Is AHRQ's National Guideline Clearinghouse disappearing for good tomorrow?

The AHRQ was started 30 years ago in 1999 when it was renamed from the Agency for Health Care Policy and Research (AHCPR) to the Agency for Healthcare Research and Quality (AHRQ) by legislative action.  I have referenced their guidelines on this blog for ADHD and depression.  The post on the depression guideline illustrated that AHCPR guidelines were generally of higher quality than the current managed care guidelines and screening guidelines.

Even looking at the web site today before it is taken down illustrates the depth of research and recommendation on the site.  A search for psychiatry yields 600 references including research and policy recommendations.  Interesting the guidelines at guidelines.gov has 74 psychiatric guidelines ranging from depression in children and adolescents to a guideline for CYP2D6 and CYP2C19 genotypes and dosing of tricyclic antidepressants.  A wide number of physician and nonphysician organizations have produced the guidelines.  These are unique sites with few comparable sites in the world.  Only the National Institute for Health and Care Excellence (NICE) in the UK seems similar.  The NICE guidelines are produced by a more uniform methodology rather than disparate organizations.

When the current administration announced it was defunding AHRQ guidelines, there was some hope that someone else would take it over - at least the existing databases.  Some physician professional organizations were suggested.  Given the government's shaky history of ancient information technology and dubious failed upgrades, I am speculating that would be the reason why nobody else would want to take that on.  Clearly nobody in the administration is interested in a smooth transition.  The smoothest transition I can think of would be to make the data available through the National Library of Medicine and their collection of databases.  But as I type this there are about 8 hours to make that transition.

There are several serious questions for the Trump administration.  Some are speculative, but when people question how doctors are influenced by a slice of pizza, I think it is reasonable to ask about health care corporations that are influenced by tens to hundreds of billions of dollars and how they influence politicians.

1.  How does it make sense to take this data and these initiatives offline when the costs are trivial compared to other government projects?

Cost analyses have been done showing not much of a price increase corrected for inflation.  Various analyses have been suggested such as this one pointed out the agency's role in reducing hospital infections resulting in 124,000 fewer fatalities per year a cost saving of about $28 billion.


2.  And possibly even more important - what are the conflicts of interest involved?

The most significant one that I can see is that industry guidelines and standards go unchecked.  There are any number of groups that are primarily comprised of health care executives that are producing standards of care that have nothing to do with medical practice or standards.  Review practices by pharmaceutical benefit managers come under the same category.  These physician intimidation strategies have nothing to do the scientific evidence or quality of care. In this regard the wholesale suspension of guidelines that counter industry practices are suddenly gone.  It is far easier to do than reverse Environmental Protection Agency (EPA) regulations - but the zeitgeist is the same.

Taking down AHRQ means there is one less place in government healthcare sites with the word quality.  I don't think that is an accident either.  Today's healthcare industry would rather advertise how they are the best without using the quality word or any scientifically valid metrics.

3.  As a corollary to the above - what about the professional guidelines that are collated and listed on the site?

I don't have the time to follow other physician professional organizations but the American Psychiatric Association has fallen off greatly over the years.  Critical issues have not been addressed in some cases for decades.  The commonest cause for this problem is cited as the expense it takes to collect all of the experts and data, but in the information age it would seem to be easier than ever.  I speculate the the real reason is that these guidelines are just ignored.  Why produce a hundred page guideline on all the aspects of the treatment of depression when the dominant managed care standard is a 2 minute screening exam and an antidepressant prescription?  Why produce that document when it affects only 5% of the work force for mental disorders?  Why produce that document when the psychiatrists involved have so little political leverage against the industry and the government that they can never use it. 

AHRQ at least provided a broader forum for discussion.

4.  Why the minimal notification and lack of feedback?  

There are so many guidelines and so much information available on this site, it is impossible to know who is using it all and for what purpose.  Unilaterally taking down a resource like this with 4 months notice has to be considered nothing more than a political decision at this point.  If the number of people and organizations accessing this site was published somewhere - I have never seen it.

