Corporate control corrupts medicine and reduces healthcare quality

Medicine and health care is always changing, and the pace of change seems to be accelerating. Some of this change is good for people -- some of the new drugs that come out actually help, either a lot of people, or more commonly a few people. Sometimes new treatments are more effective, less painful, shorter, or less debilitating than older ones. And, sometimes, they are not. One thing we can be sure of, though, when we see a new treatment advertised, whether on TV or in a magazine or on a billboard, is that someone is making a lot of money on it.

There has been a great deal of coverage of two of the most important and egregious industries in which large corporations make lots of money at the expense of our health: pharmaceuticals and insurance. They deserve it, and I have written about them often. But another extremely important area where corporatism and corporate culture has taken hold and is expanding is in the ownership and management of hospitals. The most important thing about this increasing corporatism is that it is about making money (even in “non-profit” hospitals), not primarily about providing the health care that people need; of course, if what you need (or can be persuaded to buy) is profitable for the hospital, they’re all about it. For example, new surgical techniques and imaging, and particularly high-margin, low risk procedures like joint repair and replacement in otherwise relatively young healthy people (let’s go for that high school quarterback or 40-something weekend warrior). Not so much problems that occur in people who have multisystem disease, are old, are high risk, or are poor and uninsured. And some stuff – like psychiatric treatment for the most needy, or trauma care, are big money losers. Hate that if you’re a CEO, although might be good if you are a person who needs it.

This trend has been going on for a long time, particularly in large metropolitan areas, where most big hospitals are, and most of them are now part of hospital systems. Of course, big hospitals were always big, but the overemphasis on making decisions based upon money rather than people’s health has been accelerating. And more recently the process has taken over hospitals in smaller communities, including Critical Access Hospitals in rural areas. The Critical Access designation is meant to reflect the geographic isolation of a community, such that travel to the next-closest hospital creates real health risks for the population, and so even if operating it is inefficient, it receives federal support.

This is discussed in an outstanding editorial by Andrea Wendling in the October 2018 issue of Family Medicine, “Times Are Changing”. Dr. Wendling focuses on two major areas, the reinterpretation of the “value” of physicians and the role of family physicians. Family physicians are the most common specialists in rural areas, in part because they can have such a wide scope of practice. They can care for the medical problems of adults and children, deliver babies, provide care for many musculoskeletal problems, mental health, women’s health care, and provide many procedures. At least as important to patients, they can see them in all the venues where they need to be seen – the office, the hospital, the nursing home, and even the patient’s home. Dr. Wendling notes that this is threatened by the corporate perception of physicians’ value, which is their value to the system, measured financially, rather than their value to the health of the community. Yes, you might find it beneficial to have a doctor who knows you, who has cared for you and your family for years, be able to see you in whatever setting you find yourself in, but the system has decided it is more efficient (read “more profitable”) to have your doctor be only an ambulatory care provider, or only a hospitalist.

It is not only family physicians who are affected, although they predominate in rural areas. While some specialists – those that provide care that is not necessarily the most important, but is the most profitable – have always been more highly paid and more sought after by health systems, even they are seeing decreases in their pay and status. It is hard for the family physician to cry for slight cuts in the income and power of doctors (like orthopedists and radiologists) who are making many times what they do, and in fact it is hard for most Americans to cry for the plight of even the lowest-paid doctors. Perhaps it feels like crying for the white men who bemoan their loss of privileges (real and desired) because women and minorities are finally moving the playing field to being, at least a little, more equal. But the corporate influence is far more malignant.

Family doctors believe that their contribution to people’s health is relatively greater than their income. Doctors believe that, whatever their income, they are working to improve people’s health. CEOs and corporations believe that health is a good thing to try to sell, provided we sell the kind that makes money. They do not put the health of the community first; they put the financial well-being of the corporation first. And, not surprisingly, this affects both poor and rural communities the most, because of the limited access to services they had in the first place; an arrogant and self-serving corporation taking over the only hospital in a community does not bode well for the overall health of the people who live there.

And, adding insult to injury, it is not only the dollar-centered approach that is a problem, it is the egos of the local leaders who, emulating their corporate bosses and our political class, think that they as individuals are important and deserve respect and obeisance. I have a friend who led the physician group at a rural hospital when it was taken over by a larger system, and helped negotiate the criteria for bonuses for the medical staff. Soon after, that physician was fired by the local CEO for “embarrassing them”! The doctor got their job back with the help of lawyers, but imagine the gall of that CEO! If what they were doing was right and good, they had no reason to be embarrassed; if they had reason to be embarrassed because what they were doing was corrupt, self-centered, not good for the physicians or for the community’s health, what they were doing was wrong and should have been exposed. I have no doubt that if the people in that town were asked who they valued more, the physician who had cared for them for years or the new CEO put in by a corporation, which one would get more votes. Maybe the CEO would get that of their spouse.

