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This page created April 2000 by Michael Wynne
This page examines the question of equity in
market systems and when using contracts. Experience to date is not
encouraging.
Two Tiered Care in the USA :- Market systems generate two tiered medicine. Those who can pay get more. I am not aware of a market based system which provides true equity. Despite intense policing and strong pressures every attempt to create some sort of equity which would provide basic care in the US marketplace has been resisted or subverted. In spite of laws, regulations and prosecutions cherry picking and patient dumping remain major problems in the US marketplace. Many millions have no medical insurance whatsoever. Every effort to make the system more equitable is met with intense lobbying and a massive marketing campaign. We should not believe that corporations will behave differently anywhere else?
Examples:- In the USA a two tired, almost an apartheid system has developed - those who can pay and those who can't. In a case reported in the world press someone who did not have insurance cover was injured outside a corporate hospital. Hospital staff were not allowed to provide emergency care and the patient died before an ambulance arrived. Under apartheid patients were similarly refused care at the wrong hospital but I cannot recall emergency care being denied.
A lady who took her desperately ill neighbour
to hospital with an acute bowel obstruction was rejected at hospital
after hospital because the neighbour was not insured. The lady's
husband who worked in a laboratory eventually phoned doctors he
worked with. They secured the neighbours admission and early surgery
at a hospital which had denied her care. This is the human experience
of equity in the marketplace. Why should it be any different in other
countries when multinationals whose primary concern is profit
dominate and control the market?
I have experience of contracts with doctors to provide services to non-paying subeconomic groups. While a core, probably a majority of doctors who took these contracts maintained their ethical commitment and provided good care others misused the system to generate money quickly. Patients did not received the care which they required. These contracts attracted the least ethical practitioners and the government agencies supported them in their activities.
There was always an excuse and explanation for each instance of substandard care. It was easy for them to rationalise and justify their activities. Prosecuting them was almost impossible. It was the whole picture which was so bleak and only those close to the system recognised what was happening. When the sort of corporations providing health care and the sort of people who manage them are examined then it is clear that we are likely to see the same thing on a much larger scale.
In the USA contracts which include incentives
and disincentives have been used to bind the medical profession to
the corporate mission whether that be overservicing or
underservicing.
Policing and oversight simply don't work and few inside the corporations will blow the whistle about care. There is always an explanation for individual cases. Prosecution for providing substandard care on a large scale would be a nightmare. In the USA almost all of the corporate prosecutions are for fraud. There are few if any government prosecutions for widespread neglect. To prosecute would involve using hundreds if not thousands of patients and proving each instance. Each case would be defended with a host of conflicting expert opinions and a set of red herrings. The logistics and the cost make it impractical.
MORE ABOUT EQUITY
CLICK HERE -- to go to another page which examines the market, equity in the USA and the implications for Australia - but differently.