[p2p-research] Fwd: Health care reform must eliminate the profit motive from medical care

[Michel Bauwens]

---------- Forwarded message ----------
From: Dr. Arnold Reiman <magazine at tikkun.org>
Date: Thu, Sep 24, 2009 at 10:39 PM
Subject: Health care reform must eliminate the profit motive from medical
care
To: michelsub2004 at gmail.com


  [Editor's Note: President Obama told Congress he would not sign a health
care bill that added any amount to the national debt--a criterion he does
not use when considering escalating war in Afghanistan or bailouts to banks.
Dr. Arnold Reiman argues that there is no way to meet that criterion unless
health care reform includes eliminating the profit motive from medicine,
including licensing doctors so that they get a fixed salary each year rather
than, as now, making profits from prescribing more tests, procedures and
visits that increase their incomes. Dr. *Arnold S. Relman*, M.D. is a professor
emeritus<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=1xkA4eRSDYBA%2BbcubzxkZBmWX28p9yNs>of
medicine<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=kV%2B0gnx%2F%2BOlO02aowUM8lRmWX28p9yNs>and
of social
medicine<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=CF6SKVDHTOBYw4J%2F49SSyhmWX28p9yNs>at
Harvard
Medical School<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=%2B4a%2F9XBpC8dTuAFZWm28wRmWX28p9yNs>,
Boston, Massachusetts<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=QEGyfP3UpcUxWkUHk%2FK%2Fbj3epDuiCCqv>.
He is a former editor of the *New England Journal of
Medicine<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=cmovIFw5OfxwZhhiLgHlNBmWX28p9yNs>
* (1977-91). In the article below for Tikkun he explains why the reform that
is needed must go beyond "public option" so that it can eliminate the
constant growth of medical costs. This is a perfect example of what we at
Tikkun and the Network of Spiritual Progressives call "New Bottom Line"
thinking. Please ask your medical practitioners if they would agree with
this article--and send it to all your friends. ]

 *Waiting For The Health Reform We Really Need*

Arnold S. Relman, M.D.

Professor Emeritus of Medicine and Social Medicine, Harvard Medical School

Former Editor-in-Chief, *New England Journal of Medicine*

(Written for *Tikkun Magazine*)



            There are two interrelated critical issues in health reform
right now: how to extend and improve insurance coverage, and how to control
the unsustainable rise in health care expenditures. Virtually all of the
current legislative attention is focused on the first issue but,
notwithstanding claims to the contrary, none of the proposals now on the
table offers any credible solution for the control of rising costs. Without
control of health cost inflation, the present system will not be viable much
longer.

            Expansion of coverage is of course a highly desirable goal, but
it inevitably increases expenditures even beyond today's exorbitant levels.
President Obama has repeatedly said he would veto any health proposal that
is not "budget neutral" over the next decade. The legislation now under
consideration claims to meet that requirement through savings promised by
the insurance, drug and hospital industries and through reductions in
Medicare expenditures (excessive payments to private insurers for Medicare
Advantage plans would be a major target), possibly supplemented by taxes on
employment-based health plans for high income employees. However, critics
question whether these measures would fully pay for the almost one trillion
dollars of new costs for covering most of the uninsured over the next
decade.

            But the estimate of the costs of expanded coverage does not
include the cost of the constant inflationary rise in all medical
expenditures, lately about 6 - 8 percent per year. This would increase total
health spending by roughly another two trillion dollars over the next
decade. Administration policy-makers speak hopefully of savings to be
generated in the long term by switching to electronic records, using more
preventive measures, and applying the information gained from studies of
comparative effectiveness. But skeptics might call this "faith-based"
savings, because there is no solid evidence to support such hopes. The
sobering fact remains that something more must be done soon to slow medical
inflation or the entire health system will inevitably slide into bankruptcy.
And yet none of the legislation currently being considered addresses that
problem. Adding more benefits to the system, and covering more people with
public and private insurance, are certainly important, but even if those
improvements were paid for, they would not slow down the numerous
inflationary forces that make our medical care system unsustainable.

            What are those inflationary forces? I believe the most important
among them are the incentives in the payment and organization of medical
care that cause physicians, hospitals and other medical care facilities to
focus at least as much on income and profit as on meeting the needs of
patients. I have discussed this subject in a recent book (*A Second Opinion*.
Rescuing America's Health Care. Public Affairs, New York, 2007). The U.S.,
more than any other advanced country, has come to rely mainly on private
markets to deliver medical care, and on fee-for-service to pay its
physicians. The incentives in such a system reward and stimulate the
delivery of more services. That is why medical expenditures in the U.S. are
so much higher than in any other country, and are rising more rapidly. Our
business-oriented system inevitably drives up expenditures because in
medical care the balancing tensions between the suppliers and consumers of
services that constrain costs in ordinary business markets do not exist.
Physicians, who supply the services, control most of the decisions to use
medical resources, and patients, who are the consumers of those resources,
do not pay most of the costs.