So we have a health care system that is structured to be corrupt, from the insurance companies, to the drug and device makers, to the big health systems, all geared to profit. We have many physicians, in all specialties from the rich and powerful subspecialists to the family physician, who are trying to figure out how to stay on the “good side” of these corporate systems and of the local martinets. We have physician leaders, in hospitals and medical societies and academic departments who often are looking mostly at themselves and how to show that they as individuals are important (like that rural CEO), maybe believing that what is good for them is somehow good for people. Sadly, this is even true in family medicine, no longer the ‘counterculture’[1]its founders, like Gayle Stephens, wrote about, but now often simply other supplicants for corporate largesse.

All of this is at worst immaterial and at best subsidiary. The criteria for whether a healthcare system or aspects of it are good is whether it improves the health of people and the community. We have a long way to go in our healthcare system. And it’s long since time to get started.

---

[1] Stephens GG. Family Medicine as Counterculture. Fam Med 1989; 21(2):103-9.

The Political is Personal: Corporate power, social isolation, and the health of the nation -- Part 2

This talk was presented at the 29th Conference on Primary Care Access, Monterey, CA April 16, 2018

Many officials and policymakers pay lip service to the importance of health, but most of the actual support (spelled M-O-N-E-Y) is for treatments for individuals, often with uncommon diseases. Being on the “frontiers of knowledge” is much sexier than rather than the old, pedestrian “taking care of people”. And such policies ensure enormous profit for drug manufacturers, who, like military contractors, are guaranteed huge returns while most Americans are not even guaranteed subsistence.

We abhor the individual excesses of Martin Shkreli and Turing jacking up the price of pyrimethamine (Daraprim ®) from $13.50 to $750 a pill (he has been sent to prison but not for this action against the health of the people; rather he committed the much worse sin of defrauding investors), or Heather Bresch and Mylan raising the price of Epi-Pen ® from $100 to $600, or the manufacturers of colchicine (URL Pharma), with the complicity of the FDA, being allowed to patent a drug that was identified as effective for gout in Egyptian papyri in 1500 BC and raise the price from a few cents to $5 a pill. And what is there to say about the scammer Elizabeth Holmes and Theranos and its A-List Board of Directors?

The Atlantic recently told us the history of the creation and marketing of Oxy-Contin ® by the Sackler brothers. When they bought Purdue, they inherited an expiring patent for extended-release morphine. So they not only developed extended-release oxycodone and marketed it, taking advantage of the public (and physicians’) caution about morphine, they greatly broadened the indications for this drug, which is just as addictive, from cancer and sickle-cell and the like to any chronic pain, especially back pain. Thus, we almost all are eligible users, and we see the results with our nation’s opioid crisis.

If we are still practicing, we see the results of the “breakthroughs” in recombinant DNA “-ab” drugs (actually, anyone who watches TV will see the ads for them), promising (occasionally with some validity) new hope for sufferers from cancer, auto-immune disease, and a variety of neurologic conditions. The TV ads do not contain, and I hope that we as physicians are aware of, the prices, often $30,000 to $100,000 a year or more, far more than the average family income in the US. The frequency of serious side effects, including death, from these drugs is very real – many are immune system stimulants that frequently, not rarely, cause autoimmune hepatitis, pancreatitis and the like – and these are not clearly portrayed on TV, or in marketing to physicians.

Even when the individual is partially shielded from the cost by insurance, the out-of-pocket costs to patients can still be enormous. In any case, no matter who is paying, the pharmaceutical companies are making out like the bandits they are, and less and less money within the whole system is actually available for population health, for prevention, for public health, for treatment of common diseases like hypertension and diabetes. And even for those conditions, we keep seeing newer – and always more expensive – drugs. While all the new diabetes drugs have some use for some individuals, many people with diabetes are still getting inadequate basic treatment with metformin, insulin, and good counseling and support for diet and exercise.

And what can be said about “precision medicine” (sometimes called “personalized medicine”)? Tens, or hundreds, of millions of dollars spent or promised by the federal government, promoted by former President Obama as part of the “moonshot on cancer”, the idea that every individual will have a relatively unique treatment based upon learning and understanding her genetic makeup. The promise is that we will be able to prescribe treatments for cancer and other horrible diseases as precisely as we target antibiotics to the culture results (and, I imagine, overprescribe them as we do with antibiotics). Pursuit of the money being allocated for these “cures”, as well as the cachet of being “scientific industry leaders”, has become a major motivator of medical school deans and chancellors, with every academic medical center developing Institutes for precision or personalized medicine.

