An ounce of compassion.
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Attitude to Health↗
Biomedical subjects
E Friedman
Publications and source records attributed to E Friedman.
The toad at the edge of the world.
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Acquired Immunodeficiency Syndrome↗
Freedom of choice.
This is the second in an occasional series of columns examining the ethics side of health-care reform. The first, "A Matter of Principle," appeared in the September/October 1992 issue.
Attitude to Health↗
A gift of trust.
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Community-Institutional Relations↗
Physicians, payers, and power. The United States is witnessing a struggle for control of healthcare.
From its earliest days, healthcare in the United States has been controlled by providers, that is, by physicians and by hospitals (which, in turn, were also usually controlled by physicians). But this situation is changing. In the 1920s and 1930s, providers created health insurance companies like Blue Cross and Blue Shield to help patients pay for healthcare--to pay, in other words, for those services offered by providers. After World War II, the Hill-Burton program covered the nation with new hospitals. In the 1960s, Medicare and Medicaid eased the healthcare burden of older Americans--and also recapitalized hospitals. Thus providers called the shots in the creation of both the delivery and the payment systems. But in the 1970s, payers began to become more powerful. Now, in the 1990s, they have joined employers in acting to contain rapidly escalating healthcare costs. But even those long disturbed by the arrogance of some healthcare providers are now asking themselves: Is this really what we wanted? Payers are governed by the market; they may well seek, not the best, but the cheapest healthcare available. This is not in the interest of either patients or physicians. A middle ground--a new power alignment--will have to be worked out by patients, physicians, payers, and government.
Delivery of Health Care↗
A sense of loss. Why do people make irrational demands for care and incomprehensible refusals of care?
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Attitude to Death↗
If you really mean it.
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Community Health Planning↗
A demanding issue.
The sudden condemnation of ¿inappropriate patient demand¿ begins to ring a little hollow when one notices how closely it is tied to changes in financial incentives.
Health Services Accessibility↗
Too much of a bad thing.
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Capitation Fee↗
Rules for a bumpy road.
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Ethics, Medical↗
A matter of value. Profits and losses in healthcare.
In the growing debate over for profit enterprise in healthcare, the real issues are ownership, conflicts of interest, profit margins, and what is done with those profits--not tax status or the presence or lack of a profit. Every healthcare sector--except hospitals--is now dominated by proprietary enterprise, and current attention is focusing on three types of entities: megasystems, systems and group practices, and for-profit HMOs. The question is, Do we indeed have a problem with the profit-related issues I have mentioned? A great deal of fog surrounds the discussion. Both the public and many healthcare people feel discomfort with the idea that healthcare is a commercial commodity. But there seems to be a certain amount of hypocrisy in how the argument has been framed; only certain for-profits are characterized as posing a threat. What we are really dealing with is a massive shift of power from one interest to another. Some not-for-profit providers' loss of money and power, however, does not mean that for-profits that gain money and power are scurrilous. Thus the debate over proprietary enterprise has been colored by extraneous concerns and hidden agendas. Nonetheless, three serious issues merit closer inspection: 1. Is the for-profit model flawed? Indeed, moral hazards certainly seem to be involved in stock holder-held entities that provide direct services to patients. 2. Is the problem making a profit or profiteering? Even if nonprofits are sometimes profiteers, the for-profits are hardly innocent. In addition to the huge sums being provided to stockholders, executives of proprietary firms often do very well indeed. 3. Do new models such as systems and HMOs pose any special problems when they are proprietary? In terms of systems, the jury is still out. Despite evidence that proprietary systems are forcing everyone to be more efficient, the question remains of who will subsidize unprofitable services like burn units and true indigent care if the system's hospitals and clinics do not provide it. When it comes to managed care, the tempting incentives to constrain access and skimp on services, combined with the requirements of for-profit enterprise, simply produce too dangerous a situation.
Attitude to Health↗
Your own kind.
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Delivery of Health Care↗