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Following the corporate money trail through the pediatric office
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“Since the first amphibians crawled out of the slime
We’ve been struggling in an unrelenting climb
We were hardly up and walking before money started talking/
If you’re a corporate titanic and your failure is gigantic
Down to congress there’s a safety net for you”
— Arlo Guthrie and Pete Seeger (Tom Paxton) “I’m Changing My Name to Chrysler,” 1981
“But there’s nothing you and I can do
You and I are only two
What’s right and wrong is hard to say
Forget about it for today
We’ll stick our heads into the sand
Just pretend that all is grand
Then hope that everything turns out OK”
—Steppenwolf “Ostrich,” 1968
“So bartender set me up with the Triple Crown
Double ain’t enough when I’m feelin’ this down
I’ll celebrate the misfortune I’ve found
With my own version of the Triple Crown”
—Kevin Fowler “Triple Crown,” 2004
Recently, an op-ed piece by Fredrik deBoer in The New York Times took on the creeping corporatism of the American university. deBoer was not describing a literal union of corporation and university — although there is abundant evidence for the direct presence and impact of corporations on college campuses, including outlets, ownership of bookstores, credit and loans, not to mention apparel and athletic contracts — but a destructive takeover of the soul of the academy itself. Unfortunately, a hostile takeover it is not, as there are institutions where the number of senior administrators outnumber professors; any question of an overarching academic mission has apparently been answered.
William T. Gerson
Is the same true in medicine? Clearly, yes — although today hospital networks, and not just academic centers, play a central role. Money talks, and while I am unaware of a “Chrysler” health network nor of any plans for a public giveaway similar to what prompted Tom Paxton’s lyrics, there is a lot of public money flowing to corporate medicine providing all sorts of safety nets in its wake.
The emerging presence of corporate medicine has been felt since the 1970s. The initial battle resulted in physician-led opposition to public control of public health programs and, unfortunately, ultimately enhanced the role of entrepreneurial forces in displacing the long-standing authority of private physicians, as well as local voluntary hospitals, in health care decision making. The organized medical profession acquiesced to the growing power of corporate medicine and has not opposed its influence for a long time. Newly trained physicians, and it is certainly true in pediatrics, value lifestyle over service and freedom from the job more than freedom in the job. As a profession, we have lost not only authority but autonomy. We are losing the independent small businessperson, but perhaps more damning is the loss of independent thought.
While I still cringe when children’s hospitals take on corporate names, I now need to reconsider and wonder why an academic university badge really is anything other than an acknowledgement of corporate subsidiary status. Bureaucratic professionals have taken over health care and administrators, like health care analysts, often have no primary medical background. I certainly do not suggest that our medical training grant physicians expert knowledge in the business of medicine nor that senior leadership positions should be held only by physicians. I do however suggest a new rule — no physician administrator should be raised to senior position without ever taking call. Better yet, they should continue to take night and weekend call while performing their administrative duties.
Follow the money
With mergers planned with major health insurers — Anthem taking over Cigna, and Aetna acquiring Humana, with this pair of unions alone totaling almost $100 billion — where does this leave the beleaguered primary care pediatrician? With more risk, more unknowns, and even more vulnerability.
It is all about market leverage: money and power. Using a single state’s experience, the details have been clearly laid out. An illuminating 2010 report from the Attorney General’s Office of Massachusetts found:
“A. Prices paid by health insurers to hospitals and physician groups vary significantly within the same geographic area and amongst providers offering similar levels of service.
B. Price variations are not correlated to (1) quality of care, (2) the sickness of the population served or complexity of the services provided, (3) the extent to which a provider cares for a large portion of patients on Medicare or Medicaid, or (4) whether a provider is an academic teaching or research facility. Moreover, (5) price variations are not adequately explained by differences in hospital costs of delivering similar services at similar facilities.
C. Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers.
D. Variation in total medical expenses on a per member per month basis is not correlated to the methodology used to pay for health care, with total medical expenses sometimes higher for risk-sharing providers than for providers paid on a fee-for-service basis.
E. Price increases, not increases in utilization, caused most of the increases in health care costs during the past few years in Massachusetts.
F. Higher priced hospitals are gaining market share at the expense of lower-priced hospitals, which are losing volume.
What does it mean 5 years and more corporate investment later? Simply that unless pediatricians in private primary care practice take combined action, we will cease to exist as a serious provider of care to children and young adults. We cannot be ostriches with heads in the sand because I do not believe everything will be OK. The powerful, including corporations, will control the models of care and even more sadly the education of the next generation. For they will complete a triple crown — they will own the university, the hospital and you. I’m changing my name to “Chrysler,” but hedging the bet by finding a friendly bartender as well.
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- William T. Gerson, MD, is clinical professor of pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.