The Marriage of Authority-based Medicine
and Investor-owned Corporate Medicine
Authority-based Medicine:
The practice of medicine in the US is an authority-based profession. Its legal and practical configuration has not changed since medical licensing laws were first passed in the 19th century. It is the only health profession one to enjoy “unlimited” licensure, with a legal scope of practice that includes “all mental and physical conditions”. Instead of being governed through legislature or a national set of scientific principles, all medical decisions are made by members of the profession.
Authority-based medicine rests on the principle that only a medical doctor is qualified to decide health-related issues of care and treatment. Only those who have satisfactorily completed a standardized medical training can qualify for licensure and only licensed MDs can legally make a diagnosis for a particular patient, determine which tests are appropriate, prescribe drugs, order x-rays, and penetrate or sever human tissue (i.e., surgery). Doctors stand at the top of the chain of command — they give orders, other carry them out.
Evidence-based Practice:
It is widely assumed that all aspects of medicine are “evidence-based”, that is, every action of every MD represents the “best practice” as defined by the scientific research. In an age with instant access to scientific data via the Internet, it comes as a surprise to find out that this is not the case.
Unfortunately, evidence-based medicine is actually much more limited than most people realize. The bulk of medical research is very narrowly focused – a particular cholesterol-lowering drug will be contrasted to one made by a different company or given in a different dose, or a new surgical technique will be contrasted to an older form of surgery. This kind of research compares a few similar drugs or treatments against each other, and then provides a scientific opinion as to which of the small number of options is the evidenced-based or ‘best’ choice among that particular (and limited) palette.
Mostly this research does not factor in cost-effectiveness. A large number of the original studies in the meta-analysis that constitutes the ‘evidence’ used for EBM recommendations were actually paid for by drug companies or other special interest groups.
This may explain why researchers generally don’t compare conventional medicine to non-allopathic methods of care or pursue studies that compare a particular medical treatment for a specific condition to non-treatment for that condition. There is no money to be made in therapeutic methods that do not directly relate to a conventional product or professional service, so the idea of EBM breaks down when it come to overarching models of practice.
The difference between authority-based medicine and evidence-based practice:
Evidence-based science informs a physician’s choice between two different drugs, while authority-based medicine grants him or her the right to decide whether to or not prescribe drugs and once a drug is chosen, how much of it to give and how long it should be taken.
Physician Preference – the decider of all things medical
Unlimited Licensure for All MDs, Limited licensure for all non-MD practitioners:
By design the unlimited status of licensure as an MD grants physicians the unmitigated authority to control over every facet of a patient’s care in the same way that parental authority grants parents control over their minor children.
Based on preference or ‘style’ of practice, a physician decides whether or not to hospitalize a patient and can order as many tests as he wants, prescribe drugs or perform procedures. Only another MD can legally judge the ‘appropriateness’ of a doctor’s medical choices and most MDs shy away from “second-guessing” another doctor’s medical decisions. On those rare occasions when doctors do criticize a colleague, it is usually for his or her failure to make more extensive use of medical interventions.
In the medical-legal arena, authority-based medicine means that determinations of malpractice — substandard care, negligence, or incompetence — are always and only the “expert opinion” of a physician hired as an expert witness. In theory at least, it is assumed that his testimony reflects the collective opinion (i.e. standard of care) of that state’s “community of physicians”. Nonetheless, standard of care is the numerical ‘standard’ of what is typically done. It is informed by, but not defined by, medical textbooks and policy statements by medical associations and specialty groups.
A doctor’s individual authority also applies to economic-legal opinions relative to workmen’s comp, determinations of disability for purposes of insurance or pensions, mental competence to manage one’s affairs, insanity, and legal cause of death (natural vs. the crime of homicide).
The only person in the United States who has the authority (i.e., standing in court) to challenge the medical opinion or legal determination of an MD is another MD – no one else, not even a US senator, Supreme Court justice or the President, can trump the legal opinion of a medical doctor. This give rise to that familiar courtroom scene where the attorney for one side belittles the non-physician witness for the other side by snarling “Oh yea, and just where did YOU go to medical school?”
The lack of transparency inherent in authority-based medicine institutionalizes medical decision-making as an encrypted black box to which only MDs have the key or can claim to understand its insider code. Within the traditional bounds of a specific disease diagnosis or health-related situation (heart attack, diabetes, normal labor, etc), physicians are authorized to do as they see fit, much like an artist decides what colors to use.
