Monday, October 10, 2011

Health Care's "99 Percenters"

As Occupy Wall Street has gone from an obscure protest covered only on blogs and social media to a national phenomenon, the apparent parallels between the issues it is raising and the issues we have been raising in health care grows.

99 Percenters

A growing number of protesters are calling themselves the "99 Percenters," (Alter, Jonathan.  Why Occupy Wall Street Should Scare Republicans.  Bloomberg, October 6, 2011.  Link here) referring to those who are not in the top 1% of earners.  (The top 1% of income is clearly greater than $250,000/ year [see 2009 census data on US household income here], and likely around $380,000 a year [based on the distribution of income reported on tax returns here.]) 

In health care, nearly all who are paid more than $380K/ year are either proceduralists (some medical sub-specialist physicians, and some surgeons, again mainly sub-specialist), or managers and executives of health care organizations.

Health Care's 1% 

We have been discussing since 2007 how the inequality among physicians' incomes favoring those who do procedures over primary care and other "cognitive" physicians has been driven not by the market, but by regulatory capture.  The fees paid for all physicians services by Medicare, a fee schedule adopted without question or major changes by nearly all insurers, are set through the Resource Based Relative Value System (RBRVS) by the US Center for Medicare and Medicaid Services (CMS).  CMS, in turn, gets virtually all its input on these fees from the RBRVS Update Committee (RUC), a private committee of the American Medical Association (AMA), made up largely of proceduralists, whose deliberations are secret, and whose membership has been secret until recently.  See here for most recent posts.  Note that the CMS' peculiar relationship with the RUC is now subject of a lawsuit that accuses this relationship of violating the Federal Advisory Committee Act (Klepper B, Kibbe D. A legal challenge to CMS' reliance on the RUC.  Health Affairs Blog, August 9, 2011.  Link here

The real top earners in health care, however, are not physicians, but executives of big corporations, non-profit and especially for profit.  We have discussed endlessly how huge their compensation may be, and how it seems unrelated to any aspect of their own or their organizations' performance, especially not to how much they benefit patients' or the public's health.  Furthermore, we have noted how executives have prospered even when their management seems overtly hostile to the health care mission, when it leads to ethical missteps requiring legal settlements, or even guilty pleas or verdicts to criminal charges

So health care's "99 percenters" ought to be angry at the top 1%.

The Power of Finance

Furthermore, the Occupy Wall Street protesters are not merely upset with the upper 1%, but particularly outraged by those in the financial sector, which "with regulators and elected officials in collusion, inflated and profited from a credit bubble that burst, costing millions of Americans their jobs, incomes, savings and home equity."  Then, "the initial outrage has been compounded by elected officials' hunger for campaign cash from Wall Street, a toxic combination that reaffirmed the economic and political power of banks and bankers, while ordinary Americans suffer.  Extreme income inequality is the hallmark of a dysfunctional economy, dominated by a financial sector that is driven as much by speculation, gouging and government backing as by productive investment." (Anonymous. Protesters against Wall Street.  NY Times, October 8, 2011. Link here)

In another report, the protesters "unite around a common theme: bankers are ripping off America.  Two secondary themes also emerge....  One is that the super rich own the politicians.  The other is that the news media, almost across the board, view events through the eyes of the super rich." (Johnston DC. Occupy Wall Street.  Reuters Blogs, October 7, 2011.  Link here.)

Finance's Links to Health Care

We have noted parallels between the effects of Wall Street and health care on the economy.  Furthermore, we have noted active ties among Wall Street and health care organizations. (Look here for examples.)  Top executives and board members of some of the financial firms most obviously responsible for the global economic collapse/ great recession have served on boards of trustees of top medical schools and academic medical centers, and their parent universities.  The top leaders of medical schools, academic medical centers, and their parent universities have served on the boards of such financial firms.  There are also board interlocks among Wall Street firms and all sorts of health care corporations.  The corporate culture of Wall Street and health care have long overlapped. 

We have further noted how the leadership of big health care organizations has deceptively influenced policy, particularly through stealth health policy advocacy.  Meanwhile, until the last few years, much of health care dysfunction has been anechoic.  Now the media is beginning to report some of the abuses.  Little about them appears, however, in the medical and health care literature that health care professionals are likely to trust more than news media. 


