Wednesday, September 25, 2019

Private and Commercial Interests Raise More Dander, but Here's a Salve

What raises more of our dander in these pages than anything else? Recent posts, occasionally mine but especially those from FIRM's President and blogueur extraordinaire Roy Poses MD, suggest the answer's a no-brainer: shareholder-favored large-scale commercial interests in health care. Not even creeping disruption. Galloping. So much so, maybe the take-over's now complete and fold our tents. But wait. Turns out there's a sure "what if" in that statement, in a newly appeared book. I'll come to that in due course.

For those of us who pay attention enough to write about it, this blog's subject--worrisome departures from integrity and responsibility in medicine--has converged with the larger issues roiling American society at large, becoming one and the same. In recent years that convergence has become an increasingly persistent and central topic of private discussion for our bloggers.

Just look at two of the recent subjects on which Poses has focused. I'd written a bit about the demise of Hahnemann and fading of its owner Tenet a while back. Now Dr Poses has just gone back there to decry the use of that hospital's residency program as another commercial pawn in the institutional bankruptcy game. Why did a bankruptcy judge let this happen? Well, you can read the post, but essentially it was a variant on the too-big-to-fail argument, too much money at stake.

Whose money? Why, of course, private equity's, and for the hell of it let's add hedge funds'. Behind so many events in the private and especially the public sectors--add in K Street's and lobbyists' doleful effects--loom these investors who must at all costs be protected at everyone else's expense. No different than with rapacious banks a decade earlier: "when the music's playing, you have to get up and dance." (Chuck Prince, Citigroup.)

So throw the hapless young docs under the bus. (And a lot at Hahnemann are FMGs: so why not say the hell with them?!?) To see such young trainee physicians, USMGs as well as FMGs, all of whom uproot themselves and devote scores of extra hours weekly to obtain certification, on an auction block like enslaved bodies--this is a pitiful and egregious sight. Yet there's a certain ugly logic to it, which will only start to change when corporate actors in their planning start to consider more than investors. But wait again! That's maybe already started to happen! In a recent leader, in no less than that left wing (not) rag The Economist, an editorialist usefully and eloquently ponders "what companies are for."

The leader writer argues that companies need, and not out of altruism, "to adapt to society's changing preferences." A decline in firms' ethics and the inevitable counter-reaction combine to push for a major shift, which may in fact already be under way, away from interpreting the 19th century Anglo-French introduction of limited liability as license to privilege the investor above workers and other stake-holders. And who cares if this is premonitory self-cleansing? Health care needs such a readjustment, above almost every other sphere with the probable exception of the need for blunting climate change.

And meanwhile the private equity beat goes on: despite overwhelming support for a curb on "surprise medical billing," Dr. Poses reports still more recently, private equity hides behind white coats, who are either powerless, complicit, or both. Here the white coats are employed specialist groups, backed by corporate entities, opposing a more rational approach to the reimbursement of emergency costs. Radiology and emergency medicine are particularly susceptible to this sort of manipulation, and ought to be equally susceptible to rational planning. Those specialties, being quite remunerative, won't just empty out because someone came in and capped or arbitrated their charges.

Here the problem is a lot like pharmaceutical costs, where increasingly rationality flies out the window when the profit motive runs amok. In some ways PhRMA is in fact even more retrograde, with some notable (mostly non-US) exceptions, than ER staffing companies or for-profit hospitals. The sky's the limit both for price increases and the alibis (research!) used to justify them.

The Economist leader draws to a conclusion by citing bigness and lack of accountability as the real roots of these organizations' problems They point out that large scale and anti-competitive motives are exacerbated by the rise of the digital economy, and argue that effective government's needed to counter such trends and restore competition. Amen. (Or just read any major newspaper of late--same anticipatory kumbaya pronouncements from an awful corporate leadership.) Praise the Lord and pass the ammunition.

