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This page created April 2000 by Michael Wynne
Modified October 2000, January 2004
This page provides an index to a number of pages which analyse
particular facets of marketplace activity. They were written at
different times and in response to different challenges. Unlike a
book it does not follow a logical sequence and needs to be explored
rather than read. I added the pages as I wrote them. Each link
contains a short summary of the content. In time I hope to reorder
and group these around short introcuctory sections. The pages still
need references added.
CORPORATE PRACTICES: INTRODUCTION to Analysis and Criticism
This page outlines the theme of this section and looks at the ideas behind the pages, the framework used to analyse and criticise, and where it is leading.
CLICK HERE -- to read the introduction
Joseph Califanoand the marketplace revolution
Joseph Califano was an early exponent of economic rationalism. In 1986, eighteen years ago he wrote a book advocating the use of economic levers and the manipulation of incentives and disincentives in order to secure economic outcomes. He strongly promoted DRG payments and managed care.
Califano pointed out that doctors' economic wellbeing and welfare was as important to them as to any other citizen. Doctors could be made to serve corporate interests if corporations could control their incomes and their careers. Citizens in the USA have been suffering from the consequences ever since.
This page examines the basis for his theories contrasting them with more traditional health care ethics and values. It examines and challenges the assumptions on which they were based. Quotes from his book are contrasted with what has happened over the last 18 years. The reasons why his solutions failed and why they made the situation worse and continue to do so are examined.
CLICK HERE -- to access this page
The Story of Health Care Reform
A historical understanding of the limits of markets has been replaced by a fundamentalist belief in their all encompassing validity and universal applicability. As a consequence market "reforms" have been imposed on health care with unfortunate consequences. Each failure has been met by imposing an increasingly complex more marketlike model. Not surprisingly the unfortunate consequences have multiplied.
CLICK HERE -- to follow the development of "health care reform"
The Process of Marketplace Reform
This page describes social, psychological and political aspects to the process of change. These create pitfalls and challenges which are seldom confronted. The manner in which marketplace ideology has been imposed in health care illustrates many of the problems and the unfortunate consequences.
CLICK HERE -- to go to the page about reform ?????? where is this????
The Logic of Marketplace Arguments
Proponents of marketplace reform argue their case by claiming that because other "industies" have benefited from market reform health care would also do so. Not only does the argument fly in the face of 2000 years of experience but it is logically flawed.
CLICK HERE -- to look at the logic of marketplace arguments
STARTING POINTS
In his speech to the World Bank Graham Samuel talks of the "starting points" which exist in most countries and then 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.
CLICK HERE -- to discuss the starting points behind the market and behind health care.
A CLASH OF 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.
CLICK HERE -- for an examination of these two worlds
ANALYSIS OF CORPORATE CULTURE AND PRACTICES(Sun Healthcare as an example) ::::: Lessons for the Future
This page suggests a framework for analysing corporate culture and behaviour. It builds on the ideas proposed in the page "Understanding the corporatisation of health care" to show how they apply. It explores the behaviour and thinking of health and aged care corporations by a case study of Sun Healthcare and its charismatic founder Andrew Turner. They are representative of the US corporate health and aged care marketplace. Similar analyses could be performed on other groups. Some conclusions are drawn. Suggestions are made as to how the insights provided can be used to progress the health care debate.
CLICK HERE to go to this analysis
Cultural Conflicts ::: Altruism
This page examines the importance of altruism as a community and medical cultural value. It looks at the impact of a marketplace culture on this.
CLICK HERE -- for comments on altruism
The Market, Demand and Value
Market advocates talk of products, services, demand and profit. Duty is to the shareholder. The important consideration is whether the product is highly valued by the consumer. This page examines the way in which marketing and education can cause a community to falsely value some forms of treatment highly, increase demand and so boost profit.
Professional paradigms in contrast talk of care, suffering, need and responsibility. Duty is to the patient and to the community. The community's properly informed opinion about needs and the allocation of resouces is an important issue. There is a vast difference between the two patterns of thought. The consequences for vulnerable people are profound. I suggest that there is no obligation for the tax payer or other insurer to meet demand. It is not need.
CLICK HERE -- to explore the logic of these two positions
The Health Care Marketplace
In the Healh Care Marketplace the patient is not an effective customer and the level playing field is almost perpendicular. Contracts for care are with others who are the real customers. Competition is unrelated to the patient or his care. The patient becomes a pawn in the system, a profit body, an object used by each cog to milk more profit from the system.