The impetus for ordering a battery of tests or performing a procedure can be anything from the most trivial personal convenience to a realistic fear of litigation and everything in between, including the highest level of concern for EBM and risk-benefit ratio. It can also reflect written or unwritten rules of an investor-owned facility that have made increased use of profit-making procedures the preferred ‘standard’ and if not followed, will cause the doctor to be disfavored by the administration or his peers.
When the physician is an investor in the facility or the technology, it is to his financial advantage to make sure that all the beds are filled, all technological equipment is in use and each department has lots of work to do. This may be a shocking thought, but statistics confirm the downside of the ‘ownership society’ when physicians own a piece of the economic action of a for-profit healthcare system.
In combination with 20th century deregulation and privatization of hospitals, 19th century authority-based medicine is the engine that drives our 21st century form of corporate medicine. As the deciders of all things medical, physician preference remains the lynch pin to wealth-producing medical goods and services, with price tags that run from a few dollars for a bedside water pitcher to a $100,000 for a single treatment in a building-sized MRI.
All economic activity traces back to the physician’s uncontested authority to dictate the choice of what is done and how many times it is repeated — lab tests, diagnostic procedures, drugs, medical devices, admission to ICU — and the oceans of specialized (and inordinately expensive) medical supplies. This includes IV tubing, catheters, suction machines, needles, disposable bedpans and the like. Each product represents a sale to the manufacturer and, after mark-up, a profit to the institution; the more things used or things done, the more the business of medicine thrives.
Business Model of Success:
When this scenario is carried out many times a day by a half million MDs, the result is a construction boom — more hospitals and outpatient facilities are built, more expensive machines are purchased and more people are hired to run them. The Bureau of Labor Statistics estimates a 22% increase in health care employment in the next decade.
This expansive commercial model, if judged solely by business criteria, is a success story beyond our widest dreams – that $1.2 trillion identified by Price-Waterhouse-Coopers as wasted every year is pure profit for somebody.
However, if the goal is an efficient, effective, affordable, fair and accessible health care system, the distorting effect of authority-based medicine, deregulation, and privatization must be called into question. This double whammy has given us a corporate model of medical practice that rests on the (recently discredited) idea that whatever is good for stockholders is automatically good for all the rest of us, including ill, injured and elderly patients and the taxpayers who pay the bill.
Stockholder conflict between doctors, hospital and health insurance companies
There is a built-in conflict between what is profitable for doctors and hospitals versus what is good for the stockholders of health insurance companies. The unlimited authority of MD licensure permits physicians, at their preference, to control all aspects of health care including the unlimited expenditure of the patient (or his insurance company’s) money on testing and drugs. This is immensely profitable for hospitals, private service providers and many others, but not for the insurance companies that have to pay the bills.
Where health insurance companies are king, pre-authorization is queen:
Health insurance companies were so frustrated by their inability to restrain physician-initiated spending that they developed a series of strategies to legally reduce their financial liability. While they can’t exert direct control over the tests or other medical procedure order by a physician, insurance companies did an end-run around the problem. It was called “pre-authorization” for insurance reimbursement. Physicians can still order whatever they want, and patients can still have the expensive testing and procedures performed, but the health insurance company don’t have to pay unless the doctor’s office first call to get a pre-approval.
Functionally speaking, this moved the unlimited power of MDs to order tests to the unlimited power of health insurance company CEOs, who can refuse reimbursement. In most cases this effectively stops the patient from have that test or treatment. Since the insurance company has already collected the patient’s premiums before he or she is turned down, the insurance company keep more of the money when they say “NO” to health services more often. This is in sharp contrast to the financial interests of physicians and institutions, who lose money when treatment is withheld.
The Art of Medicine – the right place for physician preference:
As grim as the above facts are, no one should go away thinking that physician authority is bad or wrong per se. These professional qualities and skills are also known as ‘clinical judgment’ and represent the ‘art’ of medicine. There are many times and places when the art of medicine is the perfect answer – in particular, places where science has never been or where it has nothing to offer. Sometimes simplicity and common sense make a one-of-a-kind response the right answer for that person at that time.
In the late 19th century, the general category of medical practice was collectively known as the “healing arts”; many state medical practice acts still have the words “Healing Arts” in their title. Clinicians often think the art of medicine is the best part of their job. It means having the skill and courage to step outside the box, to be innovative, use intuition, do detective work and by arriving at conclusions that runs counter to conventional wisdom or customary practices, to hitting a home run for the patient. Viva la difference!
