An invited opinion piece published in "Business in Practice" (Journal of the Private Practitioners Group of the Australian Physiotherapy Association) March 2003 page 10
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. The rest of the web site expands on this, explains it and gives numerous examples.
The most important distinction we need to
make when debating the future of health care is the distinction
between care of the patient (not-for-profit) and care of the
shareholder (for profit). The latter abandons the Hippocratic
tradition.
Health care is funded primarily by taxes or by insurance and this
funding is limited. Not-for-profit care offers a cooperative system
to stretch limited resources for maximum benefit. It is based on
reciprocal trust and a sense of community. For-profit offers a
competitive market system which stretches resources in order to care
for shareholders. Those who are most successful financially prosper
and those unable to compromise care for profit go under. Maintaining
adequate standards in the market depends on an informed, distrustful,
and empowered customer. This does not fit the majority of sick
citizens. It is no coincidence that those most misused by the market
have been psychiatric patients, substance abuse users, children,
rehabilitation (head injuries) and the elderly in nursing homes.
Under our legal system health care professionals make the decisions
about care, the care from which profits are made. Financial success
therefore hangs on the ability to bend practitioners to meet the
corporate mission. This is best accomplished by controlling
professional income and career prospects. Lucrative contracts (golden
handshakes) soon become golden handcuffs forcing compliance. The
pressures may be to over service (providers) or under service
(managed care).
For-profit providers and economic theorists may start with the best
intentions and will angrily reject this analysis. Corporations are
ultimately dependent on the share market for survival and the market
is unforgiving. Competitive pressures ensure that those who exploit
the funding system and reduce costs to levels which compromise care
succeed. Those who fail to do so are taken over and restructured.
Institutional investors (managed funds, pensions etc) greatly
outnumber individual investors. Their prime responsibility is to
increase value for their members and their frames of understanding
are entirely market based. They have the power to force out directors
and managers of nonconforming companies. They insist on the
exploitation of the market for the benefit of their members. These
members do not know where their funds are invested and have no
control over what is done on their behalf.
Decisions which profoundly effect the care given to patients are made
in the board room. Nursing care for example is critical in aged care.
Sun Healthcare adopted a policy of "cutting the fat" by reducing the
quantity and quality of nursing staff. It built its vast US empire by
exploiting the rehabilitation opportunities presented by post acute
care - paid for by item of service. They recruited therapists from
around the world. When the funding system was changed to stop rorting
the "demand" for therapy miraculously evaporated. Sun fired 1000
therapists.
As the market matures competitive pressures increasingly force
compliance. The only mature health care market in the world is that
in the USA. It is no coincidence that health care fraud is now the
justice departments largest headache. The biggest and most successful
companies in each health care sector have made the largest fraud
settlements, been at the centre of allegations of poor care, or been
the focus of a public outcry. Columbia/HCA has recently reached a
record A$3 billion fraud settlement. By 1995 Tenet Healthcare had
paid over A$1 billion to settle fraud and quality of care suits. It
entered into integrity agreements and accepted court injunctions
restraining its practices. In 2003 it is again being prosecuted for
alleged fraud. Once again doctors in its hospitals are accused of
carrying out invasive procedures when they are not indicated. Share
market pressures are irresistible and repeated attempts to control
aberrant practices over 20 years have failed.
The three companies mentioned have all tried to enter the Australian
market but their US misconduct rendered them unacceptable. Proposed
international trade agreements at the Word Trade Organisation will
compromise our ability to keep dysfunctional companies out of
Australia in the future.
For more information see
http://www.uow.edu.au/~bmartin/dissent/documents/health
J Michael Wynne
