Malafactor Medicine

July 2004

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How the changing patterns of ownership of the different segments of the healthcare delivery system have operated to the disservice of the patient recipients. A discussion of the zero sum approach to regulating health care costs.

When I was a kid, most doctors were out on their own: one office, a nurse, and their patients. In some cases you might have three or four doctors who shared a couple of nurses, and a receptionist. Hospitals were largely public concerns, like colleges, or the electric company. Insurance companies and pharmaceutical companies were businesses who supplied the demand that the medical establishment created.

Today, insurance companies and pharmaceutical companies own hospitals and clinics. Insurance companies own pharmaceutical companies, and pharmaceutical companies own insurance companies. Is it any wonder that our healthcare delivery system is an expensive mess?

Some time ago, I happened to be in a Chinese restaurant and had a long chat with a young doctor who was eating there. He was unhappy about how he was forced to practice medicine: "It wasn't supposed to be like this," he complained. He then explained that the hospital he worked in worked like this:

• The patient comes in with a list of symptoms. The doctor consults the procedural manual and identifies the tests that ought to be given to patients with those symptoms.
• When the test results arrive the physician consults another manual and prescribes the treatment defined for the resulting test results.
• If the patient is improving, the doctor schedules follow-ups when the manual says s/he should, for that number of times, and for that number of consulting minutes.
• If the patient is not getting better, the doctor must refer them to somewhere else.
• If the patient has symptoms not in the manual, the doctor must refer them elsewhere.
• The patient gets better, or not.

"Who made up the manuals?" I asked. He told me that they came from the hospital management group that is mandated by the hospital's insurance company. The management company is owned by a pharmaceutical company. Actually, the same people sit on the boards of the hospital, the management group, and the insurance company, more or less.

He said that he had to follow the procedures in the manual to the letter, regardless of what was good for the patient -- to stray from the manual was a dismissal offense. It was hard to just process people all day long. He didn't become a doctor to do the job of a glorified clerk. The only enjoyment he really got from his job was when people came in with real injuries and he got to put them back together, make them comfortable, and then look in the manual to see if he had to lie about what he had done.

There is something inherently wrong in a system where the insurance companies own the medical facilities. There is something even more rotten about pharmaceutical companies prescribing drugs.

Just giving everyone access to health insurance won't help healthcare to help patients. The whole industry has to be restructured. Human health and the amelioration of human suffering should not be a for-huge-profit business. It takes dedication, intelligence, and commitment to be a good physician or clinician. Clouding the issues with a pile of money just makes people suffer needlessly. Doctors motivated by greed do the same for their profession as greedy lawyers do for the law.

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