Thursday, October 21, 2010

The Biggest Health Reform Elephant in the Room

These days everybody’s favorite health care metaphor is the elephant in the room. An elephant in the room is something so big and so obvious that nobody wants to talk about it. Or it may be what some people call a “dirty little secret” that people choose to ignore because it is too big to ponder or too awful to contemplate.

Massive Medical Industrial Complex

For me the biggest health reform elephant in the room is the massive medical industrial complex. I do not deplore the size of the elephant. I think of it as part and parcel the American capitalism. I accept it as reality. Hospitals, surgicenters, health plans, employers, drug firms, medical device manufacturers, Internet high tech ventures, clinical laboratories, malpractice companies, home health firms, nursing homes, physical therapy units, the government and all its agencies, and others - make up the elephant.

If you doubt the elephant’s size and complexity. Go to any medical convention. Visit the vendor exposition. Vendors support these conventions, and as part of the Medical Industrial Complex, they are there in full force on full display to market to physicians, who they regard as the elephant’s main drivers. Elephants are smart. They pay attention to their drivers, even if the head of the herd does not.

Read the brochures, scan the online the promotional materials, or attend the proceedings of the World Health Congress, held annually, where else, in Washington, D.C. ( D.C. stands for “Darkness and Confusion”).

Here is some of the promotional material for the 8th Annual World Health Congress.

“The 8th Annual World Health Care Congress (WHCC) is World Congress' flagship event in which over 1,800 health care, government and corporate leaders formulate solutions to the challenges of health care cost, quality and delivery. In response to demands from the nation’s largest providers, payers and employers, the 8th Annual WHCC convenes the major sectors in health care to determine actionable goals and implementation strategies to demonstrate quality, consumer choice, cost-effectiveness and transparency. Thought leaders engage in debates, present case studies and share best practices from all industry sectors including leading employers, CMS officials, insurers/payers, health system and hospital providers, pharmaceutical and biotech executives, academics, analysts and government officials.”

I do not believe the federal government, no matter how “progressive,” will be able to unravel, restructure, consolidate, or to simplify America’s health system. Government cannot deliver on its promises.

The Medical Industrial Complex is so sophisticated, so ingrained, and so necessary to carry out government programs, that it will drive any post-reform innovation and collaborative effort to achieve quality, cost-effective health care.

Only the Big Elephant has the administrative, marketing, and innovative skills to make the system work.

Back in 1980, Arnold Relman, MD, editor of the New England Journal of Medicine, warned us the “New Medical Industrial Complex” would undo us all. Here is an abstract of that original article.

The New Medical-Industrial Complex


“The most important health-care development of the day is the recent, relatively unheralded rise of a huge new industry that supplies health-care services for profit. Proprietary hospitals and nursing homes, diagnostic laboratories, home-care and emergency-room services, hemodialysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to $40 billion. This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming," and it may also exercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests. Closer attention from the public and the profession, and careful study, are necessary to ensure that the "medical-industrial complex" puts the interests of the public before those of its stockholders. (N Engl J Med. 1980; 303: 963–70.)”

Perhaps that’s how it ought to be in an ideal world, perhaps physicians ought to be saints, perhaps the health system ought to be oblivious to money and "special interests," interests other than mine, but that is not the way it is in the real world.

In the real world, physicians have had little input into national health policy. They do not regard themselves as purchasing agents, and some have conflicts of interest in that they believe their knowledge entitles them to some margin of profit. Maybe that will change when the public realizes government has little control over the big elephant, and when they see costs rise sharply under the health reform law and access to doctors , particularly for Medicare and Medicaid patients, dwindle and reaches crisis proportionsn.

Maybe the medical industrial elephant occasionally puts profits before people. On the other hand, I cannot help but notice premium costs are the highest in the land and health care waits are longest in Massachusetts, the prototype of the nation’s future health system, where the not-for-profit elephant reigns supreme and where the presumed elephant trainers were educated.

Besides, the federal bureaucracies can be a white elephant – large, lumbering, bungling, wandering and wasteful – with costs out of proportion to its worth.

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