with a dying child - all of which the physician is committed to assuage. Listening with care to a human narrative provides insight to emotional complexity and permits a glimpse into the mind of another, indispensable to the act of healing. When these are ignored, as they are in scientific-based medicine, patients feel abandoned with dire consequences for patients as well as the profession.
Consequences of Abandonment
At a time when doctors are performing the near miraculous, the profession's reputation is increasingly discredited. More and more, patients complain about not being listened to and being abandoned. As medicine has conquered acute illness, it increasingly fails in coping with the growing toll of chronic disease - arthritis, cardiovascular ailments, cancer, diabetes, pulmonary impairments and neurological derangements. Lacking a cure, these illnesses require the art of healing for which the contemporary physician is poorly trained. And public, led to expect miracles which are not forthcoming, grows disillusioned and angry.
I shall touch on three of the many consequences now in evidence. One relates to the current litigation craze, a nightmare for physicians. Nearly one in three practicing doctors will be sued over a lifetime of medical practice for real or imagined wrongs. This is not surprising. As patients lose their individual identities, the ancient covenant of trust between doctor and patient unravels. When history taking is short shrifted, the doctor is likely to become lost in a sea of dire possibilities, warranting a profusion of technological interventions. In contrast, a careful history, a thorough physical examination, and a few simple routine tests provide about 85 percent of the basic information required for a correct diagnosis. Since it is uneconomic to spend much time with patients, diagnosis is performed by exclusion. This opens floodgates for endless tests and procedures in an effort to cover all diagnostic options and thereby parry accusations of negligence in a court of law. With this kind of defensive medicine, minor problems receive comprehensive and costly work-ups. However no procedure is completely safe. Even an innocuous intravenous line can become a source for infection or the nidus for a blood clot. It is ironic that the quest to avoid litigation sets the stage for the legal entrapments it aims to avert.
A second even more persuasive line of evidence of the public's diminished trust of the medical profession is the increasing popularity of alternative medicine with its exotic and unproven treatments. Included among these are hypnosis, acupuncture, chiropractic, herbalism, homeopathy, biofeedback, guided imagery, relaxation, yoga, meditation, faith healing, prayer, Christian science, megadose vitamins, massage, naturopathy, chelation, urine therapy, Bach flower remedies, iridology, orgone accumulators, ozone generators and a host of others. Doctors deem these practices the negation of science, evoking images of 19th century charlatans hyping snake oil, leeches and astrology.
Yet national surveys indicate that in 1997 more than two-fifths of the adult population - 83 million people - used at least one of 16 listed alternative therapies, an increase of 20 million since 1991. Astonishingly, in 1997 visits to practitioners of alternative therapy exceeded the number of visits to all primary care physicians by an estimated 243 million. And the use of alternative therapies are not confined to a narrow segment of society. The largest users are women, the middle-aged (35-49), individuals with some college education, and people with annual incomes exceeding $50,000. This trend may be interpreted as a vote of no confidence in scientific medicine among the educated, affluent middle classes, or as a dissatisfaction with a chaotic and impersonal health care system, or as a search for values not provided by the modern physician.
A third line of evidence, which I believe is the most telling indication of the loss of trust in the profession, is the seeming widespread public indifference to the corporate take over of community-owned hospitals, and the stripping away of physicians' clinical autonomy. The commodification of health care has been met by public silence. By contrast, whenever corporate interests have eyed popular programs such as Social Security or Medicare, angry public outcry has prevented a direct assault on these safety nets. No such outcry could be heard from Main Street as Wall Street privatized billions of dollars worth of public health institutions. Perhaps patients saw little reason to defend a dysfunctional system.
An Idiosyncratic Health Care System
In the late 1930's, the Roosevelt Administration was moving toward a national single payer health care system. However mobilization for WWII put all social programs on a back burner. The war-time wage freeze forced unionized labor to seek higher pay through fringe benefits; mainly employer-financed private health insurance. Like any other business, the goal of health insurance firms is to make money. An opposite model had been adopted by nearly all developed countries, a social insurance model which shares the risk of sickness by spreading the cost to all of society. In the business model, the exclusion of the poor, the aged, the disabled and the sick is sound fiscal policy since it maximizes profit. In the social insurance model, denying coverage to some members of society contravenes the fundamental purpose of health insurance.
Indeed, failure of the business model is an ugly blot on the American escutcheon and deflates its pretense of moral global leadership. Today over 46 millions Americans are without health insurance, their numbers rising by about 1 million annually. If one considers that an additional 20-30 million are underinsured; close to 1 in 3 of the population face major problems in financing illness for their families.
Moreover, notwithstanding prodigious expenditures, the U.S. health care system often provides poor quality care. One robust proxy for quality is life expectancy, and in this index the U.S. ranks number 25, behind most other industrialized countries. Though others spend far less than the US, they deliver far more health care. One example should suffice. From 1960 to 1989, America's two major industrial competitors, Germany and Japan, more than doubled psychiatric beds. During this same period, USA reduced psychiatric beds by three quarters, from 560,000 to 70,000. Mentally ill patients were dumped into inadequately prepared communities and became the street people and the drug culture now plaguing America's large cities. Currently, a psychiatric patient needs to be violent, suicidal or homicidal to be hospitalized. Mental illness in now criminalized - many more of the mentally ill are in jail than are in psychiatric hospitals; 10% of prison inmates are schizophrenic.
