Anyone watching the big trends in American healthcare has become aware that .
Meanwhile, the public increasingly encounters practitioners who are less well trained than physicians. And when a patient sees a physician, the chances are that the physician will have less time available than ever before.
But the costs never go down, only up. We pay more and more for less and less -- less time, less expertise.
These trends have multiple drivers. One of the biggest is this simple fact -- corporations, with their huge managerial and , are now the big players in medicine. They suck in vast amounts of money, and they spend part of that money making sure the rules of the road in American healthcare favor them, not the patient.
If you have a hunch that some politicians are likely to have been affected by these concentrations of money in healthcare-related corporations, you are on the right track. In 2018, that spent big money to lobby Washington were related in one way or another to healthcare. Even in the insurance field, .
Follow the Money
When something makes little sense in American healthcare policy and shows every sign of adding to the nation's annual tab for "healthcare" -- which, again, is burdened by much, much more than the actual delivery of care to patients -- it makes great sense to remember the old saying, follow the money.
Where do America's "healthcare" dollars go?
In terms of their power to suction dollars from the public, what are the biggest corporate entities on the landscape?
Leading the pack are the pharmacy chains, their associated (PBMs), and the increasingly consolidated hospital industry.
The Pharmacy Chains
Scrambling for market share in the primary care space, the brick-and-mortar, big-box pharmacies, such as , , and largely employ "physician extenders." or recently with insurance companies and PBMs -- astounding "cash cows" for financing the mergers and acquisitions.
The Pharmacy Benefit Managers
Did you know that comes through Caremark, its PBM?
Did you know that PBMs have been associated with very questionable practices in amassing their huge profits? Practices like:
- Exploiting their .
- (i.e., helping themselves to more Medicaid dollars).
- .
- their own brick-and-mortar and specialty pharmacies.
- out of existence.
Also eager to feed from the system, OptumRx, a United Healthcare subsidiary and one of in the PBM space, has become and has been on oncologists, orthopedists, allergists, and other specialists.
Consolidated Hospitals
Expanding regional hospital monopolies are the next-largest player in the corporatization of American healthcare. They, too, have been . And needing to increase their profits, with "physician extenders."
This will explode when corporate employers are able to collect equivalent reimbursement for the work of physician extenders, while simultaneously paying them less than they would pay physicians.
Informed patients would surely feel the same way if they understood what was happening and what it implied for the expertise of the people they look to for care.
As mergers, both horizontal and vertical, have multiplied, the dangerously aligned financial interests, the profits, and the power have metastasized.
Consequences
There are foreseeable consequences from American healthcare "going corporate."
- The existing physician shortage will deepen. Physicians themselves will dissuade bright young people from entering the rigorous profession of medicine with its years of training.
- The PBM/insurance behemoths and the consolidated hospital systems will use mid-level professionals (for example, nurse practitioners and physician assistants) to maximum financial advantage.
- A confused public will, year by year, find it harder to choose care from a physician. Many physicians who want to remain in practice will have gone "off the grid," making themselves available to those who pay by cash, without the appalling overhead and profligacy that characterize our third-party payer system. This will leave the most vulnerable among the public to the tender mercies of big-box medicine -- that rapacious alliance of special interests, administrators, and all who profit from it.
The public, whether through its tax or out-of-pocket burdens, will continue to hemorrhage dollars.
Physicians, Remember Your Oath
To protect their patients, physicians must now look beyond the confines of their exam rooms, emergency departments, and operating rooms to honor the oath they took. They can do so by:
- Educating themselves about the destructive corporatization of healthcare;
- Educating their patients and lawmakers by speaking out in the press and in person;
- Supporting reforms that focus on patients as the most important stakeholders in the healthcare arena;
- Upholding the standards of physician training that has defined them;
- Protecting the integrity of their respective disciplines in the field.
Initiatives Worth Supporting
Unleash the power of the free market in the healthcare sector:
- Expand patients' freedom and choice in the use of , especially as payment for direct primary care and other models of coverage, such as periodic-fee, .
- Codify the use of association health plans and short-term limited duration insurance as affordable, portable alternatives to .
- Allow Medicaid patients to use provided monies as a voucher to purchase periodic fee services.
- Repeal the "safe harbor" protections of for kickbacks to PBMs and group purchasing organizations (GPOs).
- Repeal the of physician-owned hospitals.
- Solve "surprise billing" via the arbitration model already working in New York and Texas. Benchmark rate-setting is tantamount to price controls, an anti-free market mechanism with an abysmal track record.
Repeal onerous, unnecessary mandates:
- Remove Electronic Health Record and Merit-Based Incentive Payment System mandates for practices having fewer than 50 physicians.
- in Medicare Advantage and other third-party markets.
Mandate transparency:
- the measures in the Administration's .
- Direct a Government Accountability Office study of PBMs' accounting (), and eventually the GPOs'.
- of medical practitioner.
Make fully transparent the funding that flows from pharmacy "channel companies" (such as PBMs, GPOs, and distributors) to advocacy groups, physicians, and think tanks. This transparency should be retroactive, so as to establish histories of possible conflicts of interest.
, is a pediatrician in the Philadelphia area and co-founder of . She is a graduate of the Duke University Medical School and was trained in pediatrics at Northwestern University.