Character and competence become irrelevant when one is guided by a mission independent of these traits. I discovered painfully that my character and competence were incidental to my performance as an employee of a corporation. When my performance is measured in numbers and quotas, my job and character are severed.I learned how easy it is to do many things diametrically opposed to everything medicine stands for, not only willingly, but often with great belief (supported by my peers and prevailing sociologic/economic/scientific assumptions of the organizational culture) that I was right and my actions were good. It was even easier when I was "rewarded" for such professional action.
It is important then to distinguish between character and decision- making. There is enough material from many sources which demonstrates and explains how you can have persons of wonderful character (e.g. good parent, goes to church, civic leader, etc.) who buckle under certain pressures and make unethical/unprofessional/inappropriate decisions. When one is part of a larger organization, one can create distance and diffuse responsibility such that all ethical responsibility shifts elsewhere or is eliminated all together.
MANAGED CARE ETHICS: THE CLOSE VIEW PREPARED FOR U.S. HOUSE OF REPRESENTATIVES COMMITTEE ON COMMERCE SUBCOMMITTEE ON HEALTH AND ENVIRONMENT BY LINDA PEENO, M.D. The National Coalition of mental Health Professionals and Consumers May 30, 1996
Dr. Peeno is describing her experience working as a gatekeeper for a "for profit" Health Maintenance Organisation (HMO). When she was rewarded and praised for denying care to a patient who died as a result she developed a deeper understanding of the processes at work and went on to further study in ethics and philosophy, playing a major role in opposing managed care.
This page summarises and links to a series of pages which describe different health care systems and develop a theoretical framework which I have used to examine what is happening and explain it. The first three pages are good starting points for exploring the web site.
The physiotherapy journal "Business in Practice" ran an issue on corporatisation in March 2003. I was invited to express my opposition to corporatised health care and the thrust of the web pages in 600 words. This was my effort and it seems a good starting point. It brings some of the key issues together in a concise way. The rest of the web site expands on this, explains it and gives numerous examples.
Rationing in
Australian health care services
In 1998 P Baume wrote an article in the Medical Journal of
Australia examining the need for rationing in health care. While the
ideas were sensible the paper completely ignored the likelhood that
in the developing corporate marketplace this would become rationing
for profit rather than to stretch resources in the community's best
interests. The MJA published a letter in which I addressed rationing
for profit.
Belief Versus Reality in Reforming Health
Care
A paper "Belief Versus Reality in Reforming Health
Care"contrasting for-profit with not-for-profit health care was
published in the August 2005 edition of "Health Issues" and is
available on their web site in due course
<try http://home.vicnet.net.au/~hissues/resources.htm#bookmark2>.
I have included a copy
on this web site. (pdf
file)
A background description of the history and nature of the different types of health system. Understanding the significant differences between public systems and private systems. The particular significance of for profit and not for profit systems, and between for profit companies which are market listed and those which are not. The pivotal role played by institutional investors. There are important implications for the way services are provided and the sort of care given.
Understanding Corporate Medicine - frameworks for understanding
Everyday thinking about criminal and exploitative behaviour in society and in health care is limited in perspective. The approach adopted by politicians is illogical. It not only fails to address the problems but often actively foments them. The market is blind to anything outside its frames of understanding.
This page examines everyday understandings and then develops a different framework of understanding. It starts with the idea that as humans we have to act in order to build our lives. We have to develop ideas which allow us to understand what we do and make it legitimate. It looks at what individual situations require of us, and what happens when what we are required to do in a particular situation is socially unacceptable. This provides deeper insights into what is happening in health care and offers different solutions.
This page is not essential to an understanding of the other pages but the ideas are central to the thrust of my criticisms and my analysis. Because readers access the web site at different places many of the ideas and arguments are repeated in pages dealing with specific corporations or particular problems. This makes the web site bigger than it need be but this is the price of the web format. This page brings these ideas together and provides a central theoretical resource on this. The theoretical aspects may be easier to understand when actually analysing the examples.
Personality and Success in the Health Care Marketplace :: Sociopathy
People with certain characteristics seem to succeed in the health care marketplace. I have used the terms "closed minded" and "successful sociopath" in a number of web pages to describe them. This page describes what I mean by these terms. It flows on and expands some points on the previous page.
The sort of people who are successful and the reasons why they succeed are explored. Many successful health care entrepreneurs display these features. Similar behaviour by groups and even communities occurs. I suggest that these people are not the sort of people who should be allowed to provide health care to vulnerable citizens.
The page provides links to pages which describe the thinking and behaviour of many of the corporate founders.
This page is also not essential to an understanding of the other pages on the web site but the ideas are central to the thrust of my criticisms and my analysis.
Private Equity enters health and aged care
In a 2007 article (pdf file) eminent business guru John Bogle described the way the focus in the marketplace has moved, from an emphasis on long term goals and solid companies functional for the community, to short term profitability, management self interest and share value - compromising functionality. This move has coincided with the move of health and aged care from community care to market care and then very recently to care by private equity financiers. Each has changed the context within which health and aged care are provided shifting the emphasis further from care towards profitability.