We have frequently suggested that true health care reform requires reform of health care leadership and governance.  We need leaders who understand the health care context, uphold health care professionals' values, and put patients first.  We do not need leaders who are ill-informed, incompetent, self-interested, conflicted, or corrupt.  We need governance that is accountable, honest, transparent, ethical, and again puts patients first.  Maybe to do that we will have to "occupy health care."

In any case, it is time for health care's "99 percenters" to stand up for their patients and the integrity of their values. 


Anonymous said...

Hospital administrators quash dissent by controlling the paid positions of so called medical staff governance, enabling intimidation and retaliation against any doctor who dissents to protect the patients.

I work 35% more hours to tread water financially compared to 10 years ago.

I am a slave to the financially conflicted hospital administrators who force me to use EMR CPOEs to manage my patients when I know that they are unsafe.

I feel about ready to join the occupants.

Anonymous said...

Doctors, lawyers and other professionals who, for decades, have been near the top of the food chain are beginning to recognize they have been supplanted by the Masters of the Universe (MBAs who have the 'gift' of failing upwards). Hopefully, many of them not only recognize that they, too, are the 99% but have a bully pulpit from which to speak and influence policy matters. Here's a supportive link for consideration:


Anonymous said...

Pittsburgh is now a hub of the currently decentralized Occupy Wall Street movement.

In an editorial last week, we applauded the movement’s use of technology to spread its message, but now we’re shaking our heads at the disorganization that has bubbled up in several cities across the country, including ours.

Occupy Wall Street essentially stands against the greed of major corporations, championing the middle class. But what does Occupy Pittsburgh advocate?

According to its website, Occupy Pittsburgh is “currently preparing” its demands, purpose and other organizational documents, which will reflect specific problems in the region. But we think it shouldn’t coordinate and publicize events when its true purpose has yet to be defined.

We have no problem whatsoever with civil protests, but there is little merit in a movement that doesn’t even state what it stands for. There’s no reason to localize a major protest if there is no local purpose. It’s unclear exactly what the group wants to occupy, considering that our financial district is nowhere near as large or influential as Wall Street..

If Occupy Pittsburgh wants to be successful and attract those who are actually interested in change, it should focus on major local issues, like Highmark and UPMC’s ongoing health care war. The dispute between the two medical-care giants might cause people to limit their hospital options — or pay the price — in just a couple of years. That’s just one issue in one city, but it affects thousands and thousands of people.

Highmark and UPMC’s battle is something specific to speak up about, more so than vague assertions about corporate greed. Corporations’ products, including those from computer manufacturers, various media outlets and cell phone providers, are — ironically — helping make the entire campaign possible. What kind of message is that supposed to send?

At this point, Occupy Pittsburgh is the harebrained, illegitimate child of Occupy Wall Street and the Internet. Although it causes many good, efficient thinkers to congregate and share ideas, the Internet is also a lightning rod for misinformation and misinterpretation. We think Occupy Pittsburgh falls victim to the latter.

Because of the insane, exponential growth of the movement thanks to people’s interconnectedness through the Internet, informed, passionate protesters become displaced by bandwagoners who want nothing but to say that they were part of the movement. This is a flaw unique to a generation rooted in technology.

This Saturday, Oct. 15, Occupy Pittsburgh plans to hold a march and rally Downtown. According to the organization’s website, “Details will be posted as they become available.” We understand that a grassroots approach to change can’t be constructed overnight, but a plan and a purpose is essential for an effective event that doesn’t waste its members’ time.

The time-wasting begins with location. Pittsburgh is no Wall Street. What is there to occupy? But make no mistake: The Pittsburgh media will cover the event as if it is actually accomplishing something.

We think Occupy Pittsburgh has two options: It should chalk up its precise point of existence before marching this Saturday, or it should disband into smaller, more efficient groups that tackle specific issues in the community. Without a goal, the group’s efforts lead to nothing: no change and no satisfaction.

Rather than taking a misdirected march onto Pittsburgh’s streets, Occupy Pittsburgh should examine itself — why does it really exist? It’s a small step, but a necessary one. Perhaps once it actually figures out its objectives, motives and goals, its marches and rallies will have meaningful tones, not just the same old rhetoric made popular by its predecessor.

And once Occupy Pittsburgh decides what it wants to be as a movement and actually applies itself to serving as a conduit for the ideas of the common Pittsburgh citizen, maybe we — and others — will start listening.

Anonymous said...

I would only add that health, drug, long term care, etc insurance premiums need to be included in the quation of healthcare costs.
Greater scrutiny of both salary and benefits of insurance company executives can not be overlooked.