The ethics of confusing art with science:
The concept of ‘physician preference’ only becomes an ethical and economic problem when it is hidden or unacknowledged, when art and science are conflated (no distinction is make between the two) or when the art of medicine is substituted for the science of medicine. Under those conditions, it is disingenuous at best and often dangerous to the many patients who get under- or over-treated because physician preference is being used as a tool to increase personal or corporate profit, thus turning professionalism into commercialism.
Trends in the physician workforce:
Between 1970 and 2000, the average number of potential patients available to the medical profession was reduced from 641 people per physician to 373 per physician. This was due to a large increase in new doctors in the decades following the Health Professions Education Assistance Act of 1963, which dramatically increased the number of medical schools in the United States.
Between 1960 and 1988, the number of first-year students in US medical schools more than doubled. While it was obvious that the number of new graduates would lead to an oversupply of physicians, no medical schools were willing to give up federal dollars by closing or significantly reducing their class sizes. During that period, new physicians entered the workforce at three times the rate that older physicians left practice.
[Ref #26 -“Physician characteristics and distribution in the US”; 2000 edition Chicago American Medical Association 2000, page 352
Defending professional turf:
The explosive growth in the supply of physicians during the 1970s and 1980s was not offset by an aging population or greater use of sophisticated medical technology. With such a prolonged oversupply of medical doctors, organized medicine (OM) became even more aggressive in protecting itself against competition from non-physician practitioners and alternative health care professions.
In the last few years, the previous oversupply of MDs has been reversed by the mass retirement of physicians from the baby-boomer generation, leaving a hole that is not matched the number of med students in the educational pipeline.
This disparity in supply and demand is so daunting that many states are wondering how they will be able to provide primary care to vulnerable populations, especially the poor and those living in rural areas or inner cities. More than three-quarters of all new graduates go into the specially practice of medicine, leaving less than 25% of all physicians to provide primary care. Primary care emphasizes first contact care, continuity of care, comprehensive care, and coordinated care.
The Numbers ~ Everyday Non-urgent Health Care:
Approximately 90% of all medical appointments are for non-acute healthcare. This category includes “self-limiting conditions” i.e., temporary situations that resolve spontaneously. By definition, self-limiting conditions do not need or benefit from sophisticated medical technology, prescription drugs or surgery.
The illustration often used is that a cold, if untreated, will go away in seven days; if treated, it will go away in one week. Ordinary, garden-variety complaints include mild illness or minor injury, psychological states such as anxiety or mild depression, normal biological conditions such as pregnancy, breastfeeding, newborn follow-up, well-woman care (contraception, pap smear), normal aspects of aging, life-style issues (diet, exercise and questions about sexual topics), school and work physicals, vaccinations, testing for STDs, managing a stable chronic disease, etc.
Challenging Chokepoint Medicine: In the early 1900s, primary care was provided by a mixture of MDs, non-allopathic physicians (osteopathic, naturopathic and eclectic doctors) and non-physician practitioners (including midwives). Organized medicine chose to do away with the traditional multi-discipline form of health care and replace it with an exclusively medical model that was purposefully configured to have a chokepoint.
The decision to get rid of non-allopathic physicians and non-physician practitioners occurred without any prior scientific research and without making any distinction between ambulatory care — non-urgent care for everyday self-limiting conditions such as ear aches, sore throats or counseling about following a diabetic diet — and acute or urgent medical interventions for serious and acute problems.
Chokepoint medicine means that every non-urgent patient must first go thru the eye of a needle to see and be seen by a medical doctor before any other aspect of the healthcare system can be accessed. The big question is whether 9 to 13 years of medical school training in life-threatening medical emergencies and the use of prescription drugs and surgery is actually the most appropriate way to provide safe and cost-effective for every headache, earache, sniffles, sore throat, tummy ache, backache, athletes foot, trouble sleeping, normal pregnancy, healthy child and all the other non-urgent and self-limiting conditions that fill up a physician’s waiting room every day? Can this possibly be rewarding way for a highly-trained medical doctor to spend his (or her) time?
Time vs. money:
These health concerns are not medically complicated, but can be time consuming and certainly take more than the 6 to 10 minutes allotted for the typical non-urgent medical or OB appointment.
