Our Healthcare Industrial Complex

I have borrowed the phrase that President and former General Dwight D. Eisenhower made in reference to being wary of the power of the “military industrial complex.” Of course, he was alerting us to the business of war and the profit that could be made by being forever prepared to do whatever battle is needed. He was right then and he is right today, as this business is still a very powerful lobby. Yet, the purpose of this post is to help define why the US is #1 in the world in healthcare…cost that is…while being #37 in healthcare quality, both according to the World Health Organization. The reason is our Healthcare Industrial Complex.

Two weeks ago, “60 Minutes” did a report on HMA, which is a for-profit national hospital chain that owns a significant number of hospitals in the US. The source of the report is an interview with approximately 100 former physicians with HMA as well as a former Medicare/ Medicaid fraud expert who was in their employ. Their stories are remarkably similar and corroborated by the expert who eventually resigned. The problem they raised is the culture which required Emergency Room (ER) physicians to admit as many emergency room patients into the hospital as possible, even if they did not need to be admitted. They shared goal sheets and emails which highlighted ER physicians who did not admit a sufficient number of patients. Those who failed to remedy this shortfall were terminated.

Why would HMA impose these requirements? Money. The hospital made more money when patients were admitted. The ER doctors noted in the interview when you admit a patient who does not need care, you are actually exposing them to things they need not be exposed to such as the risk of infection or error. In other words with no upside on care improvement, they are only exposed to the downside risk. Yet, this is not unique to for profit hospitals. Even a non-profit hospital has a gain/ loss equation and the goal is clearly to take more money in than you spend. So, the same pressures exist in non-profit hospitals to admit more patients from the ER.

You may say that cannot be true, but in October the Readers DIgest released a story by Michelle Crouch called “50 Secrets Your Surgeon Won’t Tell You.” These are a compilation of comments by named and unnamed surgeons in the US which are consistent with the above theme to make money on the business of healthcare.

#23 – “You should know that practically all surgeons have an inherent financial conflict of interest. That’s because they are paid approximately ten times more money to perform surgery than to manage your problem conservatively,” said orthopaedic surgeon James Rickert, MD.

#31 – “About 25% of operations are unnecessary, but administrators email doctors telling them to do more….The Cleveland Clinic has said this system of paying doctors is so ethically immoral that it started paying its doctors a flat salary no matter how many operations they do, ” said Marty Makary, MD.

#33 – “Some doctors hire practice management consultants to help capture more revenue. The consultants may want the practice to sell equipment like knee braces or walkers at mark-up…or get an in office MRI. Every time a doctors does this, he becomes financially conflicted…you order more MRIs, so you won’t lose money on it,” said James Rickert, MD.

I am glad the article included the Cleveland Clinic example, as this clinic is known as one of the best in the country. The gravitation to salaried doctors has proven to both cost effective and quality improving there and elsewhere. This is one of the solutions to addressing our healthcare cost crisis in the US. The Affordable Care Act is purposed to find these best practices and make them more mainstream.

When people say we have the best healthcare system in the world, that is not true when looking at all measures of results. We are by far the most costly system in the world and have been for a while. Of course, those fully insured and with a means to pay for the finest doctors can get access to state of the art care. But, that applies to the very few, not the many. And, those who have no or little insurance have a much different experience. This is why the Affordable Care Act is so important – getting people covered, paying for care at time of use, and facilitating preventive medicine rather than reactive medicine.

I should mention that the significant majority of the comments in the Readers Digest article were care-oriented. These doctors want their patients to be successful. Here are a few:

#22 – “Some problems just don’t fix well with surgery, like many cases of back pain. My advice is grin and bear it….many people have a degenerative disk with no pain. There isn’t a lot of evidence that we’re helping very many people (through surgery),” said Kevin B. Jones, MD.

#28 – “What really keeps us up at night? It’s not making a mistake in the operating room; it’s the noncompliant patients. When patients don’t do what we tell them, bad things can happen,” said OB-gyn Kurlan Thott, MD.

#46 – “If your doctor wants to give you a stent, always ask: is this better than medicine….Having something planted in your body is not a risk free proposition,” said Marc Gillinov, MD.

#47 – “If I had any kind of serious medical condition, I’d go to a teaching hospital. You’ll get doctors involved with the latest in medicine…At a university hospital, you also have the advantage of having a resident or physician bedside 24-7, with a surgeon on call always available,” said Tomas A. Salerno, MD.

#8 – “It is better to have elective surgery early in the week because lots of doctors go away for the weekend and won’t be around to make sure you are OK…you are going to get someone who’s covering for the surgeon (over the weekend),” said an anonymous general surgeon who blogs under the name Skeptical Scalpel.

These doctors also compiled questions you should ask before surgery:

– Why do I need this procedure now?

– Who is going to be doing it, and how many times has he or she done it before?

– What are the most common complications, and how do you deal with them?

– What will the recovery be like?

– Who is going to take care of me after surgery (pulled from #7)?

These helpful suggestions among many others paint a more favorable picture. Yet, the other comments paint a picture of the business of healthcare. There is a conflict of interest these doctors and nurses are placed under to drive patients to more costly care which is more profitable to the hospital. It is not primarily motivated by better quality of care outcomes. It is more aligned with making money for the provider. With consultants advising hospital and doctors how to make more money by unbundling services, doing more unnecessary or repeated tests, admitting patients and doing more surgeries than necessary, it is easy to see why we have the most expensive healthcare system in the world.

I recall the complaints of HMOs back in the 1980s and 1990s, which were echoed by one political party toward Obamacare, saying the insurance companies or government would stand in the way of the doctor and patient. I do know these MDs at the insurance companies would show data to the hospitals and doctors showing the differences in cost and patterns of care. The purpose is to help find the more elegant care. The comment above about back surgery is pertinent. As of this post, I know three people whose doctors messed up their spines on surgeries that should not have been done or done by those doctors. This is the purpose of the intrusion. Absent that, a hospital may be forcing a decision upon a doctor that is not fully in the best interest of the patient.

I encourage you to read the Reader Digest article. I cited another one over the summer about things nurses won’t tell you. They both are helpful. But, at the center of all the healthcare is you the patient. If you cannot speak for yourself, get a proxy to ask your questions. Take better care of yourself by exercising and eating more healthfully. And, please get a second and maybe a third opinion on surgery. It is your body after all. A healthy sense of skepticism is always appropriate, so ask questions. The ones noted above are good place to start.