Recently, the New England Journal of Medicine (NEJM) published the following article: Cents and Sensitivity–Teaching Physicians to Think about Costs. http://www.nejm.org/doi/full/10.1056/NEJMp1205634 Please take a few minutes to read this article. You may not understand the medical lingo, but the message is clear enough.
I wrote the following letter to the editor regarding this article, which the editor politely declined:
Cents and Sensitivity—Teaching Physicians to Think about Costs by Drs. Rosenbaum and Lamas is Socialized Medicine. Bringing dollars to mind while working up a patient conflicts the work-up. A doctor trying to save money is just as conflicted as a doctor doing procedures solely because he/she profits from them.
Costs are out of control largely because of greed:
- Multi-billion dollar insurance companies, whose sole function is clerical administration of payment of the bill,
- Thousands of not-for-profit hospitals, which garner hundreds of millions of dollars in revenue; pay administrators salaries of $500,000 to $1,000,000/year or more; and do not understand their own billing, have become independent business fiefdoms,
- Drug & Technology Companies,
- Lobbying politicians at state and federal levels,
- Malpractice lawsuits.
Capitalism and profit making are the essence of American culture. When capitalism becomes unbridled allowing open-ended greed to endanger the doctor—patient relationship, it’s time to bring the business of medicine under control, while concomitantly ensuring its negotiated profitability, not to scapegoat the doctor—patient relationship.
R. Garth Kirkwood, MD
 Uwe E. Reinhardt, “The Pricing of U.S. Hospital Services: Chaos Behind a Veil of Secrecy,” Health Affairs, 25, no.1 (2006): 57-69 http://content.healthaffairs.org/content/25/1/57.full.html
The editor’s response to my letter:
Dear Dr. Kirkwood,
I am sorry that we will not be able to print your recent letter to the editor regarding the Rosenbaum article of 12-Jul-2012. The space available for correspondence is very limited, and we must use our judgment to present a representative selection of the material received. Many worthwhile communications must be declined for lack of space.
Thank you for your interest in the Journal.
I question, Why did they not publish my letter? It is correct information. Surely what they suggest is socialized medicine, not the economic definition of that term but rather the end result of that type of healthcare system: The payer, public or private, interfering with non-conflicted clinical decision making within individual doctor patient relationships. They would make the doctor a vicarious administrator for 3rd party payers, which results in the following message to the patient: That test or therapy is just too expensive to use for your individual case. The clinical thinking of the doctor becomes conflicted with the dollar bill. This is exactly what formally socialized systems do either directly or indirectly. But here, the doctor becomes a substitute for the payer, which accomplishes that agenda.
The second part of my letter is also correct. For true healthcare reform, it is necessary to challenge all the mechanisms of greed embedded in the business of medicine and to recognize that scapegoating the doctor patient relationship is not the answer.
So, why didn’t they publish my letter?
In the following paragraphs, I am going to dissect this article a little more to show how these authors use rhetoric, which I think is misleading, to accomplish this new way of operating for the doctor patient relationship. I will italicize statements from the article and then respond to them in regular text. You should pay close attention to make sure that I have correctly transcribed the authors’ statements and that I have not taken them out of context.
First: Good care, we believe, cannot be codified in dollar signs. But with health care costs threatening to bankrupt our country, the financial implications of medical decision making have become part of the national conversation. This is true. But who is making this part of the national conversation? The answer is the 3rd party payers and their co-opted politicians from both political parties, under the guise of the noble rhetoric, reducing healthcare spending. These authors suggest that now individual doctor patient relationships should be co-opted by this business thinking. It is wrong, a thousand times over. When you start this modus operandi, the accumulation of medical information and knowledge for that individual patient becomes obstructed by the dollar bill.
Second: The fact that we can no longer ignore the financial implications of our decisions leaves the medical profession in a quandary. The operative word in this sentence is our. These decisions are not ours in the context that the authors employ this word. They belong to individual doctors and individual patients in the context of that unique, individual relationship. If you really want $$$$ to be part of that decision making, then delete the entire 3rd party payer system and tell individual patients that they will have to be first party payers. That’s the only way that financial considerations can be introduced into the doctor patient relationship without conflicting the doctors’ clinical decision making. The patients would decide whether the expense is worth it. Why do we need 3rd party payers? This would greatly reduce annual healthcare spending because many patients would have to take out loans to pay the bill or forego the clinical evaluation. Nevertheless, annual healthcare spending would be greatly reduced. Such a noble end!
Third: Can a physician remain a patient advocate while serving as a “steward” of society’s resources? The operative word in this sentence is society’s. The word, society, is a circumlocution, which makes vague the fact that the resources, i.e., dollars, in our healthcare system come from the individuals living in America in the form of health insurance premiums, taxes, and out-of-pocket- spending. The first two of these sources go to 3rd party payers, who are supposed to administer payment of the bill. That’s why individuals send money to the two types of 3rd party payers. What we cannot allow is rhetoric from bioethicists, these authors, and others to regulate our health care by using poisoned language to do so. (See, Hayek, F.A. The Fatal Conceit The Errors of Socialism-Chapter 7 for discussion of our poisoned language). Using the words, society’s resources, gives cover to the underlying agendas of these 3rd party payers, which are not in the interests of the individuals who pay for their existence.
Fourth: There are several other examples of misleading rhetoric, which have been insinuated into our healthcare lexicon and which these authors utilize, such as, evidence-based medicine, cost-effectiveness, value-based purchasing etc. I have discussed these elsewhere in this blog. But the final sentence of this article deserves comment: Protecting our patients from financial ruin is fundamental to doing no harm. If the authors really believe this, then the place to focus their efforts is the greed-driven manipulations of the business of medicine, which I outlined for them in my letter to the editor. The doctor patient relationship is sacrosanct. And this tradition must be maintained without compromise, not because it is a tradition but rather because it is the origin and ongoing source of accumulation of medical knowledge for individual patients and thus for our healthcare system.
R. Garth Kirkwood, MD