What people seeking non-urgent health care want and need is a relationship with an unhurried primary-care practitioner who is able and willing to be empathetically present, to listen, talk, ask questions, sympathize, make suggestions, and spend whatever time it takes to educate the patient (or parents) about how best to manage their health.
Not enough of both to go around:
By 2025 the growing US population, which includes children and increased proportion of elderly people, is expected to raise the number of ambulatory care visits by 42 %. The number of patients with chronic diseases – a category who benefit most from the coordination of care and continuity of care — is also increasing. [Am Coll Physicians – White Pager 2008]. By reducing rate of obesity, diabetes, osteoporosis and many other chronic and expensive diseases thru high-quality primary care, it eliminates the great volume of expensive and invasive procedures currently driving up the cost of health-related services.
Institutionalized Mismatch: According to Dr. Atul Grover, chief lobbyist for the Association of American Medical Colleges (an arm of the AMA), the answer is a 30% increase in medical school enrollments, to produce 5,000 additional new doctors each year.
However, this still misses the point, which is the extreme mismatch between what patients need and want from primary care providers, what society needs from them and what graduate doctors themselves need and want from the practice of medicine. From a patient’s perspective, it must be nearly impossible to get cost-effective services for routine low-tech care from a physician who is trying to pay off an average of $140,000 in med school loans and simultaneously meet staff payroll, office overhead and malpractice insurance premiums.
There is already one MD for every 373 people in the US. The number of doctors who report giving up primary practice because they couldn’t make enough money to stay in business is both eye-opening and distressing – primary practice by MDs is a failed economic model, does not work.
Un-choked, unhurried primary care:
Time and relationship-intensive non-urgent care is most satisfactorily provided by non-physician primary care practitioners – physician assistants, nurse practitioners, professional midwives, naturopaths. This is where preventative medicine actually starts; it is also how the routine overuse of Rx drugs and procedures is stopped.
A consensus of the scientific literature identifies primary health care by independently practicing non-physician practitioners to be comparatively safe, more cost-effective than MD care and to have a high patient-satisfaction rating. Currently there are about 140,000 non-physician practitioners practicing in the US. In event of a serious or urgent medical situation or request by the patient, non-physician primary care practitioners arranged for referral, consultation or a transfer of care to an MD or emergency facility.
Concurrent Reform in Medical Education:
Incorporating non-physician practitioners into a health care must includes change in the way all we educate MDs and non-physician primary care practitioners. We need a broad-based multi-disciplinary approach, instead of the current system that teaches students of each health care discipline in total isolation from one another. Students of medicine, nursing, midwifery, physician associates, naturopathy, etc never even met each other during their training.
At the most basic level, the body of scientific knowledge for bio-medicine includes the same course work for all primary care providers – anatomy and physiology, microbiology, taking and interpreting patient history, the logical steps of systems review and physical examination and fundamental treatment of minor problems and self-limiting conditions.
If all med students and all non-physician practitioners (students of nursing, midwifery, physician assistants, etc) sat in chairs in same room, studied same curriculum, learned from the same teacher at the same time, it would have two every important contributions to the health care system. First, it would teach every physician-to-be how to function as a primary care provider before exposing them to the more complex world of specialty medicine. For instance, med students would learn how to mange normal childbirth using the principles of physiological management before learning the standard obstetrical intervention of medically managed childbirth.
Secondly it would forge collegial bonds between these different disciplines of health care providers that will last a lifetime. The result would be a cooperative and complimentary professional relationship between those students who continue on to become MDs and those that have chosen to become non-physician practitioners.
Without this change in how we think about primary care and how we train physician and non-physician practitioners who provide primary care, we will stay stuck in the same 19th century thinking that has distorted the entire health care system for a century and continues to prevent the self-correction of these problems.
Non-physician primary care providers a threat to Organized Medicine:
Three years ago the AMA launched an aggressive campaign to further restrict the legal ability of non-physician practitioners to provide primary care. Non-physician practitioners who exercise critical judgment similar to physicians include pharmacists, podiatrists, optometrists, physician assistants, nurse practitioners, nurse anesthetists and professional midwives.
However, the AMA’s policy opposes anything that: “alters the traditional pattern of practice in which the physician directs and supervises the care”.
In particular, the AMA targeted the area of reimbursement, passing policy resolutions to prohibit physician assistants, nurse practitioners and other non-physician primary caregivers from being directly reimbursed by government programs such as Medicare and Medicaid. What that means is that MDs can continue to bill and get reimbursed at MD rates for care provided by the salaried non-physician practitioners in their employ.
