The Corporatization of American Health Care: The Rise of Corporate Hegemony and the Loss of Professional Autonomy

ISBN-13: 9783030606664 / Angielski / Twarda / 2020 / 307 str.

J. Warren Salmon; Stephen L. Thompson

Spis treści

Introduction

This intro chapter will elaborate on the purpose of the book, followed by overviews of each chapter.

Chapter 1 – The Corporatization of Medicine: The Market Paradigm

Since the 1970s, the corporatization of medicine has completely transformed the American health care delivery system; it also dramatically altered the practice of medicine and is eroding professional altruism and the dedication to science in prevention, diagnosis, and treatment. The late New England Journal of Medicine Editor Arnold Relman decried the new medical-industrial complex -- the for-profit intrusion into hospitals, nursing homes, home care, dialysis centers, and ambulatory care. Also, the pharmacy benefit management industry, which is completely for profit, arose in the late 1990s, and, along with provider institutions, is nurtured by phenomenal federal subsidization through Medicare, Medicaid, and the Part D

Medicare program. Another unique phenomenon to our nation is the rapid rise of retail clinics now eclipsing ambulatory care under the aegis of corporate pharmacy chains. Quentin Young has pointed out the "vampire effect": the so-called "not-for-profit" providers being bitten by the for-profit investor providers, making their performance behaviors convergent with a complete focus on bottom-line results at the expense of access and quality health care.

 

Beyond just the for-profit provision of services is a hugely profitable set of supply firms that have long benefited from the "medical-industrial complex," often at the expense of patient protections. These include pharmaceutical firms, medical device makers, health information technology, construction and management consulting, and accounting, legal, and other services that providers depend upon and are paid for through the public financing of the system.

Chapter

2 - ObamaCare: What Went Wrong?

The Obama Administration recognized the necessity of moving toward care for the uninsured, which had risen to over 47 million Americans denied care. In addition to this group, perhaps a larger number of people had private insurance or other means of paying for medical care, but it was woefully inadequate, due to the large number of underinsured. ObamaCare provides for some cost-control mechanisms, but not sufficient enough to quell the incentives to price increases for accelerating the profits of insurance companies, pharmaceutical companies, and a host of other upstarts that began to cash in on their new federal subsidization. Needless to say, enough studies in health services research continue to identify major quality issues, even while metrics are being developed by the Centers for Medicare and Medicaid Services and the private insurance industry to address quality issues. 

Yet, Obamacare continues to repr

esent centrist politics and incremental reform, which accepts the belief that marketplace medicine is the clear U.S. reality. Policies to support it are in tune with what corporate payers and the ever increasing number of private providers feel makes the American health system the "best in the world," when, in fact, it is not for a part of the population.  

Despite Obama criticizing the private insurance industry for many of its prior horrendous practices against patients, ObamaCare is turning over billions of taxpayer dollars to support insurance firms whose profits have increased dramatically; more so, the pharmaceutical industry, in return for its support, was handed very little regulation, which has them obviously supporting this direction of care and setting the agenda for future drug development. Pharmacy benefits managers (PBMs) are flourishing even more after Bush's Medicare Part D turnover of senior drug benefits, with now the newly insured adding

more to their coffers. All private segments of the industry have engaged in a merger and acquisition fervor to concentrate their political economic power so that subsidization continues to enhance their coffers.

Chapter 3 - Medical Practice: From Cottage Industry to Corporate Practice

The American medical profession faces much alteration in what they do as practicing physicians that has been felt as an impingement upon their professional autonomy. As more and more physicians transition from private practice controlled by them and their colleagues to employment within large health care organizations controlled by an administrative class, their discontent over their loss of status has been evident. The discontent in the profession will be reviewed while examining trends in the supply of physicians, income, specialty practices, and the significant change in moving from independent practice to wage contract conditions as employees. This set of iss

ues will be seen in light of the overall corporatization of medicine with its new structures being put in place by ObamaCare and private corporate interests. Such alterations in medical practice and its resulting discontent will likely be the prelude to the next medical malpractice insurance crisis.  

Chapter 4 - Accountable Care Organizations: Measurement as Technique Towards Proletarianization

Accountable Care Organizations (ACOs) were ushered in by the Patient Protection and Affordable Care Act (PPACA) of 2010. The dual objectives of ACOs were established as quality improvement and cost containment, though it is becoming quite apparent that the trek toward "value-based care" will be long and arduous. While there are an estimated 600 ACOs established across the country as of late, it is not apparent that physicians are fully on board, nor do they collectively understand many of their implications.  