5.  What about the Centers for Medicare and Medicaid services, the CMS web site?

Since CMS is essentially the billing and regulatory web site for Medicare - I don't think it is any danger of being shut down.  But it does promote and spread a lot of unscientific information that is biased toward running the business side of health care at the expense of the medical side.  It is a massive bureaucracy that is responsible for the bulk of physicians paperwork burden every day. Some clear evidence for the lack of science is psychiatric diagnosis related groups and how they don't accurately reflect diagnoses or the expected course of treatment for hospitalized psychiatric patients.  The most recent post on this blog looks at the rationing of inpatient psychiatric services and how a lot of that has resulted from CMS regulation.  Just a few years ago, I wrote a blog piece about a 55 page CMS document about what psychiatrists would have to do to document the diagnosis and treatment of depression.  That was subsequently taken down.     

6.  Finally what does this imply for other federally funded information programs?

My biggest concern in this era of massive profits for publishers is the National Library of Medicine (NLM) - commonly used by physicians offices on a daily basis.  It is a major resource for researchers, but it is also becoming a competitor for profitable online publishers.  If research is publicly funded - a copy is accessible without charge on the PubMed web site.  Will the day come when for profit medical publishers have enough leverage to put the NLM out of business?  Stranger things have happened.  

It is easy to blame that President Trump.  He is heading the first blatantly anti-science and pro-business administration that I can recall in my decades of existence.  But the reality is that the American healthcare system has been designed by an endless stream of bad decisions for the past 30 years all occurring in the confluence of special interest politics and massive special interest money with a little medical science (and a few doctors) sprinkled in. The press seems to focus on the influence of pharmaceutical companies, but the bulk of those bad decisions have been rationing decisions by the managed care industry.

George Dawson, MD, DFAPA

References:

1:  Heslin KC (AHRQ), Weiss AJ (Truven Health Analytics). Hospital Readmissions Involving Psychiatric Disorders, 2012. HCUP Statistical Brief #189. May 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb189-Hospital-Readmissions-Psychiatric-Disorders-2012.pdf.

Supplementary:

I pulled the following figures on lengths of stay for mood disorders and schizophrenia out of the above article.  If the site goes down at midnight this may be the only place that you can find it and any paper referencing it may lead to a dead end.

Updates:

07/16/2018: 3:30 PM  AHRQ.gov web site is up and running at this point but guidelines.gov is not found.

Do Businessmen Dream Of Medicine Without Doctors?

You bet they do.

My first exposure to the business-driven dystopian future of medicine occurred in Fort Lauderdale in 1994.  I was the Public Affairs rep for the Minnesota Psychiatric Society.  The APA decided that it would be a good idea to bring all of the Public Affairs and Legislative reps of the local district branches (DBs) to Florida for a conference.  On the surface it was supposed to be focused on getting solutions into the hands of the DBs.  In retrospect it was a shocking introduction to how the managed care industry would lay waste to the field of medicine in the decades that followed.

The keynote speakers for that conference were Governor Arne Carlson from Minnesota and a business consultant.  Minnesota has always been a hotbed of managed care activity and for the past three decades any physician practicing here has been a witness to what can happen when government and business bureaucrats practice medicine.  The end result of rationing psychiatric services over that period of time has been a system of care that is so fragmented and that provides such poor service to patients and family members that the current Governor Mark Dayton recently called for massive reform.  The result of that Task Force is quite unremarkable but that is another story.  In 1994 Governor Carlson was there to brag about MinnesotaCare, a government insurance scheme for the working poor and the Health Care Provider Tax on all health care providers in the state to finance it.  He was describing them as major breakthroughs but over the years they have proven to be very suboptimal programs.  The Provider Tax in many years acts as another revenue source for the State and that revenue is not directed at anything to do with health care.  I have never witnessed any of my working poor patients get on MinnesotaCare.  It appears to be rationed as tightly as a managed care option.  Some members of the audience were less than receptive to these ideas and the Governor did what he could to put them in their place.  The precedent of never telling a politician that they are wrong about their supposed health care reform was easily established.

