Sunday, March 22, 2015

Money as the Enemy

Dr. Danielle Ofri is a practicing physician, as well as a prolific author. She writes often about medicine and the practice thereof.  She recently penned a thoughtful (they always are thoughtful) article about the increasing role money plays in medicine and the delivery of health care. She begins below:

"In mid-January a patient called me from her pharmacy, frantic. Her asthma inhalers came to $168—a sum that she hadn’t been prepared for. But she can’t live without those inhalers, so she withdrew cash from her meager savings account and skipped her blood pressure pills for that month.

This is such a familiar story by now that it hardly makes news. Yet it is tragic, every single time.  Beyond the fact that it is monstrously cost ineffective, there is something just plain wrong about it.

Money, of course, cannot be ignored in medicine. But just because money is a realistic consideration in medicine, doesn’t mean that we have to blindly accept all the consequences..."

Read her full article here:

I often respond to Dr. Ofri, because I find her articles both stimulating and thought-provoking. My response is as follows:

You are correct when you assert that earning money is not in itself an evil thing. But it is that same old saw, “guns don’t kill people, people kill people.” And I could add, “Alcohol doesn't kill people, people with too much alcohol kill people.”
Why do these three things all say the same thing? Because excess is itself a bad thing.  Is big bad? Well no, but too big is bad.  When an entity, a bank for example, becomes “too big to fail”, then it must be judged too big to exist and should be broken up.
Money in the medical system is not in and of itself bad, but in the pursuit of more and more money, the chase begins to crowd out the central purpose of the system.  As money begins to dominate any system, the other relevant criteria of “goodness” are moved aside. We understand that corporations exist to earn money, and that means drug companies, insurance companies, medical device manufacturers, hospitals, and, even medical practitioners.  They all wish to make money.  Yet, in this vast system, if the health and well-being of people—patients—in the system becomes lost, a casualty of the financial aspects, then the entire system becomes meaningless. That is when money becomes the central evil—when it drives out the main purpose of any system.  In health care, the central purpose of the system is to maintain a full population at its expected state of health and well-being.  When folks are trading off one element of the system –say drugs to control blood pressure—in order to obtain and use another element—say asthma medication, then that system is by definition operating suboptimally.
But I should add at this point that all of our systems in this country have moved in that direction. We are trading off optimal performance in order to either reduce cost, or increase income/profits. You can observe this phenomenon in system after system. In the broad range of consumer products, by shifting to a single criterion—cost—we have opted for a consumer product system in which we produce garbage in China for sale in America, regardless of the consequences in terms of performance. Quality in this system is no longer a relevant criterion.  Reliability is nearly irrelevant.
In perhaps the most egregious example of this phenomenon, Banking, the pursuit of ever greater profit margins and ever greater CEO salaries and bonuses, we have produced an almost completely useless system that operates at the “out-of-control” stage almost continually.
In Education, we have begun to dismantle a system that has worked reasonably well over a very long time period, and we are shifting to systems that, not only do not work as well, but almost by definition are seriously flawed systems, because they favor money over performance.  In that system, we have begun to rid ourselves of the task of educating our population. Why? Because it costs money, and, not coincidentally, it produces a population capable of thinking and potentially rejecting the politicians who favor money over performance.
And so it goes. Money has become not merely the most important criterion in our systems, but is closing in on becoming the sole criterion, with all other criteria being relegated to nominal performance criteria.
And the saddest part? This has been happening with relatively little outrage on the part of the affected population.  We are all sitting around, sucking our collective thumbs, while distracting ourselves with video games, Facebook, Twitter, and March Madness.   Meanwhile, the 0.1% continue to acquire all the available money in the world, while we sink into a morass of our own making.
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