            The economic incentives in the medical market are attracting the
great majority of physicians into specialty practice, and these incentives,
combined with the continued introduction of new and more expensive
technology, are a major factor in causing inflation of medical expenditures.
Physicians and ambulatory care and diagnostic facilities, are largely paid
on a piecework basis for each item of service provided. Hospitals also bill
insurers according to the days of care and the services they provide,
although payments for treatment of an illness may be aggregated. However,
all providers compete for income and market share, often advertising and
marketing for that purpose. They almost never compete on prices because
public and private insurers, not patients, pay most of the costs.
Competition in the current medical market therefore tends to drive up total
costs because it results in greater use of services, while rarely lowering
prices.

Control of medical expenditures is unlikely without a major reform of the
payment and organization of medical care. Expanding and improving the
medical insurance part of the health system will not solve the expenditures
problem unless the perverse incentives in the delivery of care are also
corrected. In fact, expansion of insurance benefits without this other
reform would probably make matters even worse. A so-called "public option"
will not solve this problem either, although its competition might force
private insurers to reduce their premiums or increased benefits. But even if
some sort of low-cost not-for-profit insurance plan were offered as an
optional choice for the uninsured and those dissatisfied with their present
coverage, the inflationary effects of fee-for-service payments and an
entrepreneurial medical care system would still be operating. After all,
Medicare is a low-overhead plan that costs its beneficiaries less than
private plans, but the rate of inflation in its expenditures is nearly as
rapid as the inflation in private medical insurance expenditures. The
benefits of Medicare are just as threatened as those of the private
insurance system because costs are rising rapidly in both the public and
private sectors of health care.

Judging from the current debate in Washington, there is little evidence that
lawmakers are aware of these facts or, if they are, that they have the
stomach for resisting the powerful vested interests that stand in the way of
major reform. That is why the Goldman Sachs prediction of a compromised
legislative outcome is likely to be correct. At the end of this Congress we
will probably end up in a position not unlike that facing the Commonwealth
of Massachusetts. Over three years ago it enacted legislation that greatly
expanded insurance coverage, but from the outset it faced serious financial
problems in funding the increased costs. A special state commission has
recommended to the Massachusetts legislature that it consider ways to
eliminate fee-for-service payment of physicians in favor of some type of
system that would be based on organizations of physicians and hospitals that
could accept global prepayments for comprehensive care. It remains to be
seen whether and how these recommendations can be implemented, but it is
telling that Massachusetts seems now to realize what our national lawmakers
have not yet grasped: Sustainable universal, or near-universal, coverage
requires more than fixing the insurance system. It needs major reform in the
payment and organization of medical care as well.

            In my book, and in a recent article in the *New York Review of
Books* (July 2), I have proposed a system of medical reforms that would deal
with the cost problems in both the insurance and medical care sectors of our
health care system and would ensure good care for everyone. I recommend
replacement of the current mix of public and private insurance plans with
universal coverage for comprehensive care that would be funded by a
progressive national health insurance tax. Medical care would be provided
through community-based not-for-profit multi-specialty group practices,
which would be staffed by salaried physicians. When medical insurance is no
longer a for-profit business, when physicians no longer are paid on a
fee-for-service basis, and when the entire health care delivery system is
not-for-profit, economic incentives to over- or underserve the needs of
patients can be eliminated by appropriate regulation and we can expect
improved quality of care at lower costs. The total national expenditure on
medical care can be controlled by the level of national funding, while
decisions about the proper use of medical resources can be safely left where
they belong, in the hands of physicians and their patients.

            Carrying out such a transformation of the health care system
would of course be a formidable task, probably achievable only in gradual
steps. It would require a sea change in the current political climate. A
large part of the public, supported by most business leaders who are outside
the medical-industrial complex, and by an awakened medical profession, would
have to be convinced that a major reform of this kind offers the only chance
for an equitable but affordable medical care system of good quality. In a
just-published commentary in the *New England Journal of Medicine* ("Doctors
as the Key to Health Care Reform", *NEJM*, September 24, 2009) I explain how
crucial change in the organization and payment of medical services is to
achieving a sustainable health care system. The medical profession will have
to be a willing and active partner in carrying out these reforms.

Lawmakers need votes and public support even more than the money from vested
interests, so they probably would act if a majority of voters were to make
its wishes clear and if the medical profession were part of this awakening.
But before public opinion can be galvanized to demand a sweeping change of
this kind we may, unfortunately, have to experience a disastrous financial
collapse of the health care system, with widespread loss of benefits. An
expansion of coverage without changing the medical care delivery system and
controlling medical inflation, might very well hasten such a collapse.