The consultant provided an even clearer picture of the business agenda. He bombastically presented the first wave of fake news that helped establish managed care.  That fake news was - "Nobody needs specialists anymore.  There are too many of them and they are too high priced.  We are going to buy them out and put them out of business.  The only doctors we need are primary care doctors."  He focused on orthopedic surgery as a case in point, but he pointed out that the same was true of any medical specialty.  It was an implicit threat to all of the psychiatrists in the audience. Of course his statement was pure fabrication.  There is no way a businessman is going to spend a dime to buy practices when he can just manipulate them out of business.  It was the beginning of the full court press to manipulate physicians into doing whatever the business types wanted them to do.  In the following 2 decades - physicians and patients were manipulated into using primary care physician offices for a gatekeeping function for everything while simultaneously reducing reimbursement to those physicians to the point that they needed to see 30 to 40 patients a day to keep the doors open.

I was working for an altruistic multispeciality clinic at the time.  I say altruistic because one of our goals was to see all people presenting to our hospital or clinic irrespective of their ability to pay.  We had to work harder as a result, but were generally quite content.  The physicians were high quality and we were all collegial.  I never trusted any group of physicians more.  The work environment resembled the training environments that I had worked in - county hospitals and VA hospitals and clinics.  Billing, coding, and reimbursement were far removed from the work.  We had billing and coding specialists who came by, read our notes, and submitted the billing documents - totally unseen by us. All we had to do was focus on the practice of medicine.  Anyone working in those days would tell you that was more than enough.

But there was fear in the air.  Over the next several years the physicians in my group were talking about how the local managed care companies were going to put us out of business.  Since were were the largest provider of medical and psychiatric services in the east Metro area and had the market cornered on poor reimbursement,  I dismissed it as hysteria.  Over the next several years we were acquired by one of the three managed care companies that provide the bulk of medical services in Minnesota.  In the process our self funded malpractice fund disappeared.  The provision of care also started to change.  There was no longer an acute care Neurology service.  Stroke care was going to be provided by "an internist with an interest in strokes."  The internal medicine consulting service became the hospitalist service and primary care physicians no longer saw their patients in the hospital.  The decisions were not discussed.  There was no consensus.  Department heads were let go.  Physicians were just told what to do.  At some point my request to talk with the wizards behind the screen was met with a simple answer.  There was now a "firewall" between physicians and the administrators and there was no way that I would ever question their decisions or talk directly with them.  

The administrators began to proliferate.  An endless series of administrative ideas began to be put on the physicians.  Physician were no longer practicing medicine all day long.  Suddenly there were plenty of feel good meetings for administrators.  And so it went.    Outright bombastic contempt for physicians was no longer necessary.  The administrators had won.  Additional mechanisms were put in place to suppress any dissent.

The contempt is still palpable in some of those dissent suppressing situations.  These days - all it takes is a complaint against a physician to activate what is typically an airtight mechanism to scapegoat them within the organization.  It doesn't matter if the complaint is real or not.  In many organizations, a physician's annual evaluation actively solicits anonymous complaints about them.  It is part of a general effort by administrators to illustrate that physicians are really deficient human beings, only able to function in the context of a beneficent organization and supervision by a business person.  Some organizations have a "three strikes and you are out policy" and they don't want to debate the merit of any complaints.  They just list it as a strike.

