Obamacare's troubled roll out has played into this cant, and Republicans have been frothing and delighted.
The problem is, the profit motive is not always the most functional motive: Consider medicine.
In medical school, nascent doctors are taught relentlessly what constitutes good medicine: Every medical student admits patients to hospital and each new patient begins a series of quality control exercises, as the student presents the case to the ward attending and to each attending who visits the patient from each specialty. So a diabetic admitted for chest pain who is found to have an infection of his big toe will get seen by the ward attending, the attending cardiologist, the attending infectious disease faculty. Every chart note the student writes, every presentation he makes is reviewed by his intern, his resident, his attending, the specialists, the faculty member who hears the case presented at morning report. Feedback is critical, constant, valuable.
You learn, through this process to judge quality: the infectious disease consult who sees the patient for his toe infection should cut away the dressing from the toe, inspect it daily, to see how it is healing or not. Some attendings are lazy. They don't remove the bandage, which often takes time to search for the nurse for a kit to use and then to rewrap. Some never fail to examine the toe. That is quality care. The doctor who does not unwrap the toe may miss the fact the antibiotics he has ordered are not working. He may save time by not unwrapping, and he may be able to see twenty five patients on his rounds, and bill and profit more than the plodding doctor who does it right, but the rapid moving, lazy doctor is not practicing high quality medicine. The doctor who sees fewer patients, unwraps every toe, bills less, but does more good.
Mad Dog has worked for medical care organizations in which the work the physicians do is never reviewed for quality by another doctor. No chart note is ever read, not case is ever required to be presented. No conference to review performance is ever done. The only metric that matters in such organization is the metric of dollars in and dollars out. When contract renewal negotiations occur, there is never a mention of whether you unwrap toes, examine hearts or lungs because the contracts are negotiated by MBA types, not doctors. And the MBA types don't have any mechanism to check which of the doctors they are negotiating contracts with are practicing low quality medicine and who is high quality. But those MBA's can add up dollars just fine.
There is a big push in medicine now for "quality metrics" which often means some easily quantifiable thing which can be collected easily, with a minimum of effort, by an entry level staff person and plugged into a spread sheet. The glycohemoglobin fits all these criteria. It is a number which tells how high the blood sugar as been for the past three months. Want to know if a doctor is good at treating diabetes? Add up all his patients' glycohemoglobin, divide by the number of patients and presto: Quality assessment.
The problem with such easy metrics is they can always be gamed. They invite gaming. So the organization announces you will be judged by glycohemoglobins: What to do? Well, first fire all your overweight, non compliant, under performing patients. Or send them to some other doctor, an endocrinologist or a nurse practitioner; let someone else carry these neer do wells. Keep all your thin, compliant diabetics with their good glycohemoglobins and you look great.
The problem with this good assessment of diabetic control is that it attributes to the physician the entire burden of the outcome. Doctors may find themselves in the same position as teachers in the South Bronx, the poor scores of their students do no mean they are bad teachers; these teachers are not working with cooperative subjects. Doctors who work with patients who cannot or will not do the things they need to do to control blood sugar, who are judged by poor results, know they can do nothing to affect those results. So they will game that system.
All this is happening because the wrong people have been given the task of judging doctors. MBA's can only judge how much money the doctor brings into the coffers. CPA's and economists might dream up a metric or two which sounds reasonable, but they cannot see where the metric fails and how it can be gamed.
Health care systems, whether they are for profit corporations, or "voluntary hospitals" are all failing in the same way: They have excluded the very people who can judge the work of the doctors in the system, namely other doctors.
The emergence of the profit motive as the driving force in medicine, combined with the flight of doctors from being independent shop keepers to hired help has meant the culture of business has, by default, assumed control of the way doctors are evaluated, paid and ultimately what kind of quality they provide their patients.
Next time some Republican says, "Keep your government hands off my Medicare, get the private sector control of medicine, let the profit motive prevail," just tell them government may not be as efficient as we'd like, but it is still worlds better than profit driven private companies. At least the government has the motive of providing good health care. The company cares only about the bottom line.
Much as doctors love to complain about Medicare, they mostly agree Medicare generally does what is best for the patient. The private insurance company will deny a diagnostic test for its customer, knowing that two years later the patient may be much sicker because the diagnosis was missed. But, two years later the customer will likely have another insurance company, and paying for his illness will be that company's problem. Medicare knows they are stuck with every patient for life.
So Medicare will pay for a pair of shoes designed to prevent ulcers on the feet of diabetics. The shoes may cost $100 a year. A single visit to the ER for a foot ulcer is $500. Medicare makes the investment because keeping the patient out of the hospital is cost effective. The private insurer is hoping to keep the patient out of the hospital only for the term of the policy.
Democracy may be the worst form of government ever devised, as Churchill noted, except for all the other forms of government which have ever been tried. The same may be true of government guided medicine--the worst form of management except for all the other forms which are currently out there.
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