American Health Care and the Profit Motive. Part I

For the love of money is the root of all evil: which while some coveted after, they have erred from the faith, and pierced themselves through with many sorrows.” (1 Timothy 6:10) 
Looking at the development of health care in the United States there is a good case to be made for the love of money driving the ills we currently experience in dealing with the health care establishment. Simply put, money seems to be the driving force among physicians in providing care. It has supplanted the caring family doctor whose compassion and service orientation never led him to see his patients as contributing to his bottom line. Critics may claim that the high charges doctors now make (hundreds of dollars for a brief office visit) have to cover all their paperwork and office costs, especially malpractice insurance. Regarding malpractice, consider this: Until the 1950s malpractice was governed by the Hippocratic Oath. With the 1960s, medical malpractice expanded exponentially prompting legislation and insurance. 
Why did this happen? Look at the following data regarding the growth of doctors’ income and what has become the Business of Medicine for an answer. 
One way to look at trends over time is to examine when certain words became part of the English language. For example, Iatrogenic means “Induced unintentionally by a physician through his diagnosis, manner or treatment; of or pertaining to the induction of (mental or bodily) disorders, symptoms, etc. (Oxford English Dictionary OED, accessed July 11, 2015). The OED lists its first awareness of this term in  Eugen Bleuler, Textbook of Psychiatry  xiii, 502 Authorized English edition by A. A. Brill (transl. Abraham Arden Brill), 1924 as “something not entirely unimportant, unfortunately, is the iatrogenic origin of neurotic manifestations.” The next mention chosen by the OED, still from the psychiatric field was in 1948, “Difficulties, arising from medical clumsiness in the handling of patients, are common enough to have originated the diagnosis of iatrogenic, or physician-determined, conditions of health.” (1948: L. Kanner Child Psychiatry (ed. 2) ix. 143). By 1973, we find the OED citing the Guardian, 18 Jan 12, thusly, “Drug induced (iatrogenic) conditions are on the increase.”
For several decades after introduction of this word, it seems to have been limited to the literature of psychiatry. Then Aldous Huxley used it in the Devils of Loudon in 1952. By the 1970s, it became part of common medical terminology. Now iatrogenic and nosocomial causes based on U.S. government statistics make the health care system the third leading cause of morbidity and mortality in the U.S. A commonly used statistic for iatrogenic deaths alone is 230,000 to 284,000 iatrogenic deaths annually.
Nosocomial is another interesting medical term. According to the OED it means “Of or relating to a hospital; spec. (of a disease) originating or acquired in hospital.” Unlike iatrogenic, nosocomial has a much longer history. It was first used in 1853 by Robley Dunglison referring to a nosocomial or hospital fever (Medical Lexicon. A New Dictionary of Medical Science).
Why did iatrogenic illness and the disappearance of the good old family doctor happen?
Ivan Illich, in his 1974 book Medical Nemesis: The Expropriation of Health posed some answers. Illich described three levels of iatrogenesis. [i]
  1. Clinical iatrogenesis is the injury done to patients by ineffective, unsafe, and erroneous treatments.
  2. Social iatrogenesis is the medicalization of life in which medical professionals, pharmaceutical companies, and medical device companies have a vested interest in sponsoring sickness by creating unrealistic health demands that require more treatments or to treat non-diseases that are part of the normal human experience, such as age-related declines. 
  3.  Cultural iatrogenesis refers to the destruction of traditional ways of dealing with, and making sense of, death, suffering, and sickness.

 Illich went on to claim a “growing detachment of medicine from its ethical traditions and its emphasis on compassion.” saying that “Medicine has shifted from being primarily a “healingart” to a science orientated endeavor and has combined with entrepreneurial forces to redefine its role. This has been reinforced by new goals of control and profit.