The AMA and its role in the Scope of Practice Partnership: In November 2005 the AMA created the Scope of Practice Partnership (SOPP), which is a coalition comprised of itself and the Federation of State Medical Boards, plus six national medical specialty societies and six state medical associations — the California Medical Association, Colorado Medical Society, Maine Medical Association, Massachusetts Medical Society, New Mexico Medical Society, and Texas Medical Association.
The Scope of Practice Partnership characterizes all non-physician practitioners as ‘physician extenders’. The phrase “physician extender” perfectly conveys its MD-centric perspective, one that sees the proper role of other health care professionals as supporting and carrying out the orders of the medical profession.
Physicians profits from the labors of non-physician practitioners in their employ by billing a third party at MD rates. Licensing laws in 28 states already reflect this MD-centric philosophy by legally restricting non-physician practitioners to the subordinate status of a physician-extender, thus prohibiting any form of independent practice or reimbursement.
According to statements published by its Steering Committee, the SOPP intends to use its political, financial and legal resources to turn back the clock and sweep back the ocean – or as they put it, to end the illegal practice of medicine by non-physician practitioners.
In the 22 states and District of Columbia that already license non-physician practitioners as independent professionals, SOPP members plan to introduce legislation to repeal these laws. In the 28 states that have restrictive laws on the books already, the SOPP will vigorously fight any effort by nurse practitioners and other non-physician practitioners (NPP) to lift these restrictions.
At the national level, SOPP members are working to get federal legislation passed which will permanently block direct reimbursement of NPP. Last but not least is a strategic plan to elect or appoint physicians sympathetic to SOPP’s policies to state medial boards and subsequently force all non-physicians practitioners under the control of the medical board in each state.
The SOPP wants to put a stop to the regulation of nurse practitioners, midwives, pharmacists, naturopaths, chiropractors, etc, by their own professional boards. This is based on the notion that other boards are illegally authorizing their licentiates to practice of medicine without a license, thus depriving the medical profession of its legitimate income.
So far, the AMA has maintained an iron grip on its MD-centric system for the last hundred years. The Association’s SOPP is continues to fixate on eliminating alternative forms of health care and the independent practice of non-physician practitioners, which also means that the hub of the health care wheel – high-quality primary care – will continue to be disabled.
How organized medicine developed its iron grip:
The tap root of our medicalized health care system traces directly back to the lack of a scientific foundation for the medicalized system of health care designed by the AMA in 1904. Influential leaders in medical politics knew their plans to close half of all medical schools and make medical care exclusive allopathic were motivated by a political and economical agenda, not science.
At the time a glut of medical practitioners was driving down the average income of an MD to little more than the weekly wage of a mechanic. However the AMA, together with the Carnegie Foundation’s Bulletin #4 (“Flexner Report”), promoted their activities as simply a public safety campaign designed to modernize medical education and make medical care “scientific”.
Politics masquerading as science:
The public and other professionals assumed that the AMA used a scientific method of evaluation (statistical research and comparative studies) to determine the evidenced-based or ‘best practices’ model of health care: would it be multi-discipline or exclusively allopathic, MD-only care? Or would it be a cooperative and complementary model of MDs, non-allopathic physicians and non-physician practitioners, with the type of treatment and category of practitioner determined by the kind of care the patient required or requested? As we know only to well, no rational process was used in 1910, nor has one been applied in the 99 intervening years.
The uncritical acceptance of an unscientific premise:
Without understanding the long-term implications, states began adopting the exclusively allopathic, MD-centric model in 1910. The most immediate consequence of these policies was to eliminate women and minorities from the mainstream practice of medicine and dismantle and eventually discard the multi-discipline tradition of healthcare.
For instance, in 1909 California had a multi-discipline Board of Medical Examiners with 11-members — 5 MDs and 6 non-allopathic physicians. In 1911, the Medical Practice Act was amended to eliminate all 6 non-allopaths and replace them with a 12-member all-MD medical board, which is still in place today.
This same MD-centric, authority-based model provided the platform and push-off point for an exploitive form of corporate medicine that has doubled our troubles with the extremes of non-treatment and over-treatment, excessive cost and increased mortality. Too long medical politics has masqueraded as medical science and corporate politics has triumph over fiscal responsibility.
As we rightly credit medical science with saving lives, so we must discredit medical politics for costing lives.
On to Part 4 —