This is how being a physician devolved from being a fairly autonomous profession to one that is clearly under the boot of the managed care industry and the government and everything that entails.  It was largely an exercise in fake news and rhetoric on the part of the business community and a complete lack of response from physicians or their professional organizations.  That practice is alive and well today.  There is no science involved in business management and no standards.  That alone would create some suspicion about how medicine is currently managed - but there are very few critics.  Physicians as a group have never been able to grasp one of management's unscientific techniques referred to as pushback.  Instead of standing there like deer in the headlights pushback against all of the fake news generated by these managers.

If that ever caught on with my colleagues - we would all start pushing now and keep it up for the next 30 years to just break even.


George Dawson, MD, DFAPA




Supplementary 1:  Businessmen here is used as a generic form of businessman or businesswomen.  There are clearly plenty of female managers who also do not know what they are doing.

Supplementary 2:  A few words about pushback.  According to William Safire writing in the New York Times - pushback the noun began to surface in business journals near the end of the 20th century.  In my experience it started to show up in medical meetings about a decade later.  The current Merriam Webster definition is "resistance or opposition in response to a policy or regulation especially by those affected".  That does not really capture the business application of this term.  In a business meeting for example, the strategy might be to exert some kind of pressure on a group or subgroup of people affected by the business and see if there is any pushback.  In some cases, no pushback is expected because the employees are fairly expendable.  I heard a business story about retail stores that use a clopening strategy where the same employee closes the store one night and has to open it in the morning.  That is very inconvenient if you are that employee and trying to coordinate daycare for children or a second job, but pushback is not really anticipated.  In the case of professionals who are required in certain positions pushback might be anticipated with certain mandates.  I have been in meetings where the question was asked: "Has there been any pushback from the doctors or nurses on that?"  If there is none, the leverage is typically increased until there is.  In the case of physicians it rarely (if ever) happens.  There have been numerous explanations for the lack of assertiveness on the part of physicians.  The general explanation is that it is unseemly behavior that is inconsistent with the professional image of the physician.  I think the real mistake is that physicians assume that the business manager class has the same degree of professionalism and values when they clearly do not.  Any physician being pushed around or bullied by business managers knows exactly what I am talking about.  They do not think or act like physicians.  It is time to stop acting like they do.

Ref:

William Safire.  Pushback.  New York Times.  January 14, 2007.    


Supplementary 3:  From Orwell's 1984 as O'Brien interrogates Winston Smith and plants the idea that the only way man can assert power over another is by making him suffer and goes on to detail how that is done.  He concludes:  ".....Always, at every moment, there will be the thrill of victory, the sensation of trampling on an enemy who is helpless.  If you want a picture of the future, imagine a boot stamping on a human face--for ever."

That is exactly where the business world and the government want the medical profession.

Ref:

George Orwell. Nineteen Eighty-Four. A novel. London: Secker & Warburg (1949).

Attribution:  Image from this post is downloaded from Shutterstock  per their standard licensing agreement.  Image number 59502138 by Stokkete (photographer).

Financial Blogger Gets It - Sort Of

I was buoyed to see this line as the title of a financial blog today:  "Coming Corporate Control of Medicine Will Throw Patients Under the Bus".  You don't usually see that level of insight into what is going on in medicine from financial people who have usually bought the "cost effectiveness" dogma, even at a time where middlemen are siphoning off hundreds of billions of dollars from the direct provision of health care and producing an inferior product.  I will say it for the thousandth time - what other industry can make money by selling you a rationed product and denying your access to that product?  Can you imagine what the automobile or cell phone market would look like with that guiding principle?

The article is  focused on two critical issues-physician management by people with no medical experience and the message from the top.  The first part of the article discusses the situation of a pediatrician who had successfully managed a clinic but found herself being managed by a non-physician who told her that she either had  to see very complex patients in a shorter period of time or not see them at all.  The second part of the article focuses on a blog post where a CEO/physician for a managed care company flat out encourages physicians to get rid of difficult patients to improve their managed care style performance measures.