Because

ACOs are a nascent development, many issues will have to be considered, including an examination of each particular ACO serving different population groups; involvement and participation of patients; relationships between physicians and management; how much say professionals will have in management decision-making; and wither go the metrics and the incentives given to providers -- will they work, will they solidify preventive medicine to save money and improve overall population health, how will they gain acceptance, and how results of all this "bundled payment attempts" across the disciplines will fare? Most importantly, how will ownership and control over the ACOs evolve over time given the recent insurance industry concentration and centralization?

Distilling all the private forces and interests in the health sector requires examination, particularly in light of the need for physicians to grasp implications for potential loss of their power and autonomy. In

2015, it was estimated that 70% of Americans reside in areas where ACOs exist, though only 16% of patients were currently being served by them. Some ACOs and HMOs were growing very quickly, yet the majority of doctors seem bewildered by the plethora of introduced changes, as well as bundled payment mechanisms across disciplines, which are designed specifically to chip away at the old fee-for-service model -- the latter is what the profession has identified as its autonomy from interference into the practice of medicine by outside third parties, e.g., payers and patients. Clearly, the concept of ACOs is an emerging trend whose effects will not be known for many years. 

Chapter 5 - Medical Malpractice Crisis: Oversight of the Practice of Medicine

Medical malpractice results from mistakes that practitioners make in caring for patients; however, technology in medicine and the increasing bureaucratization tend to exacerbate the rates of medical

malpractice. More than a few errors are related to dysfunctional systems practice that practitioners work in and can be compounded by a failure to evaluate errors in an open and transparent manner such that they don't reoccur. It is likely that malpractice rates have increased though the number of medical malpractice suits has remained relatively stable. Nevertheless, periodically a "crisis" arises with a resultant increase in medical malpractice premiums paid by various doctors. The profession at state levels has fought back regularly, often ignorant of the underlying issue of medical malpractice insurance rates coming mainly from insurance companies not making sufficient return on investment in economic downturns. Some studies have indicated that the rates of return by insurance companies more so dictate the increased premiums they charge doctors during periods of economic recession and are not related to award settlements and payouts. State medical societies lobby their legislators in a variety of anti-patient measures that are clearly not decent public policy solutions; the current direction nationwide is likely jeopardizing the public health.  

Chapter 6 - Physician Employment Status: Collective Bargaining and Strikes

With the ongoing threats to physician prerogatives and an erosion of their place in the medical hierarchy, some physicians have sought out third-party groups to increase standing as well as ensuring a forum for their voice to be heard and respected. One mechanism over the years has been collective bargaining through unionization. The movement never caught on, and large numbers of physicians never sought out unionization in the U.S. Part of the reason was the individualistic nature of American physicians, but another reason involved anti-trust concerns caused by individual and independent practitioners banding together to set prices and restrain trade. As physician practice has evolved from a predomin

antly private practice model to one of physicians working in large group practices, faculty foundations, or outright employment by health care systems, the legal barrier to organizing has evaporated. However, the pursuit of collective solutions to what many consider an infringement of their individual rights continues to confront physicians.  

On the other hand, nursing has been able to make great strides in improving their practice situation and their economic remuneration as a result of embracing collective bargaining as a solution to what ailed them. This included a judicious use of the strike weapon to enforce their positions at the bargaining table. Medicine might do well to follow suit. Physicians, as a rule, have difficulties with the strike weapon, primarily because they see withholding services of any kind, for any reason, unethical. In order for physicians to get past this ethical issue, they might have to understand that striking could be an eth

ical response to protest organizational imperatives that violate their professional practices and norms such that longer-term goals in patient care can be met and improved upon.

Conclusion

This chapter will summarize the book, concluding that a new public health perspective is necessary to interpret policy trends upon which to build strategies within the professions, to unite with patients for a different direction for the American health care system.  

Clearly the corporate world that now exists in health care, and in particular medicine, is quite different from what existed just 30 years ago. While organized medicine has always feared interference with their professional practice from government, they never seemed to notice that the real threat to their profession emanated from the administrative superstructure that was being constructed under their watch. This administrative oversight has taken over the control

of most, if not all, health care organizations and has fundamentally changed the practice of medicine as well as the relationships of physicians to these organizations and to other practitioners. Physicians are, in effect, being captured by these corporate entities and now operate under far more onerous restrictions and controls than they might have under government control. As former U.S. Surgeon General C. Everett Koop said, in health care there can be only one captain of the ship, and at that time he was speaking of the physician. That is no longer true today, as the ship is now being steered by individuals who are CEOs, CFOs, CIOs, and who possess MBA and MHA degrees, not necessarily medically dedicated with MD degrees.

