The business of medicine

Dr Derrick Aarons

Sunday, May 12, 2019

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ON April 28, the Sunday Observer's frontpage story read “Bad Medicine: Pharmacists sound the alarm on doctors who are having their receptionists dispense drug.”

The article proceeded to express the concern of the Pharmaceutical Society of Jamaica, when doctors go beyond immediate care and start to supply medication that they ordinarily would put on a prescription and send out. The implication was that some doctors are now going beyond their traditional role of diagnosing sickness and prescribing medication, to provide and sell medication to patients.

The practice of medicine began as an art in the days of classical Antiquity and the beginnings of western medicine in ancient Greece, and evolved into a science during the scientific era.

It became a profession with the concept of the physician-professional during the Middle Ages, with development of guilds and universities and subsequently with the licensing of medical practitioners after a prescribed course of study.

The element of business

We are now in the modern era where the element of medicine as a business has been introduced. The concept of altruism and a calling that was central to the concept of professionalism, with the mandate to always act in the best interest of the patient has become secondary in many areas of medicine and the delivery of health care.

The driving ethos for some doctors is the financial benefit to be derived from the practice of their craft.

Many books have been written on the subject. These include: Money-Driven Medicine by Maggie Mahar, How We Do Harm by Otis Brawley, Overdiagnosed by H Gilbert Welch, Epidemic of Care by George Halvorson and George Isham, Too Much Medicine by Dennis Gottfried, Stabbed in the Back by Nortin Hadler, Hope or Hype by Richard Deyo and Donald Patrick, Severed Trust: Why American Medicine Hasn't Been Fixed by George Lundberg, Health Care Under the Knife by Howard Waitzkin, and An American Sickness by Elizabeth Rosenthal.

Detrimental economic rules

In the book An American Sickness, Dr Rosenthal lists 10 economic rules that are guaranteed to make money, but not improve medical outcomes or health benefit. They are:

1. More treatment is always better. Always default to the most expensive option.

2. A lifetime of treatment is better than a cure.

3. Amenities and marketing matter more than good care.

4. As technologies age, prices can rise rather than fall.

5. There is no free choice. Patients are stuck. And they are stuck on buying American.

6. More competitors vying for business doesn't mean better prices; it can drive prices up, not down.

7. Economies of scale don't translate to lower prices. With their market power, big providers can simply demand more.

8. There is no such thing as a fixed price for a procedure or a test. And the uninsured pay the highest prices of all.

9. There are no standards for billing. There is money to be made in billing for anything and everything.

10. Prices will rise to whatever the market can bear.

Further, particularly within the context of medicine in the USA: Always seek consultation, each consult can bill, add more specialised procedures, and refer back to the originating doctor!

Monetary conspiracy

In her book, Dr Rosenthal exposes the monetary conspiracy of corporate American medicine and instructs American consumers about all of corporate medicine's tricks.

Further, she recommends several actions that consumer patients can take to defend themselves against the onslaught of what some call the money-hunger that assails the US healthcare system. However, the greatest force will come from government with its regulatory powers.

In one article, Dr George Lundberg writes that capitalism is choking professionalism out of medicine. In recent times, medicine has been both a business and a profession, but problems arise when the pendulum swings too far.

In his book, Dr Howard Waitzkin cites personal examples of being denied his professionalism through the 'new employee' status given to him through the hierarchy of corporate decision-makers intent on only one thing, profit, as a part of the capitalist takeover of the medical profession, replete with gross conflicts of interest.

Medical-industrial complex

The authors of the various books provide many examples, naming names, institutions, and dates. Described as a medical-industrial complex, one book decried the large and growing network of private corporations engaged in the business of supplying health care services to patients for a profit, services which hitherto were provided by non-profit institutions or by individual health practitioners. The authors railed against the travesty of American medicine being turned into a lucrative tool of capitalism.

What is therefore needed is for some action to stop the pendulum at its current extreme, and for it to swing back towards some balance.

Critics say that the only art that currently exists in medicine is the art form of controlling corporations that fleece patients, payers and providers, in order to maximise profits. To effect a reversal requires personal 'internal' reversal among errant doctors and requisite political regulatory action at a national level.

In Jamaica, the Acts that govern medicine and health care will therefore need to be updated to address the current challenges in the modern era. Without doubt, within the Medical Act, specific regulations will have to be written.

Dr Derrick Aarons MD, PhD, is a consultant bioethicist and family physician; a specialist in ethical issues in health care, research, and the life sciences; the health registrar and Head of the Health Secretariat for the Turks & Caicos Islands; and a member of UNESCO's International Bioethics Committee.

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