Particularly over the last 10 to 20 years, medical care has been vertically integrated so that many of us—most of us—are now working for larger health conglomerates. As part of this transition, more and more of our management is professional, with MBAs or their health care equivalent, running our working environments and collecting our billings from which they generate our salaries.
The Economist, a British journal, tells us that in 2022, the U.S. health care sector spent $4.3 trillion, or 17 percent of GNP. Much of this money is managed by health care intermediaries such as pharmacy benefit programs like CVS and large insurers such as UnitedHealthcare. The administrative side of our practices has moved out of our—the physicians’—control. This has been seen as a blessing by most physicians, as billing has become an arcane ritual and pricing opaque. But some professional management has become destructive to the larger house of medicine it is meant to serve.
The master of business administration is a powerful degree, but unlike our medical degrees, it is not ethically bound. Part of being a doctor is being part of a 2,500-year-old tradition that includes medical ethics, particularly not harming your patients. This is relevant as our billing practices seem to be harming more and more patients. This harm is evidenced by bestselling books such as An American Sickness (Elisabeth Rosenthal), Never Pay the First Bill (Marshall Allen), and The Price We Pay (Marty Makary), and blogs such as An Arm and a Leg. These become more and more popular because health care expenses are out of control and bankrupting more and more Americans. We are part of that. If we ethically observe our Primum Non Nocere instructions from our ethics, then we should not be driving patients into bankruptcy or collections in our efforts to treat them in the emergency room or elsewhere. We have to own this problem, even if it means leaving our velvet cages.
I’m sure there are doctor-driven profiteering schemes that we, as doctors, should disown, but the system-wide problem of money-driven health care is ruining our physician reputations and betraying the trust of our patients. When we treat people, we have to be careful we don’t harm them. Ruining somebody financially is harmful, and we need to see that this is not what we are doing when we assign our billings to our managers.
These managers may not see not financially harming patients as part of their job description, but if they are to be our agents, then they must respect our ethics. Many of our administrators are ethical and strive not to harm patients, but many are not and do not see any problem with pursuing possible billings to the degree that they cause bankruptcy or cripple a family’s ability to send their children to college, or buy a house or a car. The Economist, a British magazine, tells us that American health care system intermediaries comprise eight of the top 25 companies in the United States by revenue.
People in the U.S. owe $220 billion, with 14 million people owing over $1,000 and 3 million people, or 1 percent, owing more than $10,000 (KFF). We have saddled these people and their families with this debt in spite