Thursday, April 7, 2016

The Downside of Corporate Medicine

The love fest for Kaiser has always rankled me.  Yes, they have good preventive statistics – but they would, wouldn’t they, isn’t that exactly what they would be good at, treating everyone the same?  It’s good to do so sometimes, but sometimes not.  I’m not of the school of “no cookbook medicine, please,” because sometimes cookbooks work just fine.  But decreasing variation and increasing quality is far from the whole story.  Corporate behavior has been chronicled too thoroughly – Dilbert! – to be summarily dismissed as irrelevant.

Consider this story given by a mother before the first year class of UCSF yesterday.  The patient was the mother’s ten-year-old daughter.  Her father was – is – a very productive family practice doc working for Kaiser.  They were all Kaiser patients, of course.  Unfortunately, the ten-year-old started losing weight and had other signs of anorexia nervosa.  They brought her to the Kaiser doctor.  The Kaiser protocol for anorexia nervosa states that the diagnosis of AN cannot be entertained for a child less than 13 years old.  Hence, instead of hearing the diagnosis of AN, the family was told that “we’ll see how it goes” and they would need to wait a few years before doing anything.

This is a faulty protocol.  AN happens to younger kids all the time.  Protocols can be faulty.  But the issue is, what course did corporate medicine take then?

The family protested within the Kaiser system.  The mother and the father advocated.  Corporate Kaiser resisted.  No change was made in the treatment of the child or in the protocol.  The family was admonished for protesting.  The child was taken to UCSF for the appropriate treatment.  That’s right, they had to go out of system.  Eventually, I imagine Kaiser will have to pay the medical bills, if the family is insistent enough.

Meanwhile, the physician father, who was a productive physician and had received a bonus for his work every year, this year was denied his bonus.

Kaiser is a prepaid system, and every disease means money lost; other systems are fee for service, so every disease means money made.  Thus, following the money, Kaiser advertises its preventive programs – Thrive!  If you are healthy, come to us!  Other systems advertise their cancer programs, their heart programs, etc.  One system is tempted to under-treat, the other to over-treat.  But the more they are all corporate, and the less the decision-makers in each structure personally face the patients they affect, the more they will all follow typical corporate incentives.  Sometimes it’s OK to do so – “population medicine,” figuring out what course of action benefits most of the people, is sometimes right.  Corporations can do this better than individual practices, probably (only probably, though, since nothing has been proved – in the end, money talks, and we don’t know what it’s saying yet.)

American medicine is becoming more and more corporate.  The profession itself needs to become aware of the pitfalls and erect ethical corporate procedures to protect the individual clinicians -- where the true repository of medical ethics will reside -- and their patients.  And the patients need to be viewed as the clinicians’ patients, not the corporation’s patients.  Or else inappropriate protocols will rule, and bonuses will be taken away from those who protect their patients and their daughters.

Corporations, my friends, are not people.

Budd Shenkin

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