Physicians have continued to fight back, but their response has been blurry, unorganized, and ineffective. What is needed to reestablish control, or at the very least attain a position of authority within these new structures? Physicians nee

d to admit that what they've tried hasn't worked and that newer strategies that accentuate collective and concerted efforts to put forth their demands are going to be needed. Whether or not they embrace collective bargaining, or other mechanisms, remains to be seen. Whatever mechanisms are chosen, care and concern for patients and the health of the population must top their list of demands; such values must remain foremost in their struggle to sway public opinion about what can be the righteousness of their cause. Any deviation from that thrust will cause their movement to fall way short of their expectations.

O autorze

J. Warren Salmon, PhD, is an author, researcher, and lecturer.  Previously, he was Professor of Health Policy and Administration, School of Public Health, at the University of Illinois at Chicago (UIC). He was formerly a Professor in and Head of the Department of Pharmacy Administration, College of Pharmacy; Professor of Public Policy Analysis, College of Urban Planning and Public Affairs; and Adjunct Professor of Medical Education, College of Medicine at UIC.  Prior to coming to UIC, Professor Salmon held faculty appointments at Thomas Jefferson Medical College and Drexel/Hahnemann Medical College, both in Philadelphia, Pennsylvania.  Professor Salmon's research interests have focused on the corporatization of medicine and pharmacy, managed care pharmacy, urban healthcare delivery, comparative healthcare systems, global pharmaceutical industry developments, and alternative and complementary medicines, among selected health policy issues.  He edited Alternative Medicines:  Popular and Policy Perspectives (Tavistock/Methuen/Routledge, 1984); (with Jeffrey W. Todd) The Corporatization of Health Care: A Two Day Symposium and Public Hearing (Illinois Public Health Association, 1988); (with Eberhard Goepel) Community Participation and Empowerment Strategies in Health Promotion, 7 volumes (Zentrum fuer Interdisziplinare Forschung, 1990); The Corporate Transformation of Health Care, Part I:  Issues and Directions (Baywood, 1990); The Corporate Transformation of Health Care, Part II:  Reflections and Implications (Baywood, 1994); and (with Linda Shapiro) Health Care for Chicagoans:  How Will Health System Integration Affect the Health of the Public?  (Health & Medicine Policy Research Group, 1995). Dr. Salmon resides in River Forest, Illinois as a still active independent researcher, writer, mentor, and frequent lecturer.

Stephen L. Thompson, PhD, is an Associate Professor in the Health Studies Department of the College of Professional Studies and Advancement at National Louis University (NLU) in Chicago, Illinois.  He is the former Associate Dean and former Interim Dean of the College of Arts and Sciences at National Louis University.  He received his PhD from the University of Illinois at Chicago in Health Policy and Administration in 2000, his Master of Science in Industrial Relations from Loyola University Chicago in 1984, and a Bachelor of Arts in Biology from Drake University in Des Moines, Iowa in 1975.  He also completed a program in Respiratory Therapy at Northwestern University Affiliated Programs in 1975, and is a Registered Respiratory Therapist (RRT) and a Neonatal/Pediatric Specialist (NPS).  He teaches in the Masters of Business Administration, Masters of Health Administration, and the Bachelor of Health Care Leadership programs at NLU.  His major interests are in health policy, research methodology, and unions and collective bargaining and organizational theory.  He has published in the areas of Collective Bargaining and Physicians, Health Reform, and Privatization of Public Education.

Blurb

In this book, the authors, as policy analysts, examine the overall context and dynamics of modern medicine, focusing on the changing conditions of medical practice through the lens of corporatization of medicine, physician unionization, physician strikes, and current health policy directions. 

Conditions affecting the American medical profession have been dramatically altered by the continuing crises of cost increases, quality concerns, and lack of access facing our population, along with the ongoing corporatization toward bottom-line dictates. Pressures on practitioners have been intensifying with much greater scrutiny over their clinical decision-making. Topics explored among the chapters include:

• History of the Corporatization of American Medicine: The Market Paradigm Reigns
• Pharmaceuticals, Hospitals, Nursing Homes, Drug Store Chains, and Pharmacy Benefit Manager/Insurer Integration
• Medical Practice: From Cottage Industry to Corporate Practice
• Medical Malpractice Crisis: Oversight of the Practice of Medicine
• Big Data: Information Technology as Control over the Profession of Medicine
• Physician Employment Status: Collective Bargaining and Strikes

The Corporatization of American Health Care offers different perspectives with the hopes that physicians will unite in a new awareness and common cause to curtail excessive profit-making, renew professional altruism, restore the charitable impulse to health provider institutions, and unite with other professionals to truly raise levels of population health and the quality of health care. It is also a necessary resource for health policy analysts, healthcare administrators, health law attorneys, and other associated health professions.