CLICK HERE -- to explore the nature of the health care marketplace
COMPETITION IMPROVES QUALITY?
This page examines the issue of quality and the market. It considers the different meanings attached to the word quality by different groups in different contexts. The use of the word "quality" is a problem in itself and symptomatic of something much deeper. The page points out that the only groups which have acquited themselves credibly in the face of severely dysfunctional conduct have been the patients, their relatives, the community, and a number of more junior employees. In the marketplace these people are powerless and lack credibility. If we are to design an acceptable health system then these people should be intimitely involved in all parts of the system.
CLICK HERE -- to examine the impact of marketplace competition on "quality"
Quality, Profit and Type of Provider
This page adresses the relationship between quality, profit and provider by examining assurances that quality is not compromised.
CLICK HERE -- for information about quality and profit.
The Collection of Data
This page looks at the collection of data in the marketplace and the collection of data about the marketplace. It describes how much of the data on this site was collected.
What are the implications for the collection of data of the fragmentation imposed by the marketplace and of the competitive environment? Data is clearly commercially sensitive. Where can we find it? What sort of data do you find? How reliable is it? The collection of data under an alternate system is considered.
CLICK HERE -- for more information about data collection
Monitoring Developments in the Healthcare Marketplace
This page examines the difficulties of collecting suitable information from the marketplace. Market models such as that proposed by Graeme Samuel to the World Bank depend on collecting information and monitoring the care given. This is extremely difficult because of the commercial sensitivity of such information.
CLICK HERE -- for more information about collecting data and monitoring care.
GOVERNMENT CONTROL OF HEALTH CARE ---- A sorry tale
This page traces the reasons government failed to exert control over corporations in the USA. Only moderately effective control has been initiated by community outrage. It indicates why similar outcomes are likely in Australia.
CLICK HERE -- for more about government control in the health care marketplace.
The Market, Teaching and Research
(This page explores the relationship between the market, universities, research and education. It started as a response to comments by Graeme Samuel but goes much wider than this - wider than health care - a broad canvass.)
CLICK HERE -- for information about the market, research and education
Marketing and Education
Marketing and education have been used by corporate health care companies to build the bottom line. They have misinformed, deceived and even restricted information. Instead of facilitating and encouraging choice they have restricted it. The great success stories of the health care marketplace have been built on marketing skills and little else.
CLICK HERE -- for more information about marketing and education
A Stable Health System
This page examines the stability of the corporate health system in the context of affordability. What is likely to happen to a corporatised health system when health care is no longer profitable or when money is short and there is less to spend on care.
CLICK HERE -- to examine corporate stability and its impact on care
The Market -- Mergers
Mergers and takeovers create a constant sense of uncertainty, repeated changes in ethos and management style, and recurrent disruption to the care which patients are receiving.
THIS PAGE IS EMPTY AND IS STILL TO BE WRITTEN
CLICK HERE -- to learn more about mergers and takeovers. (EMPTY)
The Corporate Marketplace and Choice
Choice in health care is a very different process to choice in the marketplace. Potential patients are vulnerable to manipulation, misuse and abuse. While advocates of a health care marketplace claim that the market provides more choice, it is not in the interests of corporations to provide this. In practice they have a very poor track record.
CLICK HERE -- for more about choice in the marketplace.
Not for Profit Health Care and The Market
This page examines the behaviour of not for profit community services when they are placed in a competitive marketplace and have to compete with groups whose primary focus is competition and market dominance.
CLICK HERE -- for more about not for profit and the market.
Declining Community Satisfaction
Market advocates claim that patients, now called consumers are dissatisfied with the health system and that the market solves this problem. The former is partly correct. The latter is not supported by the evidence.
CLICK HERE -- to examine the issue of Community Satisfaction
Probity
Trustworthiness is fundamental when we are dealing with citizens who cannot protect themselves. This is the reflected in the old fashioned words "probity, "fit and proper" or "of good standing". Essentially it asks if this person can be trusted. It balances the right of members of the community to be protected from those who cannot be trusted against the rights of individuals. It therefore constrains the market and is an important concept when dealing with services to the impaired or underprivileged. It is a prime target of the global marketplace.
CLICK HERE for some thoughts about probity
Professionalism
Professionalism and professional structures have been attacked by theorists of all sorts and blamed for everything which was wrong with the health care system. None have attempted to examine the cognitive and social forces. They are thought to be selfinterested, selfserving, and anticompetitive. Two pages examines these failures as they have arisen in an increasingly commercial and market oriented society. The impact of the marketplace and corporate profit interest on professionalism is examined in an attempt to learn some lessons.