What, by the way, has been the outcome? Not much, so far. Two genes have been shown to, themselves alone, cause cancers, and they have been well-known for a long time, BRCA-1 and BRCA-2. And the amazing precision/personalized medicine treatments? Well, get mammography earlier and more often and maybe consider prophylactic bilateral mastectomy. Where are the precision cocktails that cure each person? Do not fret; billions more will be spent on looking for them for years to come.

Is there a problem with this? Taken in isolation, pursuing effective treatments for terrible diseases that affect a significant (if relatively small) proportion of our population is not intrinsically a bad thing. But nothing is done in isolation. Those dollars that NIH spends on looking for these treatments, those insurance company dollars spent paying for outrageously overpriced drugs, the infrastructure development in our academic medical center that continues to support high-tech, high-specialization research and care, are dollars not being used for population health, public health, prevention and primary care, not being used to actually, effectively and broadly implement the treatment strategies that we know work so that they are not only available to but used for the benefit of everyone.

This is what we, as family doctors and primary care providers, and public health workers, can do. It is important, cost effective, and will make a real difference in the health of the population. But because it is cost-effective, it is not profitable for those corporations that have great influence in public policy, and so it continues to be recognized mostly with words and not resources.

Some years ago the VCU Center for Human Needs developed the County Health Calculator. You can click on any state, or any county, and find out the number of deaths per year, number of people with diabetes, cost of diabetes, percent of people with greater than a high school education, and percent of people with an income of at least twice the poverty level. You can compare to the best and worst county or state, and a neat slider lets you see how many lives and dollars would be saved if you had higher or lower percents. Here is Monterey County, CA, where we are. Despite the impression that might be generated by Reese Witherspoon’s HBO show “Big Little Lies”, it is not the richest or best-educated county in the state, but closer to the middle.  Allocating more of our money to addressing core societal functions, like education and poverty, will make a big difference in health, much more than any individually-directed medical care.

It should be obvious that the emphasis in medicine and health care to focus on individual treatments, despite (and maybe because of) huge costs (and remember, costs are someone’s profits!), rather than on interventions to improve the health of our overall population, is totally related to the political and social conditions and circumstances I spoke about at the beginning. We not only feel we are alone, we are actively being encouraged and directed to feel alone, and that we just need to look out for ourselves, and the treatments for our diseases, and our housing and food and children’s education and tax burden, and not for anyone else.

This serves the dual purpose of 1) pursuing, as I hope I have demonstrated for medical care (and others have also demonstrated for military contracting and other areas), strategies that maximize corporate profits, as well as 2) limiting the probability that people will organize together to attack the core structure of cynicism, exploitation, and greed that has become so ubiquitous that we can often not imagine any other way of society being organized.

I have talked about a number of issues, which I think are all related to our health, as individuals and as a nation. I have talked about social isolation, consumerism, a health system that is organized mainly for profit, the excesses of pharmaceutical manufacturers, “precision” or “personalized” medicine, and community health. Changing all of this is about changing society, but I think we, as health professionals, definitely have something to contribute. Whenever we think about these issues, whenever we are confronted by the false idea that we are each alone, that we cannot band together, that we should not care for the others in our society, that there is not value in social cohesion, we need to resist it and increase our efforts to work with others. As physicians and health workers, especially in public health and primary care, we need to continue to demand that most health dollars are spent on the strategies that benefit the health of most of the people.

       While policymakers and subspecialists and deans talk about “personalized medicine”, we as family doctors and other primary care providers, talk about personal medicine.  We are talking about the interactions between people – the medical term for whom is “patients” -- who need to be heard, and validated, and supported, with doctors and other providers who have enough time to do so. This is where the magic of personalmedicine happens, not mainly in the provision of ever-more-expensive dangerous drugs and procedures. It is what we know how to do, and need to continue to teach others to do, and it is where we need to direct our efforts. It will not be easy, given the poor pay and resultant shortages of primary care doctors, and the mega-mergers that employ strategies such as retail clinics, currently being adopted. These strategies combine two major themes I have mentioned –  it is “corporate profit meets social isolation and instant gratification”, where people are encouraged to no longer value the relationships that come from continuity and community-based practices. 

We may well be on the road to 1984, even though it’s 34 years late. But I think we can still band together and resist going all the way there.