Robert W. Morrow, M.D.
I’ll start with a story. A friend and kayak paddling mate runs a solo, independent business. Under the Affordable Care Act (aka Obamacare), he was able to buy appropriate health insurance for himself at an affordable price. He joined my family medical practice as a patient. I agreed to accept his insurance as payment, though I had previously no relationship with this insurance company.
All was well until my friend’s insurance company (a “payer” in industry jargon) went bankrupt, leaving my practice with unpaid bills.
Of course, since he now had no insurance himself, he found another payer. This turned out to be one which I already accepted thanks to my membership in an Independent Practice Association. I had even previously signed a contract directly with this new payer.
The second payer, however, placed my friend in a plan with a new, narrower “panel” of “in-network” physicians. In spite of my established relationship with this payer, the new panel excludes my practice. They do not accept my bills for my friend’s visits as a patient.
Did I mention that this friend takes a really expensive medicine, one which likely will not be fully covered anyway? A very high deductible is an almost assured outcome with passage of the latest assault on the Affordable Healthcare Act, the so-called Tax Cuts and Jobs Act of 2017. That Act intentionally undermines the delicate financing balance of payers participating in Obamacare exchanges.
And this story is about just one patient out of the 3000 or so in my practice, and by no means an exception.
Whose Healthcare is This?
One insurer goes bust, the next is doing its best to manipulate the market to maximize its profits. All the while, my friend is on the receiving end of an increasingly dysfunctional system. What is the US healthcare system good for, anyway?
From my vantage point as an independent primary care physician in a major metropolitan market, what I see is a “healthcare” system that is far more oriented toward financial transactions than concerned with delivering a good product. After all, a good healthcare product, though not easy to achieve, is easy to define: treatment at a reasonable price for my friend, for example.
There are, of course, more general measures of good healthcare: reducing infant and maternal mortality, lowering the cost/accessibility of healthcare to the general population, making the education for health professionals more affordable, and improving the financial and social status of health workers generally.
By any of these measures, however, the US healthcare system is performing abominably. Perhaps not entirely surprisingly, these are not the measures which the system, i.e. the ever-larger healthcare conglomerates that dominate the field, applies to itself.
High Finance in Healthcare
What I see is the subordination of the product – delivery of good healthcare to the general population – to financial transactions, i.e. the ability of the healthcare organizations to “bulk up” via acquisitions and to indulge in capricious spending aimed not at better healthcare outcomes, but increasing the monetary value of the organization itself.
In practical terms, the financial transactions of selling financial instruments, “growth” bonds, etc., are far more important to the major healthcare organizations than a good product.
And the financial driver of today’s healthcare organizations is not a distant mechanism unrelated to the day-to-day delivery of healthcare. It impacts my practice every day, from the lack of funding for primary care in general to the almost malignant inability of the system to address public health emergencies such as the ongoing crisis with Type 2 diabetes or rampant opioid abuse.
It seems to most people that the system is simply struggling to address all the competing demands. But whereas we can all see the US healthcare system is not optimizing patient outcomes, I believe the system is working well to optimize financial value, enriching those at the pinnacle of these organizations and the many financial support organizations that feed off of it. In my next post, I’ll share some every-day examples where financial transactions trump the health of the public.
Bob Morrow is a family physician in the Bronx with a long standing commitment to the health of his community, sometimes in spite of the constraints of the “healthcare system” that he operates. He is a Associate Professor in the Department of Family and Social Medicine at Albert Einstein College of Medicine.
The Contrary Perspective 
My wife and I were just talking about health care, and she cut to the chase: We’d rather kill than cure, she said. How can you disagree? Nearly a trillion a year is spent on “defense,” Homeland security, nukes, and wars, yet we can’t (or won’t) fund decent health care for ourselves.
We’d rather kill than cure — perhaps my wife has summed up the American zeitgeist, and in five words.
Alan Grayson, formerly a Democratic congressman from Florida said, during a House debate, that the Republican solution to national healthcare was for people to “die young”.
traven: I’d only add for POOR people to die young. The rich should live forever.
Both true, but the fact remains that each ‘item’ or brick of healthcare in the US costs twice as much as most elsewhere. indeed,the explosion/bubble of the US financial markets is led by tech and, you guessed it, healthcare.
There’s money there–but large paychecks for the c-suite and financiers do not cover infant mortality nor preventing leg amputations from diabetes.
Bob: I really appreciate your POV as a doctor. Medicine has become just another financial product in the U.S., and an immensely complicated one at that. For example, before Obamacare, people could be denied coverage for preexisting conditions. That makes sense in a profit-driven system, but it’s entirely callous and unfair in a system that should be designed to help people get better. Indeed, the American system has often been about health care denial rather than health care coverage.
I just saw again “The Doctor” with William Hurt. A really good movie, I think. There’s a patient in that movie who ultimately dies from a brain tumor that could have been diagnosed earlier with an MRI, but the MRI was not ordered in time, partly due to cost. Many procedures are denied by insurance companies as being unnecessary, i.e. too expensive, despite the judgment of medical professionals. Again, denial of procedures makes sense when profit is everything, but it makes no sense when a patient’s health is considered.
I happen to think adequate health care should be a fundamental human right — indeed, it’s essential to life, liberty, and the pursuit of happiness. Yet we’ve created a system in the U.S. that’s contrary to these fundamental values. People should not be driven into bankruptcy by health care costs, yet so many in the U.S. are. It seems health care is often more about wealth extraction — but what choice do you have when you’re sick and vulnerable and need care? We’ve created a system that often exploits the sick and vulnerable — the disadvantaged — to improve the financial health of the most advantaged.
As a doctor, that system must be incredibly frustrating to you. It’s a system that does harm — that’s contrary to the most basic principle of the Hippocratic Oath. Our “elites” should be ashamed of themselves for enabling such a system of exploitation in the name of providing care.
It does feel like we have failed on our watch over the last 30-40 years.
But I doubt that the finance world feels ashamed–they make deals or they wither as individuals and financial entities. They feel rich, for what that might be worth.
We are long past when finance invests for the sake of a better, more salable product, particularly in the healthcare sector.
Health systems exist to make transactions to enrich themselves, and the details, which I will lay out, are indeed disheartening at best. For example, if 30% of adults have a preventable disease-diabetes, why are there no funds to prevent diabetes with CDC programs that are proven over the last 17 years? Incredible!
Excellent point about diabetes. I’ve been noticing a lot of advertising on TV for new drugs to treat Type-2 diabetes. I assume the disease is such a big money-maker that the lobbyists are working hard to keep prevention programs and CDC efforts sidelined.
I saw an amazing report on Kidney dialysis on the John Oliver show. Providers of dialysis actually steer patients away from kidney transplants and other remedies. They want to keep them on dialysis since it’s covered by government insurance.
This is a tremendous opportunity for me to better understand not only the current state of healthcare, but the motivational element behind our unacceptable costs. Like so much that is American, finance is trumping patient interests in the healthcare industry, despite the obvious conflict of interest with optimal health outcomes. While I hear the miserable facts and agree with the sentiments, I very much look forward to the next commentary because a dive into the ugliness leads to a deeper understanding for us “non C-suites”, of what is not functioning and who is motivated to maintain a dysfunctional system. If enough of us look through this lens, there will be an opportunity to develop multiple models that eliminate pay-for-service. (Kaiser has one such model, where conceptually, you pay for membership, and the company invests in preventive care to reduce their overall costs.) Thanks for opening the door…
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