Imagine a well-written book, on an important
topic, that you can read online for free. Making
a Killing: HMOs and the Threat to Your
Health, by Jamie Court and Francis Smith (Common
Courage Press, Monroe, ME, (www.makingakilling.org/?),
paints a troubling tale of what has
become of our health care system.
Jamie Court and Francis Smith have written
a searing, well-documented indictment of
"corporate medicine" as practiced by
HMOs. American medicine, the authors contend, has
been taken over by the avarice of the
corporate marketplace. "The doctor-patient
relationship and its concomitant social
values of trust and confidentiality have been eroded
by the search for profits," the authors
write. HMO doctors are frequently overruled on critical
medical decisions by utilization reviewers
in distant corporate headquarters. These
reviewers are often little more than
what the authors describe as "clerks with no medical
license."
Not only does the search for profits
endanger patients (and the book documents some truly
horrifying examples), it also results
in a "colossal waste" of health care resources. The
United States spends more, per capita,
on health care and covers fewer people than any
other Western nation in the world. Where
does the money go? According to the authors, 20
to 30 percent goes to corporate overhead
and profits.
Profits-before-patients is easily translated
into corporate-dominated medicine. Greed and
focus on stocks, stock options, and
quarterly earnings rapidly degrade health care services.
The professionalism of physicians and
nurses is undermined by the juggernaut of
commercialism über alles.
The critical relations of care and compassion
between server and patient are replaced by
categorical protocols imposed by corporate
bureaucrats commanded by monetized minds
at the top of the corporate hierarchy.
The exercise of judgment, discretion,
and mercy at the server-patient level is relentlessly
eroded by the forces of mammon – the
giant HMOs, their masterminding corporate law
firms, and their political allies who
safeguard their immunities and privileges in the face of
growing public and professional outrage.
This was not the way it was supposed
to turn out, at least in the minds of the pioneers of
prepaid medicine. Commencing in the
1920s with Dr. Michael Shadid's mobilization of poor
farmers around Elk City, Okla., to form
the first cooperatively owned hospital in America,
and then the Puget Sound and Kaiser
Permanente health care plans, the ideal was to
create quality health care with attention
to preventive services within an affordable system of
prepayment.
In the 1970s the federal government began
encouraging the formation of health maintenance
organizations whose nonprofit status
and prevention orientation were believed to be well
suited to curbing the excesses of the
fee-for-service system, with its incentives to sell too
much to patients. As costs annually
far exceeded the general inflation rate and health care
absorbed a greater percentage of the
GNP, the alternative of "managed care" emerged as a
way to control costs. A dominant format
also emerged – the giant, for-profit HMOs and their
entrepreneurial billionaire bosses securing
large clusters of customers and seeking more
and more mergers.
A series of perverse economic incentives
(gag rules, bonuses for not referring, and the like)
were insinuated from top to bottom so
as to seriously compromise the independent clinical
judgments of physicians and other health
professionals, often turning the pocketbook
allegiance of the health care servers
against the interests of their patients.
The giant HMO and its deepening swamp
of commercialism over service, of profiteering over
professionalism, of denial or rationing
of care where such care is critically needed, of
depersonalization of intensely personal
kinds of relationships, are spreading without
sufficient disclosure, accountability,
and structural responsibility, to the detriment of life and
health.
Workable alternatives are available.
The underfunded Canadian universal health care system
is still probably the best in the world,
despite attempts by companies and corporate
ideologues in North America to undermine
and weaken it. For around 10 percent of its GNP,
Canada provides health care for everyone
from the cradle to the nursing home. Its
administrative expenses are about 11¢
out of each dollar, compared with double that in the
United States – which this year may
spend 14 percent of its GDP on health care, even as it
leaves tens of millions of men, women,
and children without coverage.
In Making a Killing, Jamie Court and
Frank Smith make this story and its lethal
consequences painfully clear. They searched
and researched evidence, from inside the
industry, the public records, the court
judgments, and the documentation of personal
tragedies flowing from HMO priorities,
and they found patterns, not just episodes or
examples. It is the system that swoops
the savings from rationing and curtailment of
needed care upward along the managerial
ladders where the rewards grow larger and larger
until they mock the very adjective "obscene."
Venerable institutions and traditions in need of
improvement are instead shut down and
destroyed before the onrushing corporate Moloch.
This book moves from a description of
corporations making medical decisions, the ensuing
harm, the predictable frauds, and the
shunting aside of community servers toward solutions
for institutional reforms and suggestions
for self-help by patients and their families. The
authors know well that while information
is the currency of democracy, it will take a stronger
democracy to achieve the desired changes.
As the only Western nation without universal
health care for its citizens, the United States
is long overdue for a change, and this
highly motivating book should help band together a
critical mass of citizens who are aroused
and determined to forge a health care system in
which patients and health care matter.
Copyright © 2000 San Francisco Bay Guardian