How We Got to Be 37th
BY EMILY PYLE
Critical Condition: How Health Care in America Became Big Business–and Bad Medicine Donald L. Barlett & James B. Steele Doubleday 279 pages, $24.95
at your veggies. Do cardio. Take vitamins. Whatever you do, don’t get sick. You might have heard that the United States has the best health care system in the world. You might think your insurance will take care of you when you’re ailing, or, failing that, Medicaid or Medicare. Think again. In their dissection of the medical-industrial complex, Critical Condition: How Health Care in American Became Big Business—and Bad Medicine, investigative journalists Donald Barlett and James Steele pinpoint nearly everything that could possibly go wrong for someone seeking medical care—and it’s a lot. The book is packed with the kind of awful stories that begin “Margaret Utterback was seventy-four years old and in reasonably good health…” and ends with financial ruin, chronic disability, or death. Utterback, for example, died while trying to schedule an appointment with her doctor. A call center run by health management organization Kaiser Permanente kept her on hold until the swelling blood vessel that was causing her abdominal pain finally ruptured. She bled to death within hours. Throughout the book, we hear about others who die of staph infections in improperly cleaned hospitals, are blinded as a side effect of medication, and have their breasts removed by accident. Patients are not the only victims of this system run amok, though they may suffer the harshest consequences. From doctors who pay out of pocket when insurance companies deny reimbursements, to nurses forced out of the profession by low pay and forced overtime, to the temp workers who staff sweatshop-like HMO call centers, our health care system has created plenty of victims. Meanwhile, a handful of investment bankers, pharmaceutical CEOs, and politicians get filthy rich. For all the ghoulishness of these anecdotes, Barlett and Steele rarely stray far from the book’s central tenet: The free market principles that were supposed to “streamline” medical care have instead created a system weighed down with bureaucracy and riddled with fraud, abuse, and criminal carelessness. More than 20 years into our national experiment in “managed care,” we have yet to see the savings that marketplace competition was supposed to bring us. In 2001, per capita health care spending in the United States was $4,887, accounting for about 20 percent of the average person’s disposable income. Despite this, our life expectancy is lower than that of countries who spend far less. We rank even lower in the World Health Organization’s comparisons of “years of healthy living” and infant mortality. The WHO’s global health care rankings place us 37th—below Italy, Malta, and Costa Rica. We did, however, beat out Slovenia. Narrowly. How did we get here? The answer to that question is not spelled out, though the authors give us everything we need to draw our own conclusions. Barlett and Steele seem fixed on particulars, rushing from the details of one outrageous anecdote to the next. The book sketches step-by-step how pharmaceutical companies court politicians and venture capitalists arrange hostile takeovers of hospitals. But while the authors occasionally pause and hitch a thumb back at the market forces that created this mess, they never pause quite long enough to give us a bird’s-eye view of the problem. Market forces were at work in health care long before the rise of private HMOs and Big Pharma. Doctors who routinely killed their patients didn’t get much return business. The earliest HMOs, Barlett and Steele tell us, started not as an independent industry, but as adjuncts to other businesses. In what was seen in the fifties as a dangerous socialist experiment, large employers began to staff their own hospitals and hire their own doctors. These HMOs sole aim was to keep workers healthy and on the job. By most accounts they were successful. It was under the Reagan Administration that free-market ideologues and savvy investors came together to turn non-profit, quasi-governmental HMOs into moneymaking machines. First they starved HMOs from the government seed-money that had kept them afloat. Then they made them into public companies, setting off wave after wave of consolidations, mergers, bankruptcies, and hasty re-sales that still destabilizes the health care system. Under HMOs, physicians became highly skilled (and in most cases highly compensated) assembly line workers. As for patients, proponents of the business model call them “consumers.” Theoretically, their ability to choose rationally between health care options is the engine that drives the market forward. But, as Barlett and Steele point out, the doctrine of choice presumes that all patients have the specialized knowledge to choose between doctors, insurers, and procedures. It also supposes that if being sick is too expensive, “consumers” can opt to be well. “Just exactly how consumers would judge the merits of various health care plans…was unclear,” Barlett and Steele write in their chapter on the privatization of HMOs. “Even more puzzling was how they would make this decision in an ambulance on the way to the hospital emergency room after an accident.” In fact, the pretence that sick people are shopping when they go to the hospital is a thin one. Under the business model of medicine, patients are a crop. And they are profitable only when they are sick. Our health care system benefits more from letting a patient’s condition worsen until it requires emergency intervention, than from treating it in time. If an ounce of prevention is worth a pound of cure, the health care industry wants the pound. Cost cutting is one profit-boosting practice imported into health care from the business world. Shareholders of publicly owned hospitals pressure staff to keep them profitable by any means necessary. Barlett and Steele tell