Tuesday, July 15, 2014

When Money Talks, the Sick Will Walk, or Crawl - Three Illustrations of the Brave New World of Health Care

In the quaint days of yesteryear, there were those health professionals who thought of what they did as a calling.  The best care of the individual patient was supposed to come first, especially ahead of maximizing one's own income.  Now in the brave new world of neoliberalism, economism, unregulated, laissez faire capitalism - call it what you want - health care has become a business, an industry.  Protests that it still should be a calling are anechoic.

For example, who noticed when a very famous person wrote this in 2012?

Hospitals and other facilities 'must rethink their particular role in order to avoid having health become a simple 'commodity,' subordinate to the laws of the market, and, therefore, a good reserved to a few, rather than a universal good to be guaranteed and defended,'

For those who cannot tell who that was, see the end of this post.

Recently, some illustrations of how health care now puts money ahead of patients came to light.

Intellectual Property Rights Ahead of Sick Patients

The first example is from the KevinMD blog, written by medical and business student Samyutka Mullangi.

 My business ethics class recently discussed the case of Cipla Pharmaceuticals, an Indian generic drug manufacturer drawing the ire of big pharma by blithely ignoring international patents or employing workarounds to manufacture low-cost generics in direct violation of the patents. Cipla’s founder, Dr. Yusuf Hamied, stressed that Cipla’s goal wasn’t to steal from the bottom line of the likes of Merck and Eli Lilly, but rather to serve its mission of helping the world’s poor gain access to life-saving medications that they could otherwise not afford.

Of course,

 Students hailing from careers in pharma vehemently stated their opposition to Cipla’s cause, invoking the necessity for pharmaceutical companies to amortize their costs through sales. Though the incremental costs per pill of actual manufacturing were negligible, the high initial investments in research trials and production required a modicum of intellectual property protection.

The argument was briefly halted when 

 a classmate from the Middle East, who had been holding back furious tears through most of the discussion, raised a trembling hand and broke his silence. He told us of how his father, when he contracted diabetes, would not have survived if not for the availability of exactly such generic drugs.

He said, 'This entire discussion disgusts me.'  

However, very soon another student piped up and started talking about incentivizing.  Mullangi noted that

 At the business school, we use words like incentives, value proposition and return on equity. The liberals in the room had to couch their arguments in these terms. It would have been indelicate to talk about human rights and moral obligations.

While the end of the post suggested that medical students may not understand the language of business students, while business students may not understand the language of medical students.  However, it is clearly discussion of what matters to patients, empathy, ethics, morals that is "indelicate," and incentives, value propositions, and returns on equity have won out.

Efficiency Ahead of Patients' Needs

Just published online in JAMA was a commentary by Dr Christine K Cassel, and Robert S Saunders of the National Quality Forum summarizing recent findings by the US President's Council of Advisors on Science and Technology on Health Care [Cassel CK, Saunders RS. Engineering a better health care system; a report from the President's Council of Advisors on Science and Technology.  JAMA 2014; doi:10.1001/jama.2014.8906.]  While it started with the usual paean to

an increased need to ensure care remains high quality, affordable, and centered around the needs of patients and families.

What it was really about was how

systems engineering ... includes a range of tools to improve efficiency and reliability

So, for example, while some people dislike the US fee-for-service payment system because it may encourage unneeded, useless, or even dangerous care, these authors noted just that it

rewards inefficiency and serves as a disincentive to more efficient care.

The whole point was about increasing efficiency.  But efficiency according to economists is "the use of resources so as to maximize the production of goods and services." (per Wikipedia.)  It is not about health care outcomes, benefits versus harms, or health care quality.  And there was not a word in the paper about patients' values or preferences, benefits or harms, or adverse effects of medical interventions.

The Highest Bidder, not the Sickest Patient, Gets the Earliest Appointment

The starkest example appeared in a Bloomberg article, aptly titled "Doctors for the 1 Percent."  The new start-up HelloMD is

a company that connects patients with the best doctors in San Francisco, Los Angeles and Las Vegas, as determined through a selection process. HelloMD offers faster appointments than regular patients can get, for a price: Its customers pay the doctors higher rates than insurance plans offer. And they pay those rates in cash.


HelloMD is a portal to the top specialists in every field, letting you buy your way to the front of the line.

