The High Price of Health
For Patients, Not Profits

by David U. Himmelstein, M.D. and Steffie Woolhandler, M.D. Drs. Himmelstein and Woolhandler  are Associate Professors of Medicine at Harvard Medical School and The Cambridge Hospital.

Our health care system is failing. It is expensive, bureaucratic, and denies care to many in need. Americans die younger, get less care, face greater restrictions, are less satisfied, and spend at least $1,500 more per person on health care than Canadians or Western Europeans - nations that have opted for non-profit national health insurance.

In the U.S., canons of commerce are displacing dictates of healing, trampling medicine's most sacred values. Market medicine treats patients as profit centers. The time doctors and nurses are allowed to spend with the sick shrinks under the pressure to increase throughput, as though we were dealing with industrial commodities rather than afflicted human beings in need of compassion and caring. Listening, learning, and caring give way to deal-making, managing, and marketing. The primacy of the patient yields to a perverse accountability - to investors, to bureaucrats, to insurers and to employers. And patients worry that their doctor's judgement and advice are guided by the corporate bottom line.

Policy wonks hail profit-driven care as the panacea for medicine's ills, the route to efficiency, accountability and compassion. Milton Friedman, the guru of free market economics, had no such illusions, admonishing corporate officials to shun any "social responsibility other than to make as much money for their shareholders as possible." Indeed, shareholders can sue any corporate executive who voluntarily sacrifices profits to patients' interests.

Unfortunately, good medicine requires a panoply of unprofitable, even anti-profitable actions. Prevention, cure and care are rarely the cheapest course. HMOs advertise free health-club memberships and a handful of preventive services to woo healthy, profitable customers. But few HMOs trumpet superb stroke rehabilitation or diabetes care; attracting the expensively ill is commercial suicide. Not surprisingly, research shows high satisfaction and good outcomes for healthy HMO members. But even the best HMOs undertreat the sick. HMO stroke patients get less rehabilitation and more often end up in nursing homes. Medicare HMO patients are denied needed home care. Depressed patients in HMOs are less likely to be diagnosed, get less treatment, and are more frequently disabled by their illness. Poor, sick patients have a 21% higher risk of dying in HMOs than in fee-for-service care.

HMOs prod doctors and nurses with threats and bribes to abdicate allegiance to patients, and to shun the sickest, who may be unprofitable. Physicians risk being fired or "delisted" for giving, or even discussing expensive services, and many are offered bonuses for minimizing care. A university hospital chief admonished faculty doctors "[We can] no longer tolerate patients with complex and expensive-to- treat conditions being encouraged to transfer to our group."


At the same time, the ranks of the uninsured continue to grow, while safety-net public hospitals and clinics shrink, and public health programs erode. Even many with insurance find coverage deficient when they need it most; care or payment are too often denied for emergencies or expensive illnesses. The sick are denied skilled nursing care, rushed out of hospital beds and hurried through office visits. Increasingly, patient comfort, the special needs of the elderly, infirm, or disabled are ignored if they conflict with the calculus of profit.

Public resources of enormous worth - non-profit hospitals, Blue Cross plans, visiting nurse agencies, even hospices - built over decades by taxes, charity and devoted volunteers, are being taken over by companies responsive to Wall Street and indifferent to Main Street. Communities find vital services closed by remote executives; savings are committed not to more pressing health needs, but to shareholders' profits. Not-for-profit institutions, forced to compete, must also curtail unprofitable activities like research, teaching and charity, or face bankruptcy. Hospital chains' profits reach $100 per patient per day; a single HMO president nets $990 million in a take-over deal; and insurers' overhead consumes $46 billion annually.

Nor is profit-driven care more efficient. Even as the ranks of the un- and under-insured expand, U.S. health care costs are higher and continue to grow faster than in nations with non-profit national health insurance. Profits, and the bureaucracy erected to secure profitability, consume an ever-larger share of health care dollars. For-profit hospitals are costlier, largely because of their lavish spending on bureaucrats who devise ways to raise profits, e.g. by billing scams, excluding the uninsured, paying kickbacks to physicians who refer profitable patients, or even kidnapping insured patients in order to fill beds. Meanwhile, HMOs have actually increased Medicare costs by $2 billion annually by selectively recruiting healthy seniors whose care would have cost little in traditional Medicare.

We criticize market medicine not to obscure or excuse the failings of the old fee-for-service system, but to warn that the changes afoot push medicine further from caring, fairness and efficiency. The headlong rush to profit-driven care is occurring without the assent of patients or practitioners, through a process largely hidden from public scrutiny and above citizen participation. This must be replaced by an open and inclusive process that is not dominated by the loudest voices - those amplified by money and political influence. We believe that, if given full and objective information, the American people would opt for non-profit national health insurance as have citizens of most other developed nations.

Our civilization holds that some aspects of life should be off-limits to the market. Government, the police and fire departments, and the military should not be for sale; nor should profits be made selling sexual intimacy, or children for adoption. Our constitution recognizes a compelling public interest in religious free speech, and in unfettered discourse on public policy. Here, commercial interests have no standing. They should have none in medicine.

[For further information about the fight to oppose profit-driven care visit Physicians for a National Health Program and The Ad Hoc Committee to Defend Health Care]


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