Health Reform and the Culture Clash: The Corporate Transformation of American Medicine

June 19, 2011 - When you think about what’s happening out there right in front of our nose– government experts telling doctors how to practice, doctors and hospitals being herded into accountable care organizations, young physicians rushing into hospital employment – it’s pretty obvious that the corporate transformation is still on a crash course – and picking up a head of steam.

I should know. I’ve been writing about this transformation for over 30 years. In a 1988 book. And Who Shall Care for the Sick; The Corporate Transformation of Medicine in Minnesota (Media Medicus, 1988), I wrote.

I shall discuss the struggle now going for control of health care. This struggle is mainly between the management of corporations and physicians. It is a struggle for power. To be effective in the marketplace, corporations have to harness physicians to corporate goals, thus creating internal disciple and compliance; to be independent professionals, physicians have to be free to choose what they want for patients. The government, economists, and leaders of physician organizations favor the corporate strategy because it is a way of making physicians behave economically. Health care corporations deny they seek power, saying this power flows from impersonal forces of the market. This may be, but the forces of the market are powerful indeed and are fundamentally changing the way we practice medicine.

The forces of management are winning. More than 50% of doctors are now salaried employees of organizations, mostly hospitals, rather than owning their own practices. And government has set into motion a series of measures – such as accountable care organizations, time-consuming and energy-draining rules and regulations, pre-authorization of imaging procedures, installation of electronic records to document every transaction, no matter how trivial; an Independent Physician Advisory Board - to make doctors comply to management rules, by among other things, regulating how they are to be paid.

The corporation transformation has consequences – a political clash of cultures and ideologies between managers, policy experts, and practicing physicians, an exacerbation of the physician shortage just as demand for medical services is growing; the decline of medicine as an attractive career among the young, ambitious, and entrepreneurial; and, an access problem to physicians with lengthening waiting lines with controls on payment and use of high ticket technologies such as joint replacements, medical devices, and imaging procedures.

In the midst of all of this, there is political paralysis going on in Washington, as Medicare and Medicaid entitlement programs assume center stage as the main contributors to the debt crisis, and two sides exchange insults.

In today’s June 19 New York Times, in an article “Standstill Nation.” Peter Baker asks,

Is this any way to run a country? As it happens, yes. Ideal, it is not. Inspiring, hardly at all. But the factitious, backbiting, finger-pointing, polarizing, partisan, kick-the-can-down-the-road brinksmanship of washing politics these days is. Let’s face it, this is the reality of American government in the modern era. For all the handwringing about how the system is broke, this is the way the system was designed and is now adapted for the digital age.

Democrats and Republicans agree costs must be controlled. Democrats favor a top-down approach with a panel of experts deciding which procedures are cost-effective and which are wasteful. Republicans prefer a bottom-approach empowering consumers to make their own choices with competition between providers to keep costs down. The two approaches intersect at the organizational, or corporate, level.

Baker's description of Washington gridlock leads to other questions: Will Obamacare be repealed or not? If repealed, how many of the current implementations are even reversible? Will the Supreme Court rule the individual mandate or the whole kit-and caboodle unconstitutional?

Then, there’s my question, the most important of all : And who shall care for the sick?