The blogger in this case is Yves Smith.  I have been reading her blog for years.  She wrote the book Econned and takes a generally skeptical view of that way that financial markets are regulated and run.  I have seen her do commentary on some financial television but infrequently.  I would tend to see her commentary as legitimate criticism and welcome in the area of physician and health care management.  As a blogger she is highly successful.  This post alone has about 40 pages of commentary.

In this article she has some additional comments about what physicians face in the assembly line of today's managed care environment:

"As an aside, it's hard to stress enough that this sort of demoralizing micromanagement an unwillingness to listen and learn from workers is a weird shortcoming of management American style.  And it has been weirdly airbrushed out of the media."    

I can't agree more with the second comment in particular.  The American public gets a glimpse of how their health care management occurs only when Michael Moore makes a movie about it or they are confronted face to face with an impossible situation.  That happens all of the time in psychiatry with restrictions on treatment to the point that it seems like treatment has never occurred.  To get that accomplished takes both micromanagement of physicians and a general management style that greatly emphasizes profit margin over patients.  At the public relations level, physician opinion especially physician dissent is not tolerated.  The personal experience of the physicians in these systems is considered the property of the organization.  Any public disclosure of the severe shortcomings can be ruthlessly suppressed either by firing or a series of political maneuvers designed to force resignation at some point.  

There is a divergence of medical and corporate culture at the level of disclosure of errors or wrongdoing.  For most of my professional life I have been in monthly conferences - some type of mortality-morbidity conferences where real or potential errors were discussed on a department wide basis.  I don't think that happens in the corporate world.  I think that errors in the corporate world are acknowledged if they are widely known and there is an emphasis on public relations and maintaining an almost unrealistic positive light on the company.  That has been most evident in the past decade with an abundance of managed care public relations.  Wherever I turn it seems like I come across a hospital or clinic that is proclaiming themselves as the "best" - usually in the country.  That kind of advertising by physicians was widely viewed as unethical by state medical boards.  These ratings are usually based on a few process parameters that can be actively "managed".   Contrary to what health care management tells you the quality of any hospital or clinic depends on the quality of the physicians working there and the level of autonomy they have in their medical decision making.

You can have the best surgeons, internists, or psychiatrists in the world and if they are managed to see as many patients as possible and provide the care that will provide the best profit margin for the company - their medical and surgical care will not be appreciably different from a mediocre staff.

I wrote a piece several years ago about an informed approach to managing knowledge workers that originated with management guru Peter Drucker.  The details can be found in the original piece in this newsletter (page 3) and a earlier posts on this blog.  Everywhere I look in health care we are at the opposite pole from Drucker.  Managers are generally far too authoritarian in dealing with physicians especially in cases where (like the Yves Smith blog post) - the mangers know far less than the physicians.  This managerial style is also disruptive.  Many health care managers think that they can implement any idea they wake up with that morning if they accompany it with enough "Change is good" or "Cost effective" rhetoric. All of this micromanagement and mismanagement illustrates that Dilbert has changed professions.  He is currently wearing a white lab coat.

The other bad news of course is that corporate control of medicine is not coming - it has been here for years.  In the case of psychiatry it has been here for 30 years.  Anyone who wants to see how corporate control of medicine changes things only has to look at the state of current psychiatric services or their "shortage" for a lesson.

George Dawson, MD, DFAPA

Managed Care - A Variant of Looterism?

I follow several economic and financial blogs and I came across this piece on looterism yesterday.  For those of you not interested in clicking on the blog post, looterism is defined as maximizing private benefit irrespective of a goal of creating value or "private benefit regardless of the damage."  The author is focused on economic examples like banking corruption.  If you actually follow the politics and corruption in our financial system there turn out to be endless examples.  Dao references an earlier paper that nicely describes the current dynamic of maximizing extractable value rather than net economic worth so that the current creditors are left holding the bag.

