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Uncovering health care’s true challenges: beyond doctor-patient dynamics

There are frequent accusations against physicians and other health care professionals regarding their behavior and/or education: they cannot communicate, are misogynist, racist, and ageist, and are poorly educated, despite American physicians training longer than those in other developed countries. But are these complainants aiming at the most obvious, though not most significant, target? There are more pressing problems than patient-provider relationships, as serious as they are, weightier concerns that are capable of destroying an already fractured health care system. It will accomplish little if we have doctors who are wonderful communicators but lack a functional health care system within which they could function.

A few years ago, a southern state’s Republican governor commissioned a study to determine the state’s cost of expanding Medicaid. The researchers determined that the program would generate millions of dollars for the state, a finding subsequently supported by implementation in other states. However, this was contrary to the governor’s politics, and though lives, mostly Black, would have been improved or saved, the report (though leaked) was never published, and the program was never implemented. The state also has appalling maternal-infant health statistics, especially in rural and Black locales. Having primarily Black and female providers propose rural-based pre-natal clinics and birthing centers to serve these women likely would have improved morbidity and mortality. In response, the state health department promulgated a proximity regulation of a clinic to a level III hospital for “patient safety,” although many of the women never resided within this vicinity prior to the proposal, and despite that accessible care would reduce the likelihood of complications necessitating this propinquity! If the agency was genuinely concerned for patient safety and the present dismal outcomes, why does it now establish an obstructive rule? More likely, as the people to be served are of color, both the rule and limitation of expanded Medicaid are racially motivated.

Then too, public interest groups can be misguided in their attempts to help those they serve. In two instances, these organizations exerted pressure on the Food and Drug Administration (FDA) to make decisions based on “hope,” not evidence. Two organizations for patients with Amyotrophic Lateral Sclerosis lobbied the FDA to approve a medication for which preliminary research barely demonstrated a positive effect, and subsequent studies determined it was ineffective. Another specialty association touts two medications for early-stage Alzheimer’s dementia while neglecting to mention their ineffectiveness, limited patient eligibility, and serious side effects. Aside from creating “false hope,” these groups accomplished little for their membership. Increasingly hospitals, nursing homes, medical practices, etc., are not owned by those motivated by service but by individuals or organizations interested in profit.

Making money in itself is not evil, as even non-profits require sufficient cash flow to maintain operations, but when service is subjugated to wealth generation, patient care suffers. Reports on private equity-owned institutions and practices consistently reveal, on average, lower quality care than in non-profit establishments: they employ fewer and less qualified staff, experience increased staff turnover, decrease necessary treatments, perform more superfluous tests and procedures, reduce equity, and compromise patient safety. Health insurers, including Medicare Advantage (MA) plans, also demonstrate more interest in profit than payment for patient services and, when necessary, reduce benefits, increase patient monthly and co-payments, delay prior authorizations and appeals, deny necessary care, and/or reduce physician/provider income. They frequently claim to be on the edge of bankruptcy but invariably trumpet quarterly profits. One company, for a recent quarter, claimed nearly $1 billion in earnings, while other companies ballyhooed recent quarterly gains in multiple $100s of millions.

Conservative estimates of behaviors by insurance and private equity ownership cost the American taxpayer $400-$450 billion annually and unnecessary deaths. It is estimated, for example, that private-enterprise nursing homes alone, presently ±72 percent of total facilities, account for ±1,275 needless deaths yearly. Advocates for government single-payer programs have again asserted that they could be a panacea to many of our current health care problems, given a 2024 Congressional Budget Office report. These plans, it is argued, could save between $42-$743 billion, depending on the chosen model, and improve equity and outcomes. A major area of reduction could be administration. Medicare spends ≈2 percent, while MA plans average ±13.7 percent. These programs are already threatening service reductions in response to a minimal decrease in 2025 payments from Medicare, although trimming administrative costs could easily balance this payment reduction with no loss to client services. And yet, this assumption of single-payer superiority is naive, as all countries with this system are beset with problems: increasing service costs, non-equitability, reductions in basic services, lower use of advanced drugs/techniques, low professional salaries, and rife fraud.

In 2023, for example, the U.K. recovered $280.2 billion in fraudulent payments, about 50 percent of these payments. Our problem lies with our favoring a laissez-faire approach to business and only applying regulation after years of damage and public pressure. Regulatory agencies are chronically underfunded, making them unable to effectively enforce, in the present instance, existing regulations on health care insurers and for-profit ownership of health care entities. Citizens need to pressure both state and federal legislators to improve agency funding to increase enforcement. There will be significant industry opposition, and it will take time, likely years. But, if we learn from the errors of others, we will gain an improved health care system, improve equity and health, and save money.

M. Bennet Broner is a medical ethicist.


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