By Russell J. Andrews, Special to CNN
Editor’s note: Russell J. Andrews is a neurosurgeon who has been a U.S. Army flight surgeon, a clinician and researcher in both academia and private practice and a medical device developer with NASA. He is the author of ‘Too Big to Succeed: Profiteering in American Medicine.’ The views expressed are his own.
Medicine is big business in America. Nearly one fifth of our GDP is spent on health care – 50 percent more than any other developed country. Yet by many measures we are not getting value for money. Even nearby Cuba, which spends less than one-tenth as much as the U.S. per capita on health care, has outcomes that are as good or better: life expectancy is just as long, and the infant mortality rate is actually lower. Health care in the U.S. is on an unsustainable course, and costs cannot continue to increase while outcomes continue to deteriorate.
This crisis has been blamed on greedy malpractice lawyers, drug companies, health care insurance companies and doctors who over treat patients by practicing defensive or wasteful medicine – unnecessary tests are ordered and unneeded operations are performed. And there is something to all of these. Doctors have failed to address this health care crisis, so other groups offer solutions – notably economists and political commentators. Not surprisingly these proposals represent the expected economic or political views, namely: “Which reform will rein in burgeoning health care costs?” and “Which reform will be politically acceptable?”
Medical students since ancient Greek times have sworn to uphold the Hippocratic Oath. Yet nowhere in the Hippocratic Oath is money, financing or making a profit mentioned. Medicine is a unique relationship between two people, one born of a person’s need for the skills of another person to live and be healthy. Even more than the teacher or the religious leader, the physician bears a responsibility that transcends financial gain. That responsibility to uphold the Hippocratic Oath has been lost in present-day American medicine.
Runaway costs and deteriorating patient outcomes are symptoms, not causes, of the present health care crisis. There are two primary factors at play: (1) the exchange of the unique long-term doctor-patient relationship (where the doctor assumes personal responsibility for the patient receiving the best care possible) for impersonal “corporate medicine;” (2) the morphing of American medicine from a function of humanitarian society into a revenue stream for health care professionals, drug and medical device companies, hospitals, and insurance companies. In essence, we have transformed health care in the U.S. into an industry whose goal is to be profitable, and the health of the patient is not really in the equation. Imagine if such a transformation from a societal good into a profit-making industry occurred in public safety (police and fire), clean air and water or basic education?
True, many incoming medical students have humanitarian motivations (an M.B.A. or a law degree is a quicker route to financial success than medicine). However, corporate America begins invading the physician’s professional “genome” early in training. Academic medical centers are as challenged as community hospitals in making financial ends meet: the faculty member who does not maintain the revenue stream is likely to be let go. The same is true for a physician in private practice – remaining economically viable is a full-time job (leaving less and less time for actual patient care) as for-profit insurance companies work ever harder to reduce their expenses.
The family doctor who follows you over time and place (“from womb to tomb,” and in both the office and the hospital) is being replaced by compartmentalized corporate medicine. In-hospital care is assumed by a team of hospital-based physicians (“hospitalists”). Hospitalized patients may see three or more different hospitalists in a 24-hour period – and still others if they remain hospitalized over a weekend. Indeed, one hospitalist group has impersonalized this to the point where the patient’s doctor is whoever happens to hold the “hospitalist pager” at the moment.
It is sobering how the for-profit “virus” has “infected” health care in the U.S. medical students learn that physicians must forego “the joy of healing those who seek their care” to survive in the profit-driven medical environment. Direct to consumer (patient) advertising – at present largely limited to prescription drugs, although ads for surgical procedures are appearing – clouds the physician’s ability to prescribe what is truly best for the patient. Physicians are forced to prescribe treatment plans that place the financial health of the system (including the doctor’s own “financial health”) ahead of the physical health of the patient.
Medical research and drug and device development also aren’t immune to the profit motive. Many examples exist of millions of dollars wasted in the development of drugs or devices that in the long run were doomed to fail. Competition in medical drug and device research is not like competition in the cellphone or automobile industries. Consumers quickly determine which cellphones are best for them. Health care consumers (i.e. patients) cannot determine if a novel (expensive) drug will be beneficial for them, nor can they predict if their artificial hip or lumbar spine fusion will provide many years of improved quality of life. There are “lemon laws” if your new car fails to perform – but there is no trade-in available for a “failed back.” And again, the profits are privatized up front (to the physicians, the hospitals and the drug and device manufacturers), while the losses are socialized later on (disability payments and the other societal costs of a person who cannot work).
Fortunately, there are signs of health care reform that put patient before profit. The PCMH (patient-centered medical home) places the physician-patient relationship at the forefront of a team providing full-service medical and social service care. The EPMA (European Association of Predictive, Preventive and Personalized Medicine) brings together medical societies, medical research institutes and university hospitals and medical corporations from around the world to address, comprehensively, medical challenges such as diabetes, cardiovascular disease and neurological disorders. Unlike the U.S., European countries provide basic universal health care for their citizens and are not controlled by for-profit insurers and hospitals.
Yet ultimately, the only way true health care reform will happen here is if the voting public in the U.S. rejects the unsustainable course of for-profit medicine. We must lobby our elected representatives in Congress and locally, demanding change. The public must exercise their democratic duty to make their views known – through emails, letters and the ballot box. We don’t just owe it to ourselves to do something – our lives depend on us doing so.