You are not your patient’s doctor any more. You have been replaced. However, joining the corporate medicine bandwagon, turning a blind eye and following their unethical mandates can also jeopardize your career, and your patients’ lives.
The profession of dedicated healers of the sick has become a commodity. A commodity has traditionally been defined as “anything movable that can be bought and sold” and “an unfinished article of material substance, as opposed to a service.” By redefining medical services as physical articles, healthcare has been converted to something understandable to business managers and conducive to economic modeling. Insurance companies have redefined hospitals as “cost centers,” patients needing care as “covered lives,” and expenditures for care as “medical losses.” The goal of the insurance industry, then, is to keep the covered lives out of the cost centers to keep the medical loss ratios down.
William Andereck, M.D., summed up what patients experience under today’s system of commodified medicine in his essay Commodified Care:
Your company introduced a new health insurance program last spring and you were invited to select a physician from a list of doctors. You did your homework and asked friends and several health care workers for the most competent primary care physician. The name that kept coming up was Dr. Snipe, and so you made an appointment.
It took a while to get in, but on your initial visit, he seemed pleasant enough. He spent a lot of time talking to you and, when he examined you, he made you feel confident that you had chosen a physician that you could count on in the worst of illness. Dr. Snipe would be able to guide you through your next twenty years. When you mentioned to him the tight feeling you get in your neck and arm sometimes, his ears seemed to perk up.
When you left the office you were told to return in the morning for a treadmill test. The next day, you met Dr. Able, who introduced herself as your cardiologist. After the treadmill she told you that it showed signs of poor blood flow in the heart and recommended that you undergo a cardiac catheterization in a few days, by her colleague, Dr. Burns. The next morning the tightness returned and you called the emergency number on your insurance card. The on-call physician, Dr. Chan, told you to go the hospital immediately. There you were met by Dr. Davis and his emergency room team. Dr. Evans, the admitting cardiology resident, let it be known that he would be responsible for writing all the orders that directed your medical care when you were transferred to the coronary care unit. Dr. Fudd, the hospital’s intensivist introduced himself and his team, Drs. Gavin, Hubbard and Iota. After your heart was catheterized and Dr. Juster was unable to place numerous necessary stents, further catheterization was ruled out after consultation with the attending cardiologist, Dr. Kite. Therefore, you were referred to the Medical Center’s leading cardiac surgeon, Dr. Luce. He seemed totally competent and reassuring. Surgery was scheduled for the following morning.
There are several weeks when names and events float like leaves in the wind. Doctors like Nevermore, Potter and Travis seem to be in there somewhere, along with vague memories of respirators, IV tubes and innumerable smiling, unrecognizable faces. The next thing you clearly remember is the surgical ward with Dr. Weber as the resident managing your wound. As you got stronger, Dr. Xavier assumed your care in order to manage the multiple medical complications that had developed during your ICU stay. For the past four weeks you have gotten to know Dr. Yoste quite well, as she took care of you in the Skilled Nursing Facility. And now, as you are leaving, the nurse hands you a card listing your first post-hospital visit with your new cardiologist, Dr. Zulka.
Then you wonder, “What ever happened to Dr. Snipe?”
Commodification is premised on the assumption that the whole can be completely broken down into its parts, which can themselves be precisely defined. Dr. Andereck illustrated the concept by describing the experience of shopping for a turkey for his family’s Thanksgiving dinner:
“I imagined the noble bird of our forefathers’ time, standing proud, tail fanned, head held high, red waddle flapping defiantly. What I found on the shelf bore no resemblance to the creature I was seeking. Wrapped in plastic, on a yellow Styrofoam board was a very large, pale, glob of flesh. The neatly printed label advertised two large breasts, six wings and four legs, complete with drumsticks that would make a hog proud. I had found the commodified turkey. The turkey no longer contained the gizzards and giblets I loved as a youth, and certainly there was no heart. The turkey had become something else in its journey from the farmyard in Kansas to the meat counter at Albertson’s. Some essential items had been left on the slaughterhouse floor. The key to the dangers of commodified medicine was realized. It is not what the product is. It is what has been removed.”
To reverse this trend means challenging the rapidly consolidating economic power that now influences everything. Credentialing committees determine which doctors can practice at a given hospital, which therapies will be provided for any given disease process, the length of a patient’s hospital stay, or if they will even be admitted to the hospital at all.
Hospital corporations are buying up hospitals — sometimes two at a time, so they can close one and maintain the other as a monopoly. They are also buying physicians’ practices from general practitioners to cardiologists to orthopedic surgeons. In southwestern Idaho, over half the 1,400 doctors are employed by either the St. Luke’s Health System or its competition, the St. Alphonsus Regional Medical Center. Independent practitioners outside of the larger systems in this medical battleground are increasingly denied referrals.
Boise’s situation reflects a growing national consolidation trend. Doctors who sold their practices and signed on as employees have similar criticisms countrywide. In lawsuits and interviews, they describe the growing pressure to meet financial goals of their employers — by performing unnecessary tests and procedures, admitting patients who don’t require hospitalization or by denying necessary, but poorly-reimbursed procedures such as placing defibrillators in Medicaid patients, because they are “money-losing propositions.”
