By Marc-David Munk
In our palliative medicine clinic in the working suburbs of Boston, my colleagues and I tend to some of the sickest patients in the city. Through the window I see the affected attracting to our Squat building in family -sedans, wheelchair buses and subsidized municipal ride cars. Few float themselves: most wear terrible diseases that make them too weak or stunned. As patients who can hardly dress, I look in one way or another in their best before the clinic on Sunday.
Our task, as their doctors, is to manage their pain and to offer moral support and practical help with things such as rent and transport, sometimes also spiritual support. It is important work, one of the highest vocations in medicine. But no matter how noble this work is, our clinic does not start to maintain itself financially. If there was ever a reason to grasp patients and their needs, these visits, with their sick and vulnerable patients, would be copies. We do not even receive enough payment from insurers to cover the costs of the complicated work that is necessary. Practically this translates into a few employees to help with appointments, not enough follow -up calls, nobody to help with insurance headache or shortages of pharmacy, nobody who answers the phone. Our facilities are tired. The simplest skills – coffee in the waiting room, magazines, a comfortable chair – have long disappeared.
There is a feeling of “lean” in the air. It is the feeling of getting rationed. It is an absence of anything but the really essential; No abundance, a lack of courtesy. I see leanness when my friend, an emergency doctor in a large trauma center, shares photos of his resolutive there: office chairs held together with medical tape, rooms without functioning equipment. Medical supplies that are so scarce that doctors store in their desks and fur bags.
The managers will say that these bare conditions are a result of financial scarcity. There is not enough money to pay for more than skeleton support and maintenance. Hospitals are shortages and shrinking. Maintaining the lights is apparently a matter of saving money on every occasion. And the leanness grows with every cut. This all sounds understandable at first sight until you take a step back and you realize that it is not. We know that American healthcare uses more money than any other country, per head of the population. Pour money, really floods, in our health care system. Family insurance premiums for the health insurance policy rose by 7% compared to 2023, after another 7% increase of the year before. The average family policy now costs round $ 25,000 a year.
So I want to reconcile how there can be so much money that the system comes in, with so little left for essential front-line care. I know this is not a complicated answer.
My fifteen years spent as a care manager, negotiating with payers and suppliers, I taught me that our social health care money has been simply diverted. Intermediary costs are, in a broad landscape in health care, so extreme, so unregulated, so shaky that there is only a trickle left to deliver everything, except the most mixed first -line care.
Here in America we are specialized in allowing thousands of organizations, many did not find anywhere else in the world, to pass on unprecedented costs to, well, ourselves. We have group purchasing organizations (GPOs) and Accountable Care Organizations (ACOs). There are medical service organizations (MSOs) and doctors’ organizations (POS). Care organizations (MCOs) and health maintenance organizations (HMOs) also managed. Doctors-Hospital organizations (PHOs) must also be paid. There are contract agencies, coding offices, compliance offices, credentials offices, case management offices and claims that process offices. Many organizations exist to offer a push for one outcome; Others exist to penetrate the opposite. All are costs.
Our six largest health insurers have income that would make them the 14th largest GDP in the world if they were a country, smaller than Spain but larger than Australia. They usually spend about five -five percent of what they collect from medical care … The rest is their overhead and profit. The United States spent almost twice as many as other countries with a high income of care, powered by labor, pharmaceutical products and devices and administrative costs. Drug manufacturers charge Americans more than other countries for identical medicines. Prices for cardiac implant devices are multiples higher in the US than in Germany. Hip implants in the US are more multiples than those in Canada. Insurance insurance is crushing, with some doctors pay hundreds of thousands annually liability coverage. Electronic medical records cost hospitals up to hundreds Millions of Dollars to install.
Here regulatory authorities have both made themselves expensive and indispensable. The American Council of Internal Medicine brought in $ 90 million In reimbursements in 2023 (and there are 23 other specialist boards). The Joint Commission has attracted $ 208 million last year. Press Ganey, which owns a large part of the mandatory patient research company, reportedly had income in the hundreds of millions of dollars (before they stopped reporting income after being purchased by Private Equity). The Medical Journal Business is mainly Galling: Doctors write, edit and assess free articles, but those magazines are locked behind Paywalls. The parent company of Elsevier, with more than 2500 magazines, generated £ 3.06 billion in income in 2023 with a 38% margin.
Good luck with all this against all this. We are stuck. Doctors have no choice but to be Board certified. Hospitals must be investigated. Expensive licenses and permits are non-considerable. We pay what they ask, with an increase in year after year. We set few requirements, few hard bargains and few consequences for poor value in these cocoon organizations. In my early years in medicine it felt as if there was at least a veneer of abundance. Nowadays I look at our worn clinic and our patients who react dignity while explaining that their insurer has again rejected their fifteen dollars pain medication.
I wonder when we will admit that we are at a point where – due to regulation and administrative gaming, policy reproductions and oligopolistic behavior – the opportunists have finally killed the Golden Goose. I wonder when, in an environment of doctor of doctor and heroic dedication to patients, we will know that we have reached a turning point where it is no longer an environment of leanness, but one of privacy, where balls are fell and people really suffer.
With so many deep -rooted interests, it is difficult to imagine how this is resolved. For thousands of years, when it mattered the most, there has been no replacement for the work of a doctor who takes care of a patient, one on one. There is still not there. But around the best parts of American medicine, we have taken pleasure in a Goldberg-like device that mainly functions to perpetuate itself. It gets real tolls from real people. It is unique disgusting, unique absurd, unique American.
Marc-David Munk is an academic doctor for palliative medicine and a former health care director at various private and vc-supported value-based organizations in care provision.
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