You wait weeks to finally get an appointment with your doctor, and then you don’t get a chance to discuss all your health issues. Your doctor seems attentive, but rushed. Previously, doctors were friendly and helpful, taking the time to listen to patients’ concerns and answer their questions. Now they seem to be ticking boxes and seeing patients as if they were on an assembly line. How did it happen?
The short answer is: doctors no longer work for you. They work for big companies.
Over the past few decades, health care has undergone a radical transformation. “When we look at data on the health care system as a whole, we see very rapid consolidation,” says Jane Zhu, MD, a researcher at Oregon Health & Science University who studies this aspect of health care. Companies buy hospital systems, nursing homes, medical practices and pharmacies. According to a 2021 report from the Physicians Advocacy Institute, nearly three-quarters of American physicians are employed by hospitals or other businesses. The people who run these behemoths are not doctors. The backgrounds of most healthcare company board members are largely in finance and business, not medicine. Even nonprofits operate more like corporations than public service organizations. In health care, “the distinction between for-profit and not-for-profit has become blurred as health care organizations compete and compete for market share,” says Thomas G. Cooney , MD, professor of medicine at Oregon Health & Sciences University and chairman of the board of trustees of the American College of Physicians.
Another driver of consolidation is private equity, or “consolidation on steroids,” as Zhu puts it. Private equity firms buy existing healthcare businesses to make them as profitable as possible with the goal of reselling them for a profit within about 5 years.
At first glance, corporate health care doesn’t seem like a bad idea. Having business people at the helm could make the whole business more efficient. In other words, running medicine like you run any other business could in theory improve health care.
But that’s not what happened. Instead, after years of increasingly corporatized medicine, we have higher costs, deeper medical debtmore bankruptcies – and worse health care.
According to a report published in January by the Commonwealth Fund, the United States spends more than any other high-income country on health care, but it is the only such country without universal health care. But all that money isn’t buying top-notch health care for Americans. The United States has the lowest life expectancy at birth, the highest death rates for preventable or treatable diseases, and the highest maternal and child mortality among high-income countries.
Meanwhile, paying for this substandard health care is getting harder and harder. Health expenditure represented 5% of US GDP in 1960. In 2020 it was nearly 20%. According to a report by the Kaiser Family Foundation, 100 million Americans are struggling with health care debt.
What went wrong?
The purpose of medicine is to cure patients. The purpose of a business is to make profit. When these goals conflict, the patient should come first, but this is not always what happens. “The fundamental concern with corporate involvement in healthcare is that there is a risk of prioritizing profits above all else,” Zhu says. In fact, in this business model, it’s practically unavoidable. Those who run an investor-owned business are responsible for ensuring that their investors make a profit.
“The grip of self-interest on health care in the United States is becoming a vice, with dangerous and widespread consequences,” wrote Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services and former CEO. from the Institute for Healthcare Improvement. in a January editorial in the Journal of the American Medical Association (JAMA).
These “dangerous and pervasive consequences” can be seen throughout the health care system. For example, a quarter of US emergency rooms are run by staffing firms owned by private equity groups. In keeping with the goal of making as much profit as possible, these companies often reduced the number of doctors on staff, resulting in longer wait times for patients and less time with doctors. Research by Zhu and his colleagues found that gastroenterology, dermatology and eye care practices that had been acquired by private equity firms see more patients and charge more for visits than physician-owned clinics.
In the push for productivity and therefore higher profits, doctors are pushed to see more patients per day, Cooney says, thereby reducing the time and attention a doctor has for each patient. This means that a doctor may not be able to fully address all of the issues a patient wishes to address during a given visit. It also means that health issues that might be less serious if caught early can be ignored until it’s too late. diabetes can be forgotten until it’s time to amputate a foot. “Physicians are the most expensive part of the equation for these companies,” says Robert McNamara, MD, professor and chair of emergency medicine at Temple University. “You’re going to maximize this resource by making them work as hard as possible.” This pressure to rush and balance the demands of business management with the demands of the profession has led to a crisis of Burnout among health care providers.