But another sort of amen, and a comparative international view of some of these challenges, recently came across my desk in a new book that may have escaped some in this blog's readership. After some late-60s and '70s studies at Harvard and Mount Sinai, physician and New York native Susan Levenstein moved to Rome. She's been there ever since and now emerges as today's most prominent, and probably most eloquent, expatriate practitioner. Levenstein seems to've stuck out her overseas gig for both personal and ideological reasons, admiring the equal-access and public-health features of the Italian health system.

In her book Dottoressa, a new memoir from the estimable publishing house Paul Dry Books, Levenstein spares no criticism of what she sees as that system's flaws, observed over more than four decades of practice in the Eternal City. (I furnish the first link above, Amazon's, for its several useful reviews.)  Replete with rich anecdote--some of her Roman clerics and college-abroad students will stick with me forever--Dottoressa gives us lots of information on what makes the Italian health system one this next wave of US health policy wonks ought to take a look at.

Not that Italy does it all right. The public system's chronically underfunded, she freely admits. (Indeed she was forced early on to shunt her own practice mostly to the private realm because of classic bureaucracy and nepotism.) But in key areas including urgent care (free) and access to medication (cheap), she points out how they get it right. She notes that National Health's attempts to claim some cause-and-effect between public access and the nation's vaunted longevity is rather suspect. She points instead to nutrition, ample time for relaxation and stress relief, and the social compact, as reasons for Italy's number-two (after France) rating for health in the EU.

I hope at some point to have a conversation with this author. But I haven't yet. So I'm not sure whether she'd consider it a direct extension, or something of an extrapolation from her arguments, to suggest the message of Dottoressa could be particularly useful to those engaging in current Democratic Party circular-firing-squad discussions around health care. Italy has a lot that's good about privately funded care. And in complementary fashion, it has a lot that's good about the public side. The key variables are--in a lot of ways like Switzerland--the universality of coverage and the availability of some robust government controls on key costs. Current US proposals to eliminate private insurance don't play in in either country, and the heterogeneity is seen by many as a net good.

Levenstein's new book is therefore a tonic for general readers. (I'll not dwell on the delicious speziatura of her personal story as a New York Jew serving patients in a Catholic country, not to mention tending to the embassy set.) But it should particularly be read by those among the policy army advising Democratic candidates on matters of health.

It's amazing to imagine a government, despite its own extreme dysfunction in so many realms, still managing to keep health care accessible. It helps that (to use one piccante example) an anal-pinworm medicine in Italy costs the patient what it actually costs to make--maybe a euro--with perhaps un po' of profit. Not the hundred-plus-fold multiplier to which some private equity investors leaned on the CEO to jack the US price.

At least in its northern half (many southerners choose to travel north to get what they perceive as optimal care), Italy, like Switzerland, does not suffer from more primitive care in its major referral centers. With provincial referral regionalization and a robust ambulance service (now fully equipped thanks to the EU and charity), one can observe extraordinary results despite the bilge that lobbyists in the US choose to disseminate about "socialized medicine."

This system, in its public hospitals, is vastly admired by the best and brightest of US physicians, including surgeons and cardiologists. Coronary patients were getting radial-artery catheterization routinely before we were. Emergency neurology and other specialized attending consultants in Italian public hospital ERs have rotated through the best services in the US and elsewhere in the world, including of course Italy itself.

Our public hospitals mostly withered on the vine a long time ago. So let's not go overboard criticizing an Italian one that's low on bathroom paper towels.

Why do these physicians, those who train partly abroad come back to Italy to live? They could stay in the US and make the big bucks. Well, some admittedly don't come back. But most do--and why? Go back and re-read the paragraph above that starts "not that Italy does it all right."

Bottom line: Italy does an awful lot right right now. It's likely to improve further with ongoing EU standardization.  In the US, right now, we don't do enough right. That's pretty scandalous, especially since today's Congress has so many physicians in it. But for sure, some of that lot seem to've forgotten their professional roots.

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