Neoliberalism proclaims the supremacy of the market to bring efficiencies to all human transactions. According to its more avid ideologues, the market's power derives from biology and is imbedded in our selfish genes. They aver, in the jargon of economists, that most people are maximizers of utility, meaning they navigate life by rationally calculating their self interest. Supplied with proper information their decisions are consistently on target. Forgotten in this economic babble is that the market episodically implodes, spewing woe and misery for all who are caught in its web. The liberal economist, Robert Kuttner has reflected, that historically, government has had to intervene, not only to redress the gross inequality of market determined income and wealth, but to rescue the market from itself when it periodically goes haywire. It is no secret that markets cannot properly value a host of essential societal needs such as education, health, public infrastructure, clean air and water, food safety, etc. As evidence one might reflect on ozone depletion, deforestation, species extinction, desertification, ocean pollution, global warming, and the systematic despoiling of the natural world, the mindless exposure of human beings to numerous carcinogens. John Kenneth Galbraith captured the essence in his oft quoted phrase that we live in a society characterized by "Private affluence and public squalor." Marx phrased it even more pungently, "With an adequate profit, capital is very bold. A certain 10% will seek its employment anywhere; 20% will produce eagerness; 50% positive audacity; 100% will make it ready to trample on all human laws; 300%, and there is no crime which it will not scruple, no risk it will not run, even to the chance of its owner being hanged."
While one can debate these matters endlessly, the serious flaws in the theory and the practice of market-driven managed health care are neon lighted. Key assumptions in market theory are that the consumer knows what he needs, appreciates differences in quality, is offered these at different price levels, has bargaining power and can exercise free choice to buy or not to buy. None of these is true in health care. Patients usually do not know what is wrong; they do not comprehend the diagnostic possibilities; they are not familiar with the therapeutic options, they cannot assess the quality of care needed, and they do not appreciate the numerous potential outcomes. No amount of surfing the internet, browsing the media, reading popular health books, or sharing nostrums with neighbors can provide the necessary insights. These are the very reasons that they seek out the expertise of intensely trained and experienced health professionals. They need to nurture a relationship of trust with their doctors on whom they must rely on for their well being and even survival.
Furthermore, being sick is incompatible with acting as a savvy consumer. People do not shop for new homes or automobiles while in pain, bleeding or short of breath. Market forces can regulate the costs of houses and cars, things we choose to buy. But nobody chooses to be sick. The patient has little choice but to buy and therefore lacks bargaining power.
There is a deeper problem. Healthcare does not lend itself to the efficiencies of industrialization. Common sense indicates that patients cannot be standardized, and most of their parts are not interchangeable. Health care is a customized service resisting commodification and is incompatible with the efficiencies of industrialized assembly line or other mass production technologies. Such basics are ignored by the high priests of market medicine.
Market medicine is additionally flawed because it diverts economic resources from the community, from medical education and from research. The profits generated are not reinvested locally, but are distributed to remote investors and senior management as large dividends, hefty bonuses and egregious salaries. The market has been presented as the solution, but now we know it to be the problem.
As Neoliberalism sweeps the globe, it is important for people in other nations to grasp the dimensions of the health care crisis in the USA. Sooner or later they will be facing the proponents of marketization of their own medical arrangements. The impact of corporate privatization and the commodification of health care is now eminently clear. Health care costs continued to soar, exceeding two trillion dollars annually - 16 percent of GNP - by 2006, nearly twice what is spent other industrialized countries. High administrative overhead, a mark of business inefficiency, is double that in other industrialized nations. Masterminding the system is a prodigious bureaucracy that inundates health workers with a glut of paperwork, while health policy is being defined in corporate boardrooms from which the public is totally excluded.
Patient dissatisfaction is at an all time high, as assembly line medicine puts a premium on hastening patient throughput. Downsizing, common in industry, is now depleting hospital staffing. Experienced as well as novice nurses, overburdened with high patient loads and administrative responsibilities, are often unable to provide competent and compassionate bedside care. The current mantra of reducing costs, whatever the human consequences, translates into burdening the sick with their own care. The anxiety, anguish, pain and sense of abandonment experienced by the sick and their families is not computed as debits in the outcome ledgers of marketized medicine.
The most fundamental of questions can no longer be ignored; in a democratic society is health a fundamental right of the many or a privilege for the few? The underlying concept of market philosophy is that those without means go without some products or services. The dissolution of the Soviet Union, has hastened the tempo of global capitalism in expanding the reach of market dominion to all precincts of human life.
But the public is not about to succumb to this Darwinian philosophy. People are not about to sacrifice education, health, safety nets for the aged and the afflicted, a healthy environment and a host of other areas defining the commons, the gains of which entailed more than a century of intense struggle. Numerous public opinion polls document the fact that Americans overwhelmingly oppose transforming health care from a social service to a mere economic commodity. They are unwilling to replace the ancient bond of understanding between patients and doctors with a business contract.
Conditions are ripe to mobilize the public around the issue of health care, for few issues are more intimate or more potent. Indeed a powerful backlash is in evidence across the USA. Newspapers daily proclaim the mounting crisis in care and cost. Surveys show most Americans favoring national health insurance - despite a virtual blackout on mention of this option in the mass media now dominated by corporate interests. Hundreds of local citizen groups and labor unions across the nation join with thousands of doctors and nurses in rejecting the precepts of market medicine.
Only a wide mobilization of health professionals and patients can reclaim the soul of medicine. And the political movement for this transformation must educate the public on issues transcending health, nourishing resistance to corporate domination in other spheres of life. The health of a civil society is ultimately secured by interacting dependencies of people expressed in communal life. We are bound together by a moral set of values that sees the welfare of other human beings as a benefit to the self . Citizenship must afford not only equal rights but equitable opportunities to share in the wealth produced by the many for the benefit of society writ large. The medical plains offer a unique challenge for progressives to mobilize people ready and eager to be engaged.