*Comment by Rabbi Michael Lerner*: A different and shorter version of this
article appeared today in the New England Journal of Medicine. We at Tikkun
believe that Dr. Reiman's analysis is extremely important, because it helps
people understand why the current plan to expand coverage by mandating
coverage so that everyone has to buy an insurance policy, without creating a
vigorous public option to lower costs, and without challenging the ability
of health care profiteers to endlessly raise costs, will bankrupt the system
and provide the insurance companies and other profiteers with the argument
that "we tried government intervention in health care and all it succeeded
in doing is to raise the costs for everyone an eventually lead to
collapse."  This is a perfect example of why the good is sometimes really
IS  the enemy of the best--because a "good" step forward in health care of
the sort that is now being considered by the centrist Democrats could
actually lead to a disastrous right-wing victory in the future that would
lead to a further weakening of all social restraints on corporate
profiteering at the expense of human needs--unless we get a health care
reform that from the start challenges the profit motive and the Old Bottom
Line thinking that the centrist Democrats are trying to accommodate in their
various reform proposals. The New Bottom Line proposed by the Network of
Spiritual Progressives and more fully developed in its Spiritual Covenant
with America (www.spiritualprogressives.org) calls for a whole new approach
to medicine that incorporates the "single-payer plan" and the elimination of
profit-motive from health care proposed by Dr. Reiman as well as a call to
include Western medicine but expand beyond it to emphasize other modalities
with a more holistic approach. Some people argue, "Lets get what we can now,
little reform by little reform, and then later we can deal with these larger
issues." But Reiman's argument provides a reason to fear that there will be
no such "later" because the reforms put in place now may prove so costly
that people will feel they tried reform and it didn't work, so abandon the
entire effort and go back to the unregulated marketplace in health care that
will still "work" for the upper middle class and wealthy while leaving even
greater numbers of middle income and poor people without any ability to
access decent health care.



September 24, 2009

*Help us get this kind of thinking more widely known. Send this article to
every media person to whom you have access, to your elected officials, and
to your friends. And JOIN the Network of Spiritual Progressives at
www.spiritualprogressives.org<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=KJSJGilXOdnFdtw5qBVvaRmWX28p9yNs>.
When you join you also get a free one year subscription to Tikkun Magazine,
the interfaith voice of spiritual progressives. What is a "Spiritual
Progressive?"  Spiritual Progressives say that corporations, government
policies, social practices and even personal behavior should be judged
rational, efficient and productive not only to the extent that the maximize
money and power (the Old Bottom Line), but also (and this is The New Bottom
Line)  to the extent that they maximize love and caring, kindness and
generosity, ethical and ecological consciousness and behavior, and to the
extent that they increase our capacities to respond to other human beings as
embodiments of the sacred and respond to the universe with awe, wonder and
radical amazement at the grandeur of all Being.  You do NOT have to be
religious or a believer in God to be a Spiritual Progressive--we welcome
atheists, agnostics, and other "spiritual but not religious" people along
with people connected to some religious or God-oriented approach, as long as
you agree with the New Bottom Line. If you don't want to join the Network of
Spiritual Progressives but DO want to have our analyses more widely read and
discussed, please make a tax-deductible contribution at
http://www.spiritualprogressives.org/article.php?story=donaterenew<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=1ybnZT1pMnACe6Da5PjxrD3epDuiCCqv>
*

  ------------------------------

unsubscribe: Click
here<http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=qByy8OzHL93586gJ95fS0hmWX28p9yNs>
if you are having trouble unsubscribing Click here <kay at tikkun.org>

Copyright 2009 Tikkun Magazine. Tikkun is a registered trademark.
2342 Shattuck Avenue, #1200
Berkeley, CA 94704
510-644-1200
Fax 510-644-1255



-- 
Work: http://en.wikipedia.org/wiki/Dhurakij_Pundit_University - Research:
http://www.dpu.ac.th/dpuic/info/Research.html - Think thank:
http://www.asianforesightinstitute.org/index.php/eng/The-AFI

P2P Foundation: http://p2pfoundation.net  - http://blog.p2pfoundation.net

Connect: http://p2pfoundation.ning.com; Discuss:
http://listcultures.org/mailman/listinfo/p2presearch_listcultures.org

Updates: http://del.icio.us/mbauwens; http://friendfeed.com/mbauwens;
http://twitter.com/mbauwens; http://www.facebook.com/mbauwens
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://listcultures.org/pipermail/p2presearch_listcultures.org/attachments/20090925/3b198e9e/attachment-0001.html>