For-profit care's morbid results
By Bernard Lown, 08/01/99

Health care, a fundamental right in a democratic society, has grown from issue to crisis nationwide. Seldom a day passes without some horror story. In recent US Senate testimony, a woman described falling off an embankment, then being refused emergency room care  because she failed to obtain advanced authorization from her primary care physician. The essence of most
of these tales emphasizes that with health maintenance organizations, health of the bottom line takes precedence over health of the patient.
 
Our present system has deteriorated into a hodgepodge of corporate fiefdoms whose central aim is to defend their economic well-being. In the process, patients are depersonalized, while doctors, nurses, and other providers are deprofessionalized. That there is a problem with our health care system is widely acknowledged. How serious it's become - and how pressing the need for
corrective action - too often seems to escape us. Consider the facts: At a time of unprecedented affluence, one-third of Americans are inadequately insured. Compared with the fully insured, they are sicker, poorer, and die younger. Nearly 45 million Americans are totally without
health insurance and their numbers swell by 1 million annually.
 
If the rationalization for current arrangements is to stem gluttonous mounting medical expenditures, health economists are now projecting a doubling of costs by the year 2007. Predicted is a $2 trillion annual budget, amounting to 16 percent of our gross national product, more than twice the proportion spent by any other industrialized country.
 
High administrative overhead, a mark of business inefficiency, is double that of any other industrialized nation. Masterminding the  system is a prodigious bureaucracy that inundates health workers in a glut of paperwork, while health policy is defined in corporate boardrooms from which
the public is totally excluded.
 
While managed care has reduced health costs for big business, the personal outlay for ordinary people has progressively escalated. For  the elderly, a growing chunk of health expenditures goes for drugs, doubling  in cost in the 1990s alone. These are not covered by Medicare and are being
increasingly curtailed by health plans. Yet pharmaceutical companies sell the same drugs to other countries for half or a third of what we must pay.
 
Patient dissatisfaction is at an all-time high, as assembly line medicine puts a premium on hastening patient processing. While the patient is transformed into a cipher, seasoned health professionals are replaced  by lower cost, lesser-trained personnel. Experienced as well as novice nurses,
overburdened with high patient loads and administrative responsibilities, are virtually unable to provide competent and compassionate bedside care.
 
The current mantra of reducing costs, whatever the human consequences,  resorts to burdening the sick with their own care. This is in part  exemplified by the dramatic shortened hospital stays. Early discharge in the face of an inadequate home health care system leaves patients to fend for themselves. 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 HMOs.
 
Rather than a system of managed care, what has evolved is one of managed costs. In furthering this paramount objective, time honored clinical decision-making by doctors is curtailed.
 
Arbitrary regulations, supervised by a burgeoning bureaucracy of technocrats, has now invaded every precinct of clinical judgment whether involving drug prescription, specialist referral, an emergency room visit, or hospitalization. Nurses and doctors often spend as much time battling
insurers and their utilization reviewers as they do caring for patients.
 
No wonder professional morale is deteriorating. In a recent survey of physicians, only 25 percent were very satisfied with the practice of medicine. Dr. Jerome P. Kassirer, the outgoing editor of the New England Journal of Medicine, asks in an editorial, ''Can a health care system function effectively if a sizable fraction of its physicians are disgruntled?''
 
Nurses are even more adversely affected, since they are far more intimately exposed to the human breakdown of the system. Almost two out of five nurses indicate they would not recommend their health care facility  to a family member.
 
A final factor adding to the malfunction of the system is the auctioning off to the highest bidder of not-for-profit hospitals and other health care institutions built over decades with government subsidy and private charity. Instead of being reinvested in medical research, teaching, or community health needs, the profits are disbursed to investors and senior management as hefty salaries, dividends, and bonuses.
 
All things considered, our health care system is on the verge of collapse. How did things get so bad? Like most big social transformations, there were ample warnings of an impending crisis.  It was not precipitated by an invasion of barbarians scaling the ramparts of an ethical profession.
Rather, it began when doctors were seduced by financial incentives, with unquestioning third-party payers providing an open till.
 
Care was fragmented among a bevy of super-specialists, with multiplication of mindless procedures, encouragement of uncalled-for office visits, and exposure of patients to a glut of unnecessary surgical interventions. Each procedure was converted into a profit center.
 
A far more serious contributor to the present meltdown has been acceptance of a new paradigm - namely the industrialization of health care wherein patients are commodified, the work force is proletarianized, and market forces shape health policy. In such a business model, the aim is to
make money.
 
An opposite approach, a social model, has been adopted by all other industrialized democracies. Rather than generating profit, the aim  is to promote affordability, universal coverage, and unimpeded access for the entire population.
 
For-profit health care is an oxymoron. The moment care is rendered for profit, it is emptied of genuine caring. This moral contradiction is beyond repair. It entails abandoning values acquired over centuries of professionalizing health care into a humanitarian service.
 
Few are as deeply steeped in the market or as adept at money-making as philanthropist George Soros. In a recent speech announcing the creation of ''Medicine as a Profession,'' a program he hopes will expose this unwholesome trajectory, Soros said: ''Medicine is too important to be
left to the mercy of marketplace values.''
 
Yet even beyond the ethical abridgments, market-driven health care is irrational. Key assumptions in market theory are that the consumers know what they need, appreciate differences in quality, are offered these at different price levels, have bargaining power, and can exercise free  choice to buy or not to buy. None of these are true. The sick patient can  never be a fully informed and sovereign consumer. No amount of cyber-surfing  can make one fully informed.
 
The problem we confront relates in part to a misperception of the inevitability of present health arrangements. Ultimately, in a democratic society, little is immutable if an informed public wills
otherwise. They just need to be given the chance.
 
Massachusetts can be a laboratory of change and a bellwether for our nation. This would not be the first time.

EDITOR'S NOTE: The Committee to Defend and Improve Health Care, a coalition
of Massachusetts organizations, will on Thursday file with the state a
binding question for the November 2000 ballot aimed at expanding access to
quality health care, reducing prescription drug costs, and establishing a
Bill of Patient Rights.

This story ran on page E01 of the Boston Globe on 08/01/99.
A9 Copyright 1999 Globe Newspaper Company.