Private equity is a new market phenomenon spreading across the world. Large private equity groups have purchased the largest hospital operator and the largest nursing home chain as well as several smaller companies in the USA. In 2002 a private equity group purchased Australia's largest hospital group and sold it 2 years later. In 2006 they bought the largest nursing home group. Australia's private nursing homes are now largely owned by banks, trusts and often global financiers, all of them distant from the coalface and interested only in profitability.
A 2007 Australian senate inquiry into the economic consequences of private equity has reported and saw no threat in what was happening. The two contrary submissions in regard to health and aged care, below, were discounted.
In my view these outside financial managers, distant from the bedside and interested only in profits, pose an even greater threat to health and aged care as well as to other community and humanitarian endeavours. I made a submission to the senate committee inquiring into the implications of private equity. I explored the social consequences of the marketplace and private equity with an emphasis on health and aged care.
Click Here to dowload my submission (659KB pdf file). Another submission by Marie dela Rama (206 KB pdf file) from UTS also warned of adverse consequences for aged care.
"More Profit and Less Nursing at Many Homes", a detailed analysis of nursing homes acquired by private equity groups in the USA was reported in The New York Times on 23 September 2007. In essence it confirms our prediction that private equity would impact adversely on care.
A paper "Hazards in the Corporatisation of Health Care" (pdf file) published in New Doctor in 2004 looks at the purchase of Mayne Health by Citigroup's Asian private equity subsidiary.
Building on Values: The Future of Health Care in Canada
The Romanow Commission in Canada carried out a thorough review of their health system exploring the advocated change to a more market based system. Romanow reaffirmed the importance of a system built on values and advised against market reform. I wrote a paper with a Canadian examining the significance of this review for us in Australia. A copy of this article from the Health Issues Journal is on the site as a pdf file. The 400 page (2.3 MB pdf file) Romanow Commission report can be downloaded from http://www.cbc.ca/healthcare/final_report.pdf.
Australia's
Experience with Health Reform: Are there lessons for Canadians?
In October 2004 I was invited to speak to groups of
Canadians in Alberta and I provided them with a background paper. The
title is a misnomer and was not mine. It is on the Canadian Consumers
Association web site as a pdf file and I have placed
a copy on this web site.
This analysed the systems of understanding used by for-profit
medicine and their application to health care in the USA,
particularly as it affected the behaviour of doctors. The paper
contrasted this with different behaviour in some sections of the
Australian medical profession. It explored the reasons for this. The
latter part of the paper placed events within the context of a wider
marketplace ideology. It looked at the way democratic principles had
been skewed in order to make this narrow belief system legitimate and
apply it to health and aged care. It was suggested that health care
had much to offer the wider community in achieving a more balanced
view of our society and the nature of democracy.
Those unfamiliar with the concepts in the two previous pages may have difficulty in coming to grips with these quite complex ideas. While the concepts are not essential for reading these www pages they are central to the thrust of the arguments. Other pages explore the ideas in varying degrees of depth. I use them to analyse context, understandings and conduct in specific situations.
Because readers come directly to pages about different corporations these ideas are repeated, summarised and extended in similar and different ways on many other pages.
If you have had difficulty with the previous pages and want to come to grips with the ideas then I suggest that you look at some of them next. If you want to follow on to specific instances then you can link from here. These pages are part of other sections of the web site and will be encountered there as well.
The concepts will become much clearer when examples are used. Click on the headings to go to the pages.
1. Analysis of corporate culture and practices - Sun Healthcare as an example
This page further explains and expands the framework for analysing corporate culture and behaviour. It covers the same material as the previous pages but more briefly. It looks at personality attributes in order to identify the sort of people who most readily identify with discordant belief systems and so become successful. It explores the behaviour and thinking of health and aged care corporations by performing a case study of Sun Healthcare and its charismatic founder Andrew Turner.
2. The impact of financial pressures on clinical care:: Lessons from corporate medicine
This is a detailed analysis of the thinking of the corporate healthcare marketplace using the US company National Medical Enterprises (now renamed Tenet Healthcare) as an example. It describes the way in which the marketplace context resulted in paradigms of understanding, which made it legitimate to misuse and exploit vulnerable people even when they were not ill. George Annas used the term Metaphor in a paper he wrote and I have borrowed it here.
For National Medical Enterprises during the 1980s and early 1990s it became acceptable, even desirable to defraud government and insurers of hundreds of millions of dollars. Patients became the vehicles for accomplishing this. Their welfare and their basic rights were subjugated to the market's profit priorities. The analysis reveals similar patterns of thought in Australia. It describes the disturbing way in which Australia responded to National Medical Enterprises' presence here.
3. Persistence of a Market First Culture :: Infectivity, Heredity and Resistance
National Medical Enterprises culture was infective to others, was inherited by its successors and was resistant to criminal conviction. It persisted under its new name Tenet Healthcare and then between 1999 and 2002 the company indulged in remarkably similar deviant practices in another area of health care. In 2003 it is one again the subject of multiple government investigations and court actions.