I can't think of  better example of looterism than managed care.  Starting at the top end, what exactly occurs when a managed care company decides that they are not going to pay for an inpatient hospitalization for a patient with suicidal thinking.  It gets more complicated in a hurry if that person has no housing, a history of actual suicide attempts, and a substance abuse problem.  What happens if they say that they can be seen in an outpatient visit despite the fact that visit is two weeks away and it will involve a 15 minute conversation and a prescription that  also may not be covered by the managed care company?  I am a psychiatrist - so all of these denials are abhorrent to me, but what is the economic analysis of this situation?

The economic analysis is straightforward.  The managed care company is not creating any value.  Their product is supposed to be patient care and the situation as I described it is anything but patient care.  Managed care advocates might say they are creating value by being better stewards of the resources.  That is quite a stretch when they have essentially destroyed inpatient psychiatric care by promoting their mantra that a person needs to be "dangerous to oneself or others" in order to get admitted.  Forget the notion that things are out of control at home and nobody has slept for a week.  If the patient doesn't use the suicide word in the emergency department they are not getting in.

That completely artificial barrier to hospitalization has destroyed inpatient psychiatric care as a resource.  People come in a crisis and many leave in the same crisis.  There is no time for stabilization or a thoughtful analysis of the problem.  Short crisis stays and inadequate reimbursement has a corrosive effect on staff morale, resources for the physical plant, and the quality of care delivered.    Less and less value is created.

Eventually, staff with expertise can no longer tolerate the environment - especially when they are seeing more people and they are less able to help them given the managed care restraints.  These staff leave and move to a more suitable patient care environment.  The loss of knowledge workers creates even less value but it is a critical strategy in extracting value from mental health services and putting it somewhere else.  If knowledge workers can't be demoralized managed care can always come up with a strategy to simply not pay them or pay them very little.  The outpatient equivalent of inpatient care is seeing high volumes of outpatients - often for the sake of producing billing documents.  The associated appointments are often low in value.

I would say that looterism is alive and well in the medical industry.  You don't have to look very far in the health care economics field or your own health plan.  The associated marketing campaigns that talk about high quality care associated with looterism should be cautiously approached.  But that is a story for a different day.

George Dawson, MD, DFAPA

Francisco Dao. Looterism: The Cancerous Ethos That is Gutting America.  August 7, 2012.

What does the Minnesota bill collecting scandal really mean?

The news this week in Minnesota was that the Attorney General had negotiated a settlement with Accretive Health Care over their collection techniques.  When I read the original articles and summaries on the AG's web site, it reminded me of a conversation I had with a psychiatrist many years ago.  He was hired by a hospital CEO who told him that he would be responsible for reminding patients that they needed to bring their insurance card for appointments.  I thought that was an odd job for a physician but chalked it up to the generally poor level of administrative and clinical support that most psychiatrists get.  One of his patients complained to the CEO about this process and he was fired. Another example of medical professionalism being compromised and then scapegoated by business practice.

I encourage anyone with more than a passing interest in just how far business practices have intruded and compromised medical practice to read the scenarios described in this Pioneer Press article.  Patient after patient describing a situation where they were confronted bill collectors when they were either critically ill or just before surgery.  The article also contain the industry's perspective:

"Point of service collections have become fairly standard practice." (page 6A, par 5)

The bottom line here is that this is really not quite the scandal that the Attorney General and the media are holding it up to be.  The reason is very simple.  Managed care is the dominant force in health care markets today.  They hold that position because politicians in both state and federal governments want them to have that kind of power.  As an example, Minnesota Statutes have managed care tactics written into them.  These tactics have misplaced any professional input from physicians a long time ago.  They use their own standards - many of which are made up within the industry and have no scientific backing.  Business entities do not have any ethical standards.  The ethics of a business are relative and depend a lot on the executives running it.  It is clearly acceptable to confront you for a co-payment or past due bill even if you were too sick to think about picking up your wallet.