So in the brave new world of HelloMD, presumably a wealthy patient with a chronic or even trivial problem could bid his or her way to specialty care ahead of a more acutely and severely ill patient who lacks the extra money (and even if the latter patient has full conventional health insurance.)   Most codes of medical conduct suggest that the needs (meaning clinical needs) of individual patients come first, presumably ahead of the wants of wealthier patients.  Yet HelloMD allows the wants of the rich trump the needs of the less rich.  (For any rich people who think that may be good for them, remember there is always somebody richer.)  To an old school doctor, this seems completely unethical.  (And some lawyers might think that participating doctors risk violating any contracts they have with health insurance companies.) 

(Note: see another post about HelloMD on the Health Business Blog.O


So right now those who believe that health care should be a business, not a calling, are winning.  In an era of deregulation and rampant suspicion of anything government can do to level the playing field, those with more money will win, and patients, no matter how sick, will lose.

By the way, anyone thinking that they are rich enough to buy their way to good care in this brave new world, remember there will always be someone ahead of you who is richer. 

Good health care will not survive long in a time when it is indelicate to talk about human rights and moral obligations.  Obviously, true health care reform will take more than talk.

Answer to Quiz - Pope Benedict XVI, see this post.


Steve Lucas said...

“The rich are different than you and I.”

My concern is not with the rich but with the bulk of the medical care being provided by doctors in suburban offices. The entire focus has become on revenue generation. Ask a doctor about Choosing Wisely or the latest specialist recommendations to drop a test and you will get a blank stare. Worse is the dismissal of your comment and the statement that they are your doctor and they know best.

Not that many years ago education was priced to cover cost and administration was kept to a minimum. Today administrators claim large staffs that are unrelated to their function and universities have become aware and seek to participate in students future income streams through such things as student loans. Alumni groups use tactics that would be illegal if used by a bill collector. This sets the tone for many students as they have been taught to maximize all income situations.

We will soon spend 20% of GDP on medical care in this country, twice what is spent in many other countries, and yet we have no better outcomes. Doctors schedule six minute office visits or roll their panel every two weeks in an effort to maximize revenue. We do not have to look hard or far to see why costs are high and care is poor.

Food, gas, housing and medical cost now consume almost all of the average persons income leaving no discretionary funds to fuel an economic recovery. Medical costs now are the largest budget item in many households and there is no indication of any slowing in the future.

Our problem is not a two tiered system but a one tiered system where only those with money can afford medical care. This suits many in corporate America so long as we do not cut their income as part of a 50% reduction in medical spending to bring us in line with the rest of the world.

Steve Lucas

Brad Evans said...

"The argument was briefly halted when

a classmate from the Middle East, who had been holding back furious tears through most of the discussion, raised a trembling hand and broke his silence. He told us of how his father, when he contracted diabetes, would not have survived if not for the availability of exactly such generic drugs.

He said, 'This entire discussion disgusts me.'"

One problem is that there has to be a tradename for the generics to copy. Let's say there were no patent rights, generics could come out right away, and that this has been going on for 20 years or more.

What might happen? The diabetes drug that saved the young man's dad might not have come out as tradename. No tradename, no generic. The dad dies. Others die too. Bad, I know, but take a good look at the other side of the ethical ledger.

First, no one would know that a great diabetes drug went missing. No one would blame the deaths on public policy. Patients would feel good they can get hold of medicines inexpensively. Doctors could feel good, compassionate, and Hippocrates-compliant. Politicians would feel good, because there is no angry electorate. Because no one monitors medicines that have NOT been brought out, no one feels bad at all.

In a world of "the greatest good for the greatest number," it's time to say, "Do away with patent rights, let the generic companies market medicines at low prices."

Roy M. Poses MD said...

Brad Evans,

I don't think I, or anyone in the above post, said anything about abolishing drug patents.

So you seem to be working off a straw man argument.

But since you brought up the topic, surely there is room for argument about the details of drug patent law, especially given how expensive drugs have become, making them close to inaccessible in less developed countries? And surely business schools should not suggest that human rights and moral obligations are taboo topics?

By the way, I wonder which Brad Evans you are, the soccer player, the Brad Evans and Merz Pharmaceutical, the Brad Evans at Gentiva, or someone else?

Steve Lucas said...


From a purely business standpoint there will be no loss of revenue from sales in a market the drug companies do not enter. Today we find many patented medicines not being offered in certain nations due to cost. With no possible sales there is no loss of revenue.

Additionally, the US is one of the few nations that does not set drug prices making us a high cost drug market. We now find that many drug companies are marketing generic versions of their patented medicines the moment they go off patent using a separate corporate entity, but the same manufacturing facilities.

Would it be ethical for the US, one of only two countries that allow DTC ads, to eliminate DTC ads so that consumers would not know about all of the drugs pharma has to offer, or should we continue to be subject to false and misleading advertising?

Steve Lucas