how surgeons at a hospital owned by the management company Tenet Corporation, discovered in 2000 that they had been performing operations with bacteria-infected instruments. For weeks, administrative staff had known the sanitizer that sterilized the instruments was broken, but had not ordered the expensive repairs. The Tenet-owned Palm Beach Gardens Hospital, in Palm Beach, Florida, kept such unsanitary conditions that 16 people died of staph infections contracted there. At least one Tenet-owned facility found an even grimmer way to bolster its bottom line. At the Redding Medical Center in northern California, an FBI investigation found two doctors had performed a large number of unwarranted cardiac procedures, some on patients with normal hearts. Several of those patients died of complications following surgery. In theory, the business model of medicine was supposed to make health care more efficient and correspondingly cheaper. Ironically, the bureaucracy that manages “managed care” is one of the fastest-growing industries in the world. Entire job sectors have been created to enforce cost-cutting measures; the authors list them in a chapter devoted to the new industry: the Professional Association of Health Care Reimbursement Specialists, the National Association for Claims Assistance Professionals, and the American Medical Billing Association, to name just a few. HMOs also employ a catalogue of shady practices to deny reimbursements to doctors. “Nearly one of every three dollars now spent on health care goes for administration, from processing the voluminous paperwork of billing to enforcing the length-of-stay guidelines,” Barlett and Steele write. These guidelines, set by insurers, widely reviled by physicians, list the time patients should be kept in the hospital for various complaints. A patient with double bypass heart surgery gets four days, according to one widely used set of guidelines. A child in a coma with seizures gets three days. Anyone who has ever been forwarded to an HMO-run call center may have guessed the truth about another common cost-cutting measure. These labyrinths of phone menus and customer service representatives are indeed designed to keep you from seeing your doctor. Barlett and Steele tell us operators in a call center run by Kaiser Permanente receive bonuses for scheduling fewer doctor appointments, and are chastised if they spend longer than four minutes on each call. KPC Medical Management, Inc. took cost cutting to its logical extreme in 2000, ultimately refusing to pay anyone anything. Barlett and Steele devote an entire chapter to KPC’s spectacular six-month meltdown in 2000. First, specialists started refusing to see patients referred by KPC’s doctors. Many specialists eventually canceled their contracts with KPC, saying the company hadn’t reimbursed them for care provided to its clients. Then supplies began running out—the chemicals to process mammogram film, the implements to perform biopsies, even medications. Finally, even doctor’s lab coats were eventually repossessed. It turned out KPC wasn’t paying its vendors, or anyone else for that matter. Checks to suppliers and staff were written, but never mailed. KPC director Dr. Kali Chaudhuri made repeated promises that the company would mend its ways. Instead, the company simply folded one morning in November 2000. Patients arrived for their appointments to find clinic staff clearing out their offices. Though KPC failed on a grand scale, it is hardly the only company where lives have been endangered and lost through poor business practices. But the difference between KPC and other managed-care operations, Barlett and Steele write, is “only one of degree. Increasingly, all the problems faced by KPC’s patients are confronting patients elsewhere, although in many instances they may not be aware of what’s taking place.” In Critical Condition, the authors trace the cozy relationship between for-profit health care corporations, Wall Street investors, and government officials that allows fraud and abuse to persist. They also illuminate the triangle of pharmaceutical companies, the FDA, and the media that has led to the boom in prescription medications—and the discovery of an ever-expanding array of new, medicable conditions. The FDA has leapt to Big Pharma’s defense over the importation of cheaper drugs from Mexico and Canada. The agency has also turned a blind eye while drugs with dangerous and deadly side effects remained on the market long after the were pulled in other countries. The threat of disease almost pales in the face of what could happen in the hospital. “Corporate decisions at a manufacturing plant may have economic consequences affecting the paychecks, dividends, or stock options of workers, executives, and investors,” Barlett and Steele write. “The same decisions in a health care company are matters of life and death.” To their credit, the authors are not merely critics of the present system. After five years of research, talking to people in every aspect of the present health care system, they are qualified to offer a solution, and they do. Wisely noting that the obvious solution—single-payer universal health care—has too much political baggage to get off the ground, they propose instead an independent, quasi-governmental agency modeled on the Federal Reserve System. This and other proposed reforms are some of the freshest thinking on health care reform this reviewer has heard for some time. Too bad their chances of getting a hearing any time in the near future is approximately zero. In the meanwhile, we’ll put up with rising costs, shrinking coverage, and the possibility that we just might die while we’re trying to get well. I feel sick. But please don’t call a doctor. Former TO intern Emily Pyle is a freelance writer based in Austin. Her article about the crisis in emergency health care in Houston, “The Emergency,” was published in the November 19, 2004 issue of the Observer.