There is no reason to expect that these onerous collection practices will not be routine in the future.  That should be obvious to anyone who can see that the influence of medicine and medical doctors is at an all time low.  We frequently hear from politicians and bureaucrats that physician influence is never coming back and we should all: "Get used to it.".  Hoping for a series of activist Attorney Generals is about all that's left.

If you are critically ill and somebody asks you for your charge card and looks irritated when you don't have it - you will have the managed care cartel and the government backing them to thank.

George Dawson, MD. DFAPA

Cristopher Snowbeck.  Patients, hospital see lesson in billing furor.  Pioneer Press.  August 5, 2012.

The $40 Call

One of  the local HMOs has been heavily advertising their nurse practitioner diagnostic line. It caught my attention because the radio ad was focused on wood tick season, and it suggested the diagnosis and treatment of Lyme disease could be rapidly made over the phone and that it could require e-mailing in a picture of the rash or tick.

I used to teach a course in medical diagnostics and diagnostic reasoning and one of the examples I used in that course involved expert diagnosis of rashes from photographs.  An important part of medical diagnostics is pattern recognition. There is probably no better example than the diagnosis of rashes and it should not come as a surprise that experts in rashes or dermatologists do a much better than physicians who are not experts. That is true both in terms of making the actual diagnosis and in the total amount of time that it takes to arrive at that diagnosis.

When I heard about this new service to diagnose Lyme disease based on photographs I went to Medline to see if I could find anything written about it. Managed care organizations and HMOs frequently advertise the fact that they are evidence-based organizations. I really cannot find any studies done on using the Internet or telephone consultation for the diagnosis of rashes or Lyme disease.

I think that this new service has implications for how the business models are impacting the practice of medicine. With all the talk about transparency it would be useful for the public to know the false positive and false negative rates for this diagnostic service. That certainly would be consistent with the literature on the misdiagnosis of Lyme disease.

From a purely economic perspective, it is interesting that the cash charge for this service is on par with the most common cash charge for seeing a psychiatrist in person. As I have previously posted, there is a wide range for the psychiatric charge and it is conceivable that this telephone service generates considerably more cash than a psychiatrist does sitting in a clinic, seeing patients, and doing all of the associated administrative work.

The next logical step for this telephone service is to have patient's complete a number of rating scales and be treated for depression. Whether it is Lyme disease or depression the diagnosticians with the greatest pattern matching and pattern completion capabilities are taken out of the loop.

George Dawson, MD, DFAPA

Another Lesson from the Business World

When you are in business  the goal is to make money.  The interpersonal aspects of that continuum range from "The business of business is business" to "The customer is always right."  An op-ed piece in the New York Times introduces us to another approach to making money and that is with the client or at the expense of the client.  A Wall Street insider gives us a rare glimpse into one of the largest investment banking firms and how their culture shifted over the past two decades to focus on profiting from their clients rather than profiting with them.  That same firm was already accused in 2010 of selling its clients mortgage-backed securities and betting against them.  A professor of corporate governance from the University of Delaware commented about how the structure of these companies changed as they became public and started to look for as many clients as possible.

For the same period of time the change in corporate governance of healthcare corporations has also gone through a revolution. There has been a shift from medical guidance to business guidance. Many if not most clinics and hospitals have changed their corporate governance so that doctors are subordinate to businessmen.  The changes are often very subtle but the overall process has a focus on making money rather than optimal patient care. There is plenty of window dressing along the way that is frequently sold as quality but the bottom line is that any physician or patient will generally sustain some kind of significant cost dealing with a healthcare corporation or pharmacy benefit manager.

When physicians are taken out of the loop, the business  of medicine is no longer treating illness and alleviating suffering but it becomes making money and the only way that happens is to profit from patients and get as much free work as possible from doctors.

George Dawson, MD

Nelson D. Schwartz .  A Public Exit From Goldman Sachs Hits at a Wounded Wall Street.  New York Times March 14, 2012.

Greg Smith. Why I Am Leaving Goldman Sachs.  New York Times March 14, 2012.