The AMA recently weighed in on the issue, warning doctors facing divided loyalties to always prioritize patient welfare, even if this is in conflict with the economic interests of the hospitals who employ them. However, without organization, doctors who object to the consequences their patients face if they follow corporate decisions to restrict care or schedule unnecessary tests, are easily replaced by colleagues more compliant with the “brave new world” of corporate medicine.
POC has handled multiple requests from member physicians who have been removed from their positions, taken off call schedules, reassigned or starved of patient referrals after standing up to corporate medicine’s dictates. Legal remedies have been ineffective in resolving these matters except in extreme cases like that of Michael Fitzgibbons, M.D. where the Mathews Law Group won a $5.7 million judgment against Integrated Healthcare Holdings Incorporated (IHHI) for having hired someone to plant a gun in his car and slash the tires of his wife’s and daughter’s cars in retribution for his fight against IHHI.
Physicians themselves have now been reduced from professionals to mere commodities to be hired or fired. Physicians no longer have jurisdiction over prescribing therapies and procedures in the patient’s best interest, so essential to gaining the trust of patients. One POC member described the effect on the doctor-patient relationship as equivalent to having a third-party stranger in the exam room when you are asking the patient to undress for an exam.
he case of POC member Peter Navolanic, M.D., was a harbinger of things to come. In 2005 Sutter Connect took over the contract to manage his practice from East Bay Medical Resources. He was soon informed that his practice was losing money and the 401(k) plan was underfunded. After he terminated his relationship with them, Sutter Connect refused him access to the electronic and file copies of his practice’s medical records and billing information. Nine months later, with nearly $1,000,000 in unpaid claims and other losses, his practice was ruined.
One ICU director told POC of a situation where a credentialing committee questioned his credentials when he refused to cooperate with a “recommendation” made by the hospital’s “expert” to classify a blood sugar level of 200 as “out of control diabetes,” just to get more money.
Even executives who don’t play ball can be fired. Paul Meyer, a compliance officer for Florida-based Health Management, which operates 70 hospitals, said he was fired in 2011 in retaliation for questioning what he felt were improper admissions.
The economic transformation of medicine has paralleled that of other industries, with the growth of regional monopolies. The addition of bank capital allowed these regional medical care monopolies to expand and gain economic interest in hospital chains, clinics and diagnostic centers. Finance capital became a force in its own right, directing the development of medical resources to maximize profits. Doctors end up somewhere near the bottom of the chain.
Unorganized doctors are reduced to being medical workers, deprived of professional decision-making ability, rendering professional ethics secondary to business plans and leaving doctors without control of either their patient treatment plans or their own lives (many work under at-will contracts that can be terminated within 60 days.)
Without organization, doctors’ input concerning medical matters will continue to be ignored in plans to construct and operate medical facilities. To protect the 1.5 million people served by Stony Brook University’s burn unit, the late Harry Saroff, M.D., when in his 70’s, had to organize multiple rallies of doctors, patients and staff to save it from closure. Despite universal condemnation from psychiatrists and other physicians, Sutter Health, a non-profit hospital chain, projected to build 630 hospital beds in San Francisco without including a single mental health bed. An organized campaign by physicians played a major role in sending this plan back to the drawing board.
When doctors are organized, as has been demonstrated by intern and resident organizations and small groups of dedicated physicians across the country, patient care can be defended and preserved.
Doctors at numerous hospitals have noted that criticizing policies of their hospital or investor-owned physicians group is often difficult because, as employees without rights, they could be fired, with the hospital corporations blaming them for “poor performance.” Yet doctors are ethically bound to remedy harmful patient safety practices.
POC’s founding mission takes on new urgency every day. Per our Statement of Principles, we are committed to “defending medical professionals who are facing impending loss of property, tenancy, ability, ethical practices and constitutional rights as professionals; through the inability to practice their profession to the mutual benefit of the community and profession, in the face of governmental regulation and program.”
Huge corporate entities are currently accumulating capital and monopoy positions at a rate far out pacing physicians’ ability to contain the damage to our health care system. Physicians have been left fighting one defensive battle after another as highlighted in the Spring 2013 issue of New Diagnosis.
In this context it is vital for physicians to learn a new profession, that of organizing. POC provides training on the job in physician organizing as well as classes on the politics and economics of health care, teaching from history what does and does not work.
POC is designed to bring doctors together as a skilled, professional, highly trained workforce capable of defending the practice of medicine from the abuses and commodification so prevalent today. The efforts described in this publication have progressed as far as they have, because individuals have stepped forth to take the training and put in the time to learn on the job how to wage these fights.
POC calls on physicians to contact us today to find out about enrolling in our physician organizing training programs, so you can learn how to help expand the movement to battle the ruthless consolidation and perversion of our medical care system — and put an end to it in the interests of our patients and our profession.