No longer are local, primary care doctors deciding what services are appropriate; rather, remote professionals and non-professional government appointees take control of treatment choices and other aspects of medicine.
Historical data is perhaps an even more objective way of looking at these changes that affect each of us. Consider the implications of these facts based on the publication Historical Statistics of the U.S. Colonial Times to 1957. U.S. Government Printing Office, updated with numbers from the Bureau of Labor Statistics, the MedscapeCompensation Report, and a national survey.
In 1900, there were 131,000 physicians, surgeons, osteopaths, chiropractors, therapists and healers lumped together. In 2010, there were 850,085 physicians and surgeons alone. Based on comparative population there were 581 patients per doctor in 1900 and 378 patients per doctor in 2012. The net income of doctors in 1929 (the earliest figures available—perhaps because in earlier times doctors tended to be paid in chickens or vegetables) was $5,224 and in 2012 primary care physicians alone averaged $220,942 per year. The three highest specialties in 2012 made a lot more: Orthopedics $405,000, Cardiology $357,000, radiology $348,000.
Based on CPI calculations, to purchase a similar standard of living an income of $5,224 in 1929 would compare to $59,000 in 2012—not $220,942. Is medicine a financially rewarding profession? It would appear so. When so much money rests upon maintaining the style of living that $220,000 or $400,000 gives one, given human nature, whic assumes primary importance—the individual patient’s wellbeing or the number of patients one can cram into a day’s work? Other interesting facts from the Medscape report show that doctors are seeing more patients a week than just a year ago. About 35% see between 50 and 99 patients per week, compared with 29% the previous year. Forty percent see between 25 and 75 patients per week.
Although the Medscape report says doctors still spend a “meaningful amount of time with their patients,” their definition of meaningful for the largest group of doctors is between 13 and 16 minutes per patient. Fifty-one percent spend between 13 and 20 minutes per patient. How many readers of this blog believe 13 minutes is enough to get their health issues addressed in a meaningful way? Although, based on a survey in Dr. Jerome Groopman’s book How Doctors Think, most doctors stop listening and make up their minds after the first four minutes of a consultation, so perhaps the total length is irrelevant.
Perhaps the most interesting part of that Medscape survey has to do with doctors’ attitudes towards their work. Two questions dealt with what doctors felt was the most rewarding part of their job and whether, if they had it to do over again they would still become doctors. It may seem cynical, but there is an interesting contradiction in the responses to these questions, which leads to some doubt about the truthfulness of respondents about how rewarding their job is.

Only a minuscule minority (2%) found nothing whatsoever rewarding about being a physician. The rest used positive terms to describe their work such as “Doing a good job in an honorable profession”; “Seeing people heal physically, emotionally, and spiritually”; “Knowing that I’m meeting a need and I’m good at what I do”; “I enjoy my patients, particularly the veterans of WWII”; “Helping indigent uninsured patients get care”; “Giving others hope.”

However, when asked if they would do it all over again, only slightly more than half would choose to become doctors again, down from 54% in 2012. If all but 2% find the profession so rewarding, why do slightly less than 50% wish they had chosen something else? Could the money have something to do with at least 50% willing to make the same career choices? Mostly it is the specialists who would chose to repeat a career as Medscape reports. Least likely to choose their own specialty again are internists (19%), family physicians (28%), and obstetricians/gynecologists (37%). Compare this to the income disparities between medical areas and try to maintain money is not the driving force.

There is no reliable statistical evidence, only anecdotal based on memories of older generations and written narratives. Still, it is hard to believe that doctors in the latter 19th and early 20th centuries, with all the reminiscences of the kindly family doctor coming to your house, which even I remember as a child, tried to see 75 patients a day or spend only 13 minutes with a patient. Only with the changes described by Illich and others, when medicine became a business and the bottom line came to predominate, did medical care degenerate to the level it has reached now.

The horror stories that make the media, such as the Detroit-area doctor who gave cancer treatments to 553 patients who did not need them or even have cancer in order to defraud Medicare  are only the tip of the iceberg. Medicare itself says fraud costs billions of dollars and has a link to examples of fraud. Who is committing this fraud? Is it patients or venal doctors and clinics?

When the focus is on profit, how do you expect to get the best care from the system? Elementary profit theory shows that the secret to success is maximizing throughput and minimizing your costs. The inevitable result is lowered quality, which in health care produces results such as those seen in the English National Health Service, the model for Obamacare’s start on a single-payer system in the U.S. “In total, NHS trusts have paid out more than £4.5 billion in the past five years for medical mistakes. About a quarter was paid to law firms to cover legal costs and most of the rest in compensation to patients harmed by medical blunders.”

Is there any answer to this problem? Only one in this blogger’s opinion. Spend the time to become the most informed health care consumer in the world. Do not accept at face value any doctor’s recommendation that involves tests, particularly invasive ones, drugs, particularly ones with less than seven years on the market (to allow for problems hidden by the pharmaceutical companies to surface), or referrals without first doing your own research. Use recommended sources to check on the reliability record of doctors and problem rates in hospitals. Look up your doctor in state disclosures of malpractice suits or other claims. Follow the suggestions in these posts:Some Useful Medical Databases, TheBest Defense Is Preparation and Finding Medical Information Online.

Above all, banish the idea that “The Doctor Knows Best.” While there may still be a few MarcusWelby’s, the epitome of the kindly and caring family doctor, still practicing, what most doctors know best is how to see the most patients in the least amount of time and keep their bottom line healthy.

[i]Robert J. Barnet, “Ivan Illich and the Nemesis of Medicine: The Man and His Message.” In Medicine, Health Care and Philosophy 6: 273–286, 2003. © 2003 Kluwer Academic Publishers. Printed in the Netherlands.