This is Comptetion?, Boston Globe, Aug 16, 2009

Ah competition, the wellspring of all our prosperity. Is this how we get anything done at the least cost no matter what? In some arenas it takes a nasty turn that is actually detrimental to the claims it wishes to promote. Some of this was visible in an article in the Boston Globe today. It's title, "You Don't Want To Go To War With Me," although exaggerated, lends some insight into the reality of who the so called competitors in health care delivery are and what they compete for:

http://www.boston.com/business/healthcare/articles/2009/08/16/hospitals_aggressive_recruiting_efforts_in_spotlight/

Apparently a CEO of one hospital center(Caritas) wrote an email to another CEO(Mt Auburn) and mockingly threatened(his post exposure assertion) that he would take retribution because Mt. Auburn hospital had attracted 3 physicians to their staff. But, as they say, the plot thickens.

Deeper in the article it portrays a medical world unfamiliar to the general public. We have a new kind of paid slavery, based on fears and a destructive outlook for physicians entering practice at this time. Hospitals actually barter and cajole to have physicians sign on a dotted line to exact a kind of unthinking loyalty and dependency. This is turning the profession into a 9 to 5 job with a resultant attachment to the institutions that hire them. It forces patients to become the pot of institutional gold and consequently erodes the focus of the very personal doctor-patient relationship.

Medical schools are imbuing their student wards with the notion that small practices just can not make it. It is not that specialty care is so attractive but the control one needs to enter primary care practice has become a mine field. The student yearning to be a general care doctor hears stories of complicated billing procedures, poor pay, and the time consuming task of building a practice along with their other learning. This naturally discourages them from entering primary care on their own. If they do so, they look for a sponsoring hospital or large group practice. They refuse to get involved in the "business side" of practice since it seems so daunting.

What is more disturbing is the mythology of why the path of being salaried is chosen. A kind of overlying belief system has evolved for these young to be healers. The true dismay for not becoming an owner in a small practice is covered over. The cover story for their choice reads that being an employee brings a better lifestyle, an assured income, and will provide more time for patients. This happens when the aspiring physician is told that working for someone else removes pesky business routines. Further with the introduction of hospital paid hospitalists, they become attracted to this service, since for a new doctor it is a time waster, namely taking care of your own patients in a hospital. We are selling one of our most precious societal traditions to a corporate kind of medicine. Unbeknown to the general public, we are losing the physician owned small practice who makes his living attending as fully as he or she can to the personal care of the patient.

It is not enough to whisk away this tie between patient and doctor. Hospitals also will either make deals for favored treatment from doctors, insurers, or medical service providers. The goal is to assure their hospital remains full and meets or exceeds a bottom line. This produces redundancies in a region with concomitant under utilization and decreased expertise. It is also counter productive raising expenses by setting off a whole new "competitive" strategy to make up the difference.

The nature of all this undoubtedly drives up medical expenses but extra dollars are not paying for any extra care. It is all going to feed this competition beast that the present system has fostered.

On the health insurance side the same methods apply. These companies secure deals with medical services that have "brand name" appeal and the ensuing negotiations drive up the premiums. It is the highest bidder who wins in this game. Even the entities that buy the insurance as a group negotiate rates. If you have enough so called skill or the clout in numbers, you get a good contract. Without the leverage you are up the creek without a paddle. Remember also the insurer is coming to your company after the other deals are done so this sets the bar at a much higher level to begin with. This is the source of double digit inflation of premiums. It takes human capital by the insurance company(very expensive) and a complicated bureaucracy to pull this off(very expensive). Marketing departments, contract negotiators, and accounts payable departments are not cheap.

Nowhere in these shenanigans has the patient been mentioned. They are the silent commodity in this exchange and their prescribed role is not known until all the processes above are completed. They are put into a take it or leave it position. If their employer thinks his insurance charges are too high the company pay in will be cut and the patient pays a higher percentage of premium. If the business can obtain other options, namely a lower premium plan, this will be chosen. The higher deductibles and co-payments will be shifted to the subscriber. The employer may even do both or drop the insurance altogether.

The rhetorical question, "Where are we all going with this?" Instead of ethical competition we get backroom deals and clandestine arrangements. The patient only becomes front and center when insurers and employers sell this ill gotten fruit. It is camouflaged with health clubs, store discounts, beautiful brochures and TV advertising(most of it directed to healthier populations). It is time for the press to investigate this and open the eyes of the public