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This page created April 2000 by Michael Wynne
This page examines the way in which marketing
and education can cause a community to falsely value some forms of
treatment highly and increase demand. I suggest that there is no
obligation for the tax payer to meet this. It is not need.
Graeme Samuel in his speech
to the World Bank sets great store on
what the community values highly and this is clearly linked to demand
in his mind. I will address this when I discuss professionalism
and contrast it with the market in its responsibility for the needs
of others and the good of the community. What I want to illustrate
here is the impact which the market system itself has in creating
demand and in determining what is most highly valued. Outside
medicine we need only look at the value placed by the young on
designer clothes to see the same thing. A Macmedicine model of care
copies this.
Creating Value and a Demand:- In a marketplace system the community can be persuaded by marketing or corporate education to value a particularly profitable form of care "most highly". This can be extremely profitable. The best example of this is the way in which corporations providing psychiatric care induced the community to value Psychiatric care for children most highly by writing and promoting educational books and running public seminars. In their educational seminars there was always a desk at the back where appointments could be made for an assessment. Children were portrayed as being at risk of numerous problems which would impede their future development. A variety of trivial behaviours were portrayed as symptoms of potentially serious disease. The community came to value psychiatric assessment and early treatment of problems very highly.
Capitalising on Demand:- Those who carried out these assessments were required to persuade and not to assess. They were given a percentage target of admissions to meet. Their performance was evaluated on their "conversion rates". This was the number of insured patients persuaded into hospital for further assessment. Once a child was in the hospital the parents could be persuaded of the seriousness of the problems and the need for prolonged hospitalisation.
Tenet/NME also sent bounty hunters paid for each head on a bed into the community to persuade these sensitised people into hospital. Children's fairs and parties were paid for by the company. Children's mental and physical wellness were promoted and "assessments" were part of the fair.
The object of these fairs was simply to get these children into their hospitals and the assessors were rewarded on the basis of the number of people they succeeded in persuading into hospital. Staff reported the success of these activities in generating admissions up the system. As a consequence vast numbers of children were needlessly incarcerated in psychiatric hospitals for many months and many were mistreated.
Staff at hospitals proudly passed reports up the system explaining how they were offering weekend parties to get parents and children to agree that the children should stay in hospital over weekends and get more treatment rather than go home. They boasted about the number of children persuaded to stay. This meant that the insurer could be charged for 2 more days in hospital and that additional weekend "treatment" could be given. Hardly good psychiatric care! These practices were all strongly supported by the company and were integral to the "intake culture" with which staff identified.
Those involved in all this did not think they
were doing anything wrong. They were enthusiastic. It was all part of
a valued corporate intake culture. It is because market based
corporate systems have the capacity to create problems like this that
they are such a threat in health care. If one examines the documents
then it is clear that these people and this company were simply
applying basic market principles and practices to the health care
context.
Advocates of contracting public care to private systems, like Craeme Samuel speak of providing the community with what it values and what it demands. He is talking about a system of care for patients paid for by the government with tax payers money - the public delivery of health care by private groups. I do not believe that the public is required to fund what particular individuals influenced by corporate marketing value highly, nor the health care equivalent of currently fashionable designer clothes.
An integrated not for profit system can meet some of the objectives of efficiency in a human and caring way. The idea of "providing the services that people value most highly" is not one which a community service would necessarily subscribe to if by people are meant individuals rather than community. We cannot talk about costs, rationing, equity and access in the same breath as what a particular group considers "highly desirable". There are other important considerations such as need.
What we are talking about whether provided by the community or the market is some sort of system where those with limited resources are supported by the community. This is equity. The community has a reasonable responsibility to provide sound basic care. Those wanting something which they personally value highly have every right to pay for that service inside or outside a community health system, provided there is a reasonable person prepared to provide that service. Some protection against dangerous quackery is still required. What we cannot have is vulnerable people exploited and misused for the profit of others.
In the sort of system which I envisage as an alternative to Samuel's proposals the community itself will be involved in looking at the hard data and setting this against fashion and fad so making reasonable compromises when paying for care.