Who does your doctor work for?

You wait weeks to finally get an appointment with your doctor, and then you don’t get a chance to talk about all your health problems. Her doctor seems caring, but she’s rushed. The doctors were often friendly and helpful, taking the time to listen to patients’ concerns and answer their questions. Now they seem to be checking boxes and viewing patients as if they were on an assembly line. How did that happen?

The short answer is: 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 on the health care system in general, what we see is really rapid consolidation,” says Jane Zhu, MD, a researcher at Oregon Health and Science University who studies this aspect of health care. Corporations are buying up hospital systems, nursing homes, doctor’s offices, and pharmacies. According to a 2021 report from the Physicians Advocacy Institute, nearly three-quarters of American doctors are employed by hospitals or other corporate entities. The people who handle these monsters are not doctors. The backgrounds of most healthcare corporation board members are largely in finance and business, not medicine. Even nonprofit organizations function more like corporations than public service organizations. In healthcare, “The distinction between for-profit and not-for-profit organizations has blurred as healthcare organizations compete with each other and gravitate toward market share,” says Thomas G. Cooney, MD, professor of medicine at Oregon Health & Science University and chairman of the Board of Regents of the American College of Physicians.

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 reselling them for a profit within 5 years or so.

At first glance, corporate healthcare doesn’t seem like a bad idea. Having business people at the helm could make the entire company more efficient. In other words, running medicine like any other business could possibly improve healthcare.

But that’s not what happened. Instead, after years of increasingly corporatized medicine, we have higher costs, deeper medical debtfurther bankruptcies – and worse medical care.

According to a report Published this January by The Commonwealth Fund, the United States spends more than any other high-income country on health care, yet it is the only country without universal health care. But all that money isn’t buying the best health for Americans. The United States has the lowest life expectancy at birth, the highest death rates from preventable or treatable conditions, and the highest maternal and infant mortality among high-income nations.

Meanwhile, paying for this substandard health care is becoming increasingly difficult. Accounted health expenditure 5% of US GDP in 1960. In 2020, it was almost 20%. According to a 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 objective of the business is to make a profit. When those goals conflict, the patient should come first, but that’s not always the case. “The fundamental concern about corporate involvement in health care is that there is a risk of prioritizing profit over everything else,” Zhu says. In fact, in this business model, it’s almost unavoidable. Those who run an investor-owned company are responsible for ensuring that their investors make a profit.

“The control of financial self-interest in US health care is becoming rampant, with pervasive and dangerous consequences,” wrote Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and former executive director. of the Institute for the Improvement of Medical Care. in a January editorial in it Journal of the American Medical Association (NEVER).

These “pervasive and dangerous consequences” can be seen throughout the health care system. For example, a quarter of emergency rooms in the US are run by staffing companies owned by private equity groups. In keeping with the goal of making as much profit as possible, these companies often reduce the number of doctors on staff, resulting in longer wait times for patients and less time with doctors. Research by Zhu and his colleagues found that gastroenterology, dermatology and ophthalmology practices that had been acquired by private equity firms see more patients and bill more for visits than clinics owned by physicians.

In the drive for productivity and therefore higher profits, doctors are under pressure to see more patients per day, Cooney says, which reduces the amount of time and attention a doctor has for each patient. That means a doctor may not be able to fully address all of the issues a patient wants addressed at any given visit. It also means that health problems that could be less serious if caught early can be ignored until it’s too late; diabetes could be overlooked until it’s time to amputate a foot. “Doctors are the most expensive part of the equation for these companies,” says Robert McNamara, MD, professor and chair of emergency medicine at Temple University. “You’re going to maximize that resource by making them work as hard as possible.” That pressure to hurry up and balance the demands of corporate leadership with the demands of the profession has led to a crisis of exhaustion among health care providers.

If patients are just beginning to learn about the giant behind their healthcare, doctors are staring it in the face every day. But talking can be dangerous. Employed doctors often work under contracts that allow them to be fired at will without due process. Many reasonably fear that speaking out would cost them their jobs. In January 2017, Raymond Brovont, MD, an emergency physician from Missouri, was fired by EmCare, an emergency room staffing company, after it raised safety concerns about the level of staffing at the pediatric ER.

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

However, the doctors are talking. One place they are talking is in court.

Thirty-three states plus the District of Columbia have some type of restrictions on the corporate practice of medicine. The idea behind these regulations is to “ensure that commercial interests cannot interfere in the doctor-patient relationship, that the doctor who swears to do what is best for the patient is the one who makes the decisions that could affect the patient’s care, not someone from Wall Street,” explains McNamara. But corporations have figured out how to get around these regulations.

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

The No Surprises Act, federal legislation that protects patients from unexpected bills for out-of-network care, went into effect in 2022. It was a direct result of grassroots organizing by citizens, he says. The industry lobbied against him, but Congress listened to the people. “Getting angry can absolutely affect change,” says McNamara.

“We are not going to fix [health care] if we continue to move in the direction of commodifying it,” says Cooney. “We need a coherent, rational and adequately financed health system.” Exactly what that would look like is still up for debate, but there are plenty of examples to learn from. For inspiration, Cooney suggests, the US should look to European models, where healthcare is less expensive and outcomes are better. For many Americans, the main point of comparison with the US health care system is the UK’s National Health Service, which runs many of the country’s hospitals. But Robert Derlet, MD, professor emeritus at the University of California Davis School of Medicine and author of Corporatization of American Health Care: How We Lost Our Health Care System, points instead to countries with lesser-known systems, such as the Netherlands, whose public-private approach “is not as rigid as in England”. To keep drug costs in check, committees made up of doctors, pharmacists, and health insurers negotiate maximum prices and, as Derlet points out, “offer half the price of care in America.”

“Do you want corporate medicine? Where the goal of a CEO is to make money with you? Derlet asks. “Or do you want some socialized system, where the goal is to help you?”