4. Tenet Healthcare and its Doctors :: Doctors in the marketplace
National Medical Enterprises and its successor Tenet Healthcare have been remarkably successful in bending the medical profession to its corporate mission. In the first scandal doctors connived in the needless admission of many adults and large numbers of children to psychiatric institutions where they were kept for long periods and misused in order to generate profits.
In 2002 doctors in its hospitals were accused of needlessly carrying out high risk heart procedures and bypass surgery on hundreds of people who did not need this, some of them perfectly normal. The company paid US $54 million to settle government allegations made about its involvement in this but of course without admitting any wrongdoing! Private actions against the company and its doctors are ongoing.
I have devoted a web page to examining what happened in these two situations and looking at the processes at work. It illustrates what happens in the marketplace.
5. HealthSouth :: Context, Leadership, Culture and Community
HealthSouth was the only large very successful growth company which seemed to be "clean". Then in 2003 its halo went up in a cloud of smoke as one senior executive after another pleaded guilty to fraud and described the US $2.5 billion accounting scandal which was the basis for the company's success. A vast amount of information became available. This page describes its bizarre founder and the way in which he built a culture which gave rise to the fraud and to many other unacceptable practices. It looks at HealthSouth's relationship with the wider marketplace and the community.
6. HealthSouth Auditors and Banks
Particularly revealing is the web of cultural relationships involving banks, auditors and others who are suspected of being if not a partner to the fraud then at least very willing to turn a blind eye - a fascinating insight into Wall Street and how it works. All of them benefited financially from what was happening.
7. Professionalism - response to economists criticisms
The medical profession has sometimes failed to act in the best interests of patients and the community. This page uses the same concepts to analyse the how and why of this. It concludes that professionalism has failed when the context in which medicine is practiced has been changed, when conflicting paradigms have been imposed, and when professional value systems become passé because society has not supported them.
Each of us filters the world through a personal set of understandings. We therefore experience it differently. In a sense we live in different worlds. In this page I contrast the world the rest of us live in with the health care corporate world and suggest that one of us lives in an illusionary world - and I don't think it is the rest of us. The page ends by looking at risk and cost as understood in these two worlds.
In his speech to the World Bank Graham Samuel talks of the "starting points" which exist in most countries. He sets out to promote a system of health care with very different "starting points". This page examines the nature of "starting points" and their impact on identity. It attempts to understand what Samuel is really proposing by examining both starting points. It concludes that he is telling us how to get from where we are to somewhere we don't want to be and most certainly should not be.
10. Whistleblowing in Health Care
This page touches briefly on whistleblowing and dissent in health care. It extends the paradigm I have developed to suggest some ideas about the structures of society - why some fail. It examines the role of whistleblowing and dissent within this framework. It examines the context of whistle blowing. When do people speak out and when do they remain silent?
11. Overview of Corporate Nursing Home Care
A description of what has happened in the US nursing home marketplace. The page describes and analyses the way in which the particular context combined with entrepreneurialism and market forces led corporate chains into the misuse of subacute care and the neglect of the elderly.
12. Social Darwinism in aged care
This is part of the nursing home page above. Events in the US nursing home marketplace illustrate the concepts of Social Darwinism and sociopathy well. The idea that the context within which people find themselves selects for the sort of people who will be successful there - hardly unexpected.
13. Implications of the entry of Columbia/HCA into Australia
This is the submission I wrote opposing Columbia/HCA's entry into Australia in March 1997. Australia still looked at health care dysfunction as a number of isolated bad eggs in the corporate marketplace. This sounds ridiculous today after Enron, World.com, HIH and a host of other scandals but at this time it was a real issue and the ideologists in Canberra were in denial. Anyone who challenged the new market goodness was considered suspect and without credibility.
The thrust of this submission was not only to stop Columbia/HCA but to challenge this by showing that disturbingly dysfunctional thinking and the processes were society wide, health care wide, and Australia wide. In part 1 I explore economic thinking more widely and discuss the implications for "social control". I then look at these processes and conduct in the wider US marketplace (part 2) and in Australia (part 3). Part 4 is a more detailed description of the information available about Columbia/HCA at this early stage when the fraud scandal had just broken. Part 5 is a page about Mayne Nickless describing the similarity of its thinking and practices to Columbia/HCA. Part 6 in the conclusion and this brings the issues and ideas I raised in the background back into focus. I am also looking at the wider implications of this sort of behaviour for Australia. Part 7 is a list of references. Each part is a separate web page.
The issue of social control and the wider implications for society are not dealt with elsewhere.
14. Managed care
I have recently added some limited pages about managed care. Many others have written in greater detail. The pages look at the managed care marketplace, at the citizens revolt and the battle for patients rights legislation, and at the way in which managed care has marketed itself across the world. I have supplied links to papers by Dr. Linda Peeno. She has had personal experience and has studied the subject in great detail. She writes with great insight.
15. The marketplace
I have used the giant multinational financial conglomerate Citigroup to study the marketplace and the way the market thinks and operates. It has been involved in a series of ongoing scandals. It shows a remarkable similarity to health care. One page looks at Citigroup's culture and the personalities of those involved.