Physicians also face other pressures. McNamara recently published a study on the working conditions of emergency physicians. Doctors interviewed for the study report being pressured to admit patients who could be treated on an outpatient basis (but to send Medicare patients home if their insurance does not cover admission), to order more lab tests and imaging than is clinically necessary, and to discharge or transfer uninsured patients.
In addition, this model of health care can harm the relationship between physicians and their patients. When patients visit their doctor for a health problem, they depend on these doctors, who have years of training and experience, to advise them on what tests or imaging they might need, what medications to take and the risks and benefits of various treatments. “They believe that the physician makes these judgments considering the best interests of the patient, and not the interests of financial entities or any other third party,” Cooney says. Corporate medicine erodes that trust.
Until recently, most physicians still worked in private practice. NOW, almost 70% of doctors in the United States work for companies and hospitals.
While patients are just beginning to discover the juggernaut behind their health care, doctors are staring it in the face every day. But talking can be dangerous. Salaried doctors often work under contracts that allow them to be fired at will without due process. Many reasonably fear that speaking out will cost them their jobs. In January 2017, Raymond Brovont, MD, an emergency physician from Missouri, was fired by EmCare, an ER staffing company, after raising safety concerns about the level of staffing at pediatric ERs.
This is a huge problem for doctors whose job, as McNamara points out, “is to do no harm, to put the best interests of the patient first.”
Nevertheless, the doctors speak up. One place where they talk is in court.
Thirty-three states plus the District of Columbia have some type of restriction on practicing medicine in the workplace. The idea behind these regulations is “to ensure that commercial interests cannot interfere with the doctor-patient relationship, that the doctor who swears to do what is best for the patient is the one who makes the decisions that could affect the care of the patient, not someone from Wall Street,” says McNamara. But companies have figured out how to circumvent these regulations.
The American Academy of Emergency Medicine Physician Group (AAEM-PG) sued Envision Healthcare, a private physician recruitment company, for violating California laws prohibiting non-physician-owned practices. Similar lawsuits are underway in other states. “By getting court rulings, we’re looking to set a precedent, which will then shake up the industry,” said McNamara, chief medical officer of the AAEM-PG. But he acknowledges that the approach is long and costly.
Meanwhile, physicians are increasingly turning to collective bargaining as the best way to protect themselves and their patients. Fairer contracts and the ability to advocate for patients without fear of losing their jobs would not only protect doctors but also their patients. According to the American Medical Association, in 2019 nearly 70,000 American doctors were unionized, a 26% increase since 2014. New doctors seem even more enthusiastic. The Interns and Residents Committee, a union representing medical residents, has grown from 17,000 to 24,000 members since 2020.
Ultimately, however, the solution may lie with the public.
The No Surprises Act, a federal law that protects patients from unexpected bills for out-of-network care, took effect in 2022. It’s a direct result of citizen organizing at the local level, he says. Industry lobbied against it, but Congress listened to people. “Getting excited can absolutely change things,” McNamara says.
“We are not going to fix [health care] if we continue to move in the direction of commodification,” says Cooney. “We need a coherent, rational and appropriately funded health system.” Exactly what that would look like is a question yet to be debated, but there are plenty of examples to draw from. Cooney suggests that for inspiration, the United States should look to European models, where health care is cheaper and outcomes are better. For many Americans, the main point of comparison with the American healthcare system is the UK’s National Health Service, which runs many of the country’s hospitals. But Robert Derlet, MD, professor emeritus at the University of California Davis School of Medicine and author of Societing American Health Care: How We Lost Our Health System, instead points to countries with lesser-known systems – such as the Netherlands, whose public-private approach is “not as rigid as in England”. To control drug costs, committees made up of doctors, pharmacists and health insurers negotiate maximum prices and, as Derlet points out, “provide half-price health care in the United States.”
“Do you want company medicine? Where is a CEO’s goal to make money with you? asks Derlet. “Or do you want a socialized system, where the goal is to help you?”