On Health Care Renewal, we have noted how the direct care of patients in the US is increasingly in the hands of large corporations, often for-profit. We have noted the plight of the corporate physicians who swore oaths to put patients first, and now report to managers who put revenue first.
Health Care Renewal was hardly the first to raise these issues. For years, the renowned editor emeritus of the New England Journal, Dr Arnold Relman, has been warning about the effects of the commercial practice of medicine, which once was illegal in most US states, and until 1980 was condemned by the American Medical Association (look here).
Yet in a world in which market fundamentalism (or economism, or neoliberalism) is increasingly dominant, there is little room for the view that turning health care into a business, and having the new health care businesses lead by people who are only interested in increasing short term revenue (financialization) and increasing their own compensation might be bad for patients' and the public's health.
However, close reading of a recent article suggests that many physicians "get" this problem, although may be reticent about protesting it.
Summary of the JAMA Article
Tilburt et al authored an article published in July, 2013 that focused on physicians views about "controlling health care costs."(1) They sent a survey to 3900 randomly chosen physicians less than 65 years old and in active practice. 2556 (65%) responded.
The survey included questions about who should be responsible for reducing health care costs, and about the physicians' enthusiasm for various means of cutting costs. The results that got the most publicity were that physicians thought others (trial lawyers, health insurance companies, pharmaceutical and device manufacturers, hospitals and health care systems, patients, and government) were more responsible for controlling costs than physicians.
Nonetheless, the physicians were relatively enthusiastic about potential cost control measures that would improve "quality and efficiency of care," for example, promoting 75% were very enthusiastic about continuity of care, 69% about promoting chronic disease care coordination, and 70% about "rooting out fraud and abuse." They were also relatively enthused about "improving conditions for evidence-based decisions," for example, 51% were very enthusiastic about "expanding access to quality and safety data," and and 50% about "promoting head-to-head trials of competing treatments" (also known as a type of comparative effectiveness research).
Strikingly, however, 63% of physicians were "very enthusiastic" about "limiting corporate influence on physician behavior." The article did not further explain that item.
An Almost Unnoticed Result
The article's results section noted "some or strong enthusiasm for improving conditions for evidence-based decisions," including "limiting corporate influence on physician behavior." It included no further comments on this issue.
The public discussion it generated largely ignored physicians' views on corporate influence..
An accompanying editorial by Dr Ezekiel Emanuel and Mr Andrew Steinmetz (2) called the survey's findings "discouraging" and chided physicians for not having an "all hands on deck" approach to controlling health care costs, stating they "must lead" on this issue, because they "captains of the ship." It ignored the notion that the physicians may have thought that their first responsibility was
to "individual patients best interests," and thus controlling costs
(especially costs that do not accrue directly to patients) should be a
secondary concern. It also belittled their enthusiasm about curbing "fraud and abuse," implying that it was "sufficiently vague" that it "may offer only modest improvements but certainly will not transform the health care system." Instead, Emanuel and Steinmetz wanted physicians to support six strategies for transforming health care delivery, without citing evidence in support of these strategies. The Emanuel and Steinmetz editorial ignored the physicians' views on corporate influence.
A post on the In My Humble Opinion blog by Dr Jordan Grumet in turn wondered why physicians should support "Ezekiel's fantasies about healthcare [which] are unsubstantiated." Dr Grumet decried how particularly primary care physicians have been marginalized, and suggested that if Emanuel and Steinmetz want physicians to act like the captains of the ship they perhaps should not dictate their navigation. But Dr Grumet apparently did not notice that physicians may realize that their captaincy has been challenged by corporate influence. .
Media coverage in, for example, the Los Angeles Times, Fox News, and the Pioneer Press focused on the question of whether physicians were denying a responsibility to control costs, and whether that responsibility was really theirs. It did not comment on the issue of corporate influence.
However, so far the striking result that a large, well conducted survey showed that the majority of physicians support limiting corporate influence on their behavior remains almost completely unnoticed.
We now have some reasonably good data suggesting that the majority of physicians are very troubled by "corporate influences" on them.
It could be that they are troubled by the most direct corporate influences, the practice of medicine by physicians who are employees of corporations, often large, and for-profit.
Dr Arnold Relman reminded us that physicians used to shun the commercial practice of medicine (look here). Yet now increasing numbers of physicians are employees of for-profit corporations. Physicians and other health professionals who sign on as full-time
employees of large corporate entities have to realize that they are now
beholden to managers and executives who may be hostile to their professional values, and who are subject to perverse incentives that support such hostility, including the potential for huge executive compensation. It is not clear why physicians seem to be willing to sign contracts that underline their new subservience to their corporate overlords, and likely trap them within confidentiality clauses that make blowing the whistle likely to lead to extreme unpleasantness.
It could also be that physicians are troubled by slightly less direct corporate influences. We have blogged about
- suppression and manipulation of clinical research by corporations
sponsoring such research to assess their own products and services
- deceptive corporate practices like stealth marketing of stealth lobbying
- financial arrangements among physicians (and other health professionals) and health care corporations (e.g., drug, biotechnology and device corporations) which often seem to deliberately produce conflicts of interest meant to help market products and services, particularly the use of paid "key opinion leaders" as marketers
- institutional conflicts of interest that involve academic institutions, disease advocacy organizations, and other non-profit groups in corporate marketing and public relations
Furthermore, stories about and criticisms of these issues remain
markedly muted in the media, and even more muted in medical and health
care scholarship and scholarly journals. We have attributed this anechoic effect
to individual and institutional conflicts of interest, fear of
offending conflicted friends, relatives, colleagues and supervisors, and
fear of offending the rich and powerful.
Despite the anechoic effect, the article by Tilburt et al suggests that
physicians want to reduce corporate influence in medicine. Yet this
evidence of physicians' discomfort with corporate influences itself has
been greatly muted by the anechoic effect.
While the survey results are reminiscent of opinions I have heard from many physicians, it is striking that there is no perceptible organized movement by physicians against excess corporate influence. At best, public expression of concerns about excess corporate influence has been muted and fragmented, often relegated to blogs and sometimes derided as coming from malcontents, dissidents, disgruntled employees, and other assorted trouble-makers. But again it looks like the majority of physicians may (often silently) agree with these "whiners and complainers."
Physicians need to realize that they mostly agree that to fulfill their oaths to put patients first, they have to reduce the influence of rich and powerful organizations, like health care corporations, with other agendas. Maybe once they realize this, they will be able to start doing something to reduce such influences. Maybe once they start, they will be able to rethink the notion that direct health care should ever be provided, or
that medicine ought to be practiced by for-profit corporations. I submit that we will not be able to
have good quality, accessible health care at an affordable price until
we restore physicians as independent, ethical health care professionals,
and until we restore small, independent, community responsible,
non-profit hospitals as the locus for inpatient care.
Roy M. Poses MD on Health Care Renewal
1. Tilburt JC, Wynia MK, Sheeler RD et al. Views of physicians about controlling health care costs. JAMA 2013: 310: 380-388. Link here.
2. Emanuel EJ, Steinmetz A. Will physicians lead on controlling health care costs? JAMA 2013; 310: 374-375. Link here.
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