Trust,The Market and Professionalism
This page examines the way in which the market has corroded the values and ethics of the professions and induced doctors to place care for the corporation ahead of care for the patient.
CLICK HERE -- to examine the impact of the market on professionalism
This page acknowledges that professionalism has failed on a number of occasions and more so recently. It explores the reasons for this and argues that the meaning systems and the values which form the basis for professionalism are sound. Professionalism has failed when confronted by powerful forces which introduce meaning systems which are not congruent with professional values.
CLICK HERE -- to explore professionalism and the market at this level.
Professional Independence
The medical profession has cherished and protected its professional independence. There are pluses and minuses to professional independence. On balance this independence has served society well and should continue to do so. While it has bent to the winds of change it has served democracy by keeping the embers of community values burning in the face of totalitarianism and ideology. The embers reignite as soon as the wind changes. Its response to economic ideology is no diffferent to its response to apartheid.
CLICK HERE -- to look at professional independence
Health Care and Empowerment
This page examines the development of paternalism in health care and its progressive replacement with an ethic of empowerment. The difficulties in accomplishing this in a market system are considered. The track record of the market is examined.
CLICK HERE -- to explore paternalism and empowerment
THE "CONSUMER", THE PROFESSION AND THE MARKET
This page explores the claims that in the market consumers would decide what care they were given, and that health care is currently organised for the benefit of the medical profession. It examines the way in which decisions about care are actually made in the marketplace. It does so by using examples.
CLICK HERE -- to explore the relationship between the "consumers", professions and the market.
The Consumer in Samuel's Model
This page was written as part of a criticism of Graeme Samuel's market model of health care. Samuel's model is built around competitive roles. I consider this model to be a form of managed care. This page examines the health care consumer's role in managed care and Samuel's model
CLICK HERE -- for comments about the consumer.
Controlling the Utilisation of Health Care
This was part of my original criticism of Samuel's denial of managed care's problems. It addresses the question of who controls utilisation of health care services.
CLICK HERE -- for comments about utilisation
Quality in the Health Care Marketplace
Corporations have imposed their own meanings on the word quality. They have misused the term in order to deceive themselves and their customers. Had they used a better word with clearly defined meanings then they might have been held accountable and much suffering may have been avoided.
CLICK HERE -- for more information about the misuse of this word
Profit versus Care
This page gives an overview of the way in which the pressures for profit have impacted on care in the various sectors of the US and Australian health care marketplaces.
CLICK HERE -- to explore the issue of care and profit
The Cost of Efficiency
One of the main arguments used to promote marketplace reform is efficiency. In practice the market has been anything but efficient. Instead it has used the language of efficiency to justify unconscionable practices and the misuse of citizens.
CLICK HERE -- to go to the page about efficiency.
Competition and the "efficiency dividend"
This page examines the claim that competition results in efficiency. It examines the difference in efficiency originating in the board room and efficiency originating at the bedside.
CLICK HERE -- to go to the page about competition and efficiency
The Market and Equity
This page examines the question of equity in market systems and when using contracts. Experience to date is not encouraging.
CLICK HERE -- to explore the issue of equity
EQUITY
Marketplace advocates promise us equity. This page examines the issue of equity in the marketplace, and shows how equity has been compromised in the USA. It then examines the implications of a market system, particularly that proposed by Graeme Samuel for equity in Australia. It suggests that equity is integral to a community service but must be imposed on the marketplace. Continuous costly monitoring is required.
CLICK HERE -- to explore the issue of equity and understand why it is compromised in the marketplace and what the implications for Australia are.
Access to care and the Marketplace
This page discusses the problems of reduced access in managed care and augmented access in item of service for profit systems. It responds to issues raised by Graeme Samuel.
CLICK HERE -- to explore access.
Structure of the Health System
Health care is currently structured along lines of funding. Graeme Samuel in his speech to the world bank has suggest it be structured in terms of an economic theory. I suggest that it be structured along the lines of the services provided so that these can be brought to patients balancing efficiency against need and service.
CLICK HERE -- to go to the page about structure
INTEGRATED HEALTH SYSTEMS
This page looks at integration in a corporate health care context and relates this to Graeme Samuel's proposals. It goes on to address the related issues of flagship hospitals, corporate control of markets, difficulties in enforcing contracts and the problems of gate keeping.
CLICK HERE -- to go to the page about integrated systems
Accountability
This page examines the way in which corporate staff were held accountable to management for profit and cost but not for care. It examines the way in which those bodies responsible for ensuring that corporations were accountable to the community and that adequate care was provided to citizens failed to fulfil their responsibilities.
CLICK HERE -- to learn how no one in the market is held accountable - least of all management. None of them went to prison.
Government Oversight ::: Regulation and Surveillance
This page examines the repeated failure of government regulation and oversight of the health care marketplace.
CLICK HERE -- for information about government oversight
Professionalism and Regulation.
This page examines the important regulatory role of professional values and ethics when contrasted with the ethic of the marketplace.
CLICK HERE -- for information about professionalism as a regulator.
Regulation in the USA
This page examines the failure of regulation in the USA and gives a number of examples.
CLICK HERE -- for information about regulatory failure in the USA
Why Regulation Fails
This page explores some of the reasons why oversight and regulation are so ineffective in health care.
CLICK HERE -- for some explanations.
Accreditation
Accreditation has failed repeatedly to ensure that US citizens receive good care and that they are not misused for profit. There are concerns that the relationships between accreditation bodies and corporate interests is incestuous. It is not that accreditation is not a desirable process but its inability to deal with the pressures generated by the market.
CLICK HERE -- to examine the facts about accreditation.
Politics, Markets, Health and Democracy
This www page examines the different ways we look at democracy and the close relationships which develop between politicians and the corporate marketplace as each scratches the back of the other. Within a democratic system which emphasises personal rights to pursue selfinterest and compete for influence this appears to be acceptable. Within a democratic system built on personal responsibilities for others and the common good this is totally unacceptable.
The page looks at the close relationships between the market and politicians in the USA and Australia. It examines the financial practices which cement this at the expense of the rest of us. It is a rewrite of 3 older pages.
CLICK HERE -- for the relationship between politicians and corporations
The Legal Stories
The way in which the law operates in the USA and enables deals to be struck. This has unfortunate consequences for other countries, particularly Australia. Information about the numerous court actions taken against these corporations will be provided.
THIS PAGE IS IN PREPARATION - only a few limited comments available
CLICK HERE -- to examine the legal happenings in the USA.
Whistleblowing in health care
This page touches briefly on whistleblowing and dissent in health care. It explores 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
CLICK HERE -- for some thoughts on whistle blowing.
WELCOMING MULTINATIONALS IN AUSTRALIA -- Some considerations
This page examines some issues surrounding overseas ownership of health care.
CLICK HERE -- for some thoughts about this.
The new corporate world of medicine
In 1997 I found myself in possession of vast numbers of documents describing what was happening in corporate medicine. It was impossible for me to copy and circulate them and there was little prospect that so much material would be read. I therefore made a collection of extracts which illuminated the corporate world to accompany my correspondence. This was in late 1997 afer Columbia/HCA had backed away and Sun Healthcare had announced its entry into Australia.
They reflect many different points of view. They give the flavour of corporate culture, of the patterns of thought of health care's corporate leaders and of the debate about corporate health care. It is illuminating.
CLICK HERE -- to read this selection of quotes.
Social Process and Health care
When Columbia/HCA made its bid to enter Australia in February 1997 I wrote a submission opposing its entry into Australia. In the background introduction I wrote about global processes, economic thinking, social processes and health care. I put this submission onto the www as a series of pages in 1998.
CLICK HERE -- to go to the background page in this submission.
Submission: Corporate Medicine - Hospital licences: Revising the regulations
In August 1997 Thomas Frist replaced Richard Scott as chairman and did a mea culpa effectively acknowledging Columbia/HCA's disturbing business practices and promising to reform the company. The practices he acknowledged were those I had been writing about. Queensland was revising its hospital licensing regulations and I seized the opportunity to make a submission using these acknowledgements to press for regulations which would prohibit these business practices.
CLICK HERE -- to go to "Hospital licences
Further Developments in 1997 - Overview
This page was developed in 1997 as the entry page for the www pages I wrote during that year. These pages can now be accessed from other pages. It simply indicates what was happening at that time.
CLICK HERE -- to go to this page
Corporate Medicine in Australia
By the end of 1997 there was a vast amount of information documenting the failure of the US marketplace. I wrote this page at this time in order to relate what was happening in health care to the other problems of our times and to move attention from the visible manifestations of corporate medicine to the underlying processes at work. It drew attention to similar thinking and similar practices in Australia.
CLICK HERE -- to go to this page about processes at work