Written by John H. Akhavan, M.D.
What is wrong
with America? (and its treatment.)
United States'
Health System in jeopardy! (by NEJM)
How to improve Public Health (June 2009)
We are constantly constructing, please visit us often
United States' Health System in jeopardy, this is an unpleasant opinion of many medical scholars whose voices are not heard clearly by the society. I read a Commentary by the Editor-in-Chief of the New England Journal of Medicine which was very similar to my views so I am very pleased to bring to everyone's attention some of his warnings. He writes:
Physicians have adhered to a distinguished code of professional behavior for centuries.
The recent dramatic changes in the system of health care threaten this noble heritage and
tempt us to abandon these principles at a time when preserving them is more important than
ever.
This is arguably the most tumultuous time in the history of medicine in the United
States'. Because of the enormous cost of care and the political ineptitude of our
national leaders, the delivery of care is in a volcanic state, reforming itself day by day
under market forces. Instead of yesterday's familiar and comfortable model of one patient
and one physician, we now have market-driven health care with vertically integrated
systems, massive health maintenance organizations, huge for-profit conglomerates with
money hungry stockholders, and armies of health care lawyers and consultants.
At the same time, the amount of money that reaches physicians for the care they provide is
shrinking. Less money is available from the government, employers, and insurers, and some
is globbled up by the new participants in health care. As the dollars available for
patient care shrinks, the temptation for physicians to maintain their income grows, and in
this environment difficult conflicts of interest emerge. Let me consider only two, both of
which threaten physicians' integrity and professionalism. The first is a familiar one-- an
arrangement in which physicians benefit financially from referring patients to facilities
the physicians partly owns such as laboratories or radiation therapy centers. The second,
more important one, is a consequence of the change from fee-for-service medicine to a
system that rewards physicians for restricting services. In this new arrangement,
physicians' loyalty to patients is threatened. As managed care takes over in a community,
some physicians are forced to join managed-care organizations or risk being left with few
patients. When physicians join, they may be compelled to sign contracts that contain
"no cause" nonrenewal clauses. Then their contracts can be terminated for any
reason at all. In addition, some companies' contracts contain nondisclosure clauses that
forbid physicians to tell their patients what a plan does or does not offer. Physicians
under such restrictions can easily be torn between their loyalty to their patients and
their loyalty to their families, because with one or two false moves they can be out of
their job.
Tese divided loyalties that threaten physicians' livelihood is wrenching. The incentive
for physicians to keep their jobs may be so strong that they may no longer be willing to
act exclusively as patients' advocates. They may even be unwilling to advocate for a
patient with management when they think that a given service is needed but is being
restricted inappropriately. Physicians placed in this position simply cannot tolerate it,
and that can produce an even greater threar--namely, a loss of their integrity. Soon some
of them will find themselves conforming to the restrictions and deceiving themselves that
what they are doing is best for the patient. In short, they will be living a lie.
These are some of the realities that threaten the preservation of medicine's noble
heritage. Our ethical standards, which have evolved over two millinnia, never envisioned a
market-driven health care system with incentives to undertreat patients. As members of our
profession, we alone must be its keepers. We must continue to be vigilant in case the
consequences of our market-driven delivery system go too far and prevent us from giving
the kind of care we think appropriate.