Who does your doctor work for?

You wait weeks to finally make an appointment with your doctor – and then you don’t have the opportunity to discuss all your health problems. Her doctor seems caring, but in a hurry. Doctors used to be friendly and helpful, taking the time to listen to patients’ concerns and answer their questions. Now they seem to be checking off boxes and seeing patients as if they were on an assembly line. How did it happen?

The short answer: the doctors no longer work for you. They work for big companies.

In recent decades, healthcare has undergone a radical transformation. “When we look at the data for the health care system as a whole, we see a really rapid consolidation,” says Jane Zhu, MD, a researcher at Oregon Health & Science University who studies this aspect of health care. Companies are buying up hospital systems, nursing homes, doctors’ offices and pharmacies. According to the Physicians Advocacy Institute’s 2021 report, nearly three-quarters of American physicians are employed by hospitals or other companies. The people who run these places are not doctors. The backgrounds of most healthcare company board members come largely from finance and business rather than medicine. Even nonprofit organizations operate more like corporations than public service organizations. In healthcare: “The distinction between for-profit and not-for-profit has blurred as healthcare organizations compete and vie for market share,” says Thomas G. Cooney, MD, professor of medicine at Oregon Health & Medical University. University of Science and President of the American College of Physicians’ Board of Regents.

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 selling them at a profit within 5 years.

At first glance, corporate healthcare doesn’t seem like a bad idea. Having business people at the helm can make the whole business more efficient. In other words, if you run medicine like any other business, you can conceivably make health care better.

But that’s not what happened. Instead, we did it after years of increasingly corporate medicine higher costs, deeper medical debtmore bankruptcy – and worse health care.

According to the report The United States spends more on health care than any other high-income country, yet it is the only country without universal health care, the Commonwealth Fund said in a statement released this January. But all that money is not going to buy the best health for Americans. The United States has the lowest life expectancy at birth, the highest death rate from preventable or treatable conditions, and the highest maternal and infant mortality among high-income countries.

Meanwhile, paying for this substandard health care is becoming more and more difficult. Medical expenses were accounted for 5% of US GDP in 1960. In 2020, it was almost 20%. According to the report by the Kaiser Family Foundation, 100 million Americans struggle with health care debt.

What went wrong?

The goal of medicine is to care for patients. The purpose of the business is to make a profit. When these goals collide, the patient should come first—but that doesn’t always happen. “The fundamental concern with corporate health care is the risk of putting profit above all else,” says Zhu. In fact, it’s all inevitable in this business model. Those who run an investor-owned business are responsible for making a profit for their investors.

“The stranglehold of financial self-interest on US health care is becoming a stranglehold, with dangerous and pervasive consequences,” wrote Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services and former director of the Institute for Healthcare Improvement. the January editorial in 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 emergency rooms in the United States are managed by staffing firms owned by private equity groups. In order to maximize profits, these companies often reduce the number of doctors, resulting in longer wait times for patients and less time spent with doctors. Research by Zhu et al found that gastroenterology, dermatology and ophthalmology practices acquired by private equity firms see more patients and bill more for visits than physician-owned clinics.

According to Cooney, in order to achieve productivity and thus higher profits, doctors are forced to see more patients each day, reducing the time and attention doctors can devote to each patient. This means that the doctor may not be able to fully address all of the problems that the patient wants to solve in a given visit. It also means that health problems, which are less serious if detected early, can be overlooked until it is too late; diabetes can be missed until it is time to amputate the leg. “Physicians are the most expensive part of the equation for these companies,” says Robert McNamara, MD, professor and chief of emergency medicine at Temple University. “Maximize this resource by working as hard as you can.” The pressure to rush and balance the demands of corporate leadership with the demands of the profession led to a crisis. burn out between healthcare providers.

If patients are just beginning to learn about the behemoth behind their healthcare, doctors are staring it in the face every day. But talking can be dangerous. Employed physicians often work under contracts that allow them to be fired at will without due process. Many people rightly fear that speaking out could cost them their jobs. In January 2017, Raymond Brovont, MD, was an emergency physician in Missouri kicked out EmCare, an emergency staffing company, after raising safety concerns about pediatric emergency staffing.

This poses a huge problem for doctors, whose job, as McNamara points out, is “to do no harm, but to put the patient’s interests first.”

Still, doctors are speaking out. One place where they talk is the court.

Thirty-three states and the District of Columbia have some restrictions on corporate practice of medicine. The idea behind this regulation is to “make sure that business interests do not interfere with the doctor-patient relationship, that the doctor who swears to do what is best for the patient makes the decisions that which may affect patient care. not someone from Wall Street,” McNamara explains. But companies have figured out how to get around these rules.

Ultimately, however, the solution may lie in the hands of the public.

The No Surprises Act, the federal law that protects patients from unexpected bills for out-of-network care, took effect in 2022. This is a direct result of grassroots citizen organizing, he says. Industry lobbied against it, but Congress listened to the people. “Getting angry can make an absolute difference,” says McNamara.

“We’re not going to fix it [health care] if we continue to move toward commoditization,” says Cooney. “We need a coherent, rational, adequately funded healthcare system.” Exactly what this would look like is up for debate, but there are plenty of examples to learn from. For inspiration, Cooney suggests, 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 US healthcare system is the UK’s National Health Service, which runs many of the country’s hospitals. But Robert Derlet, MD, is a professor emeritus at the University of California, Davis School of Medicine and the author The Socialization of American Health Care: How We Lost Our Health Care System, instead pointing to countries with lesser-known systems – such as the Netherlands, where the public-private approach is “not as rigid as in England”. To keep drug costs under control, committees of doctors, pharmacists and health insurers negotiate maximum prices and, as Derlet points out, “provide health care at half the price in the United States.”

“Do you want corporate medicine? Where does one CEO aim to make money? Derlet asks. – Or do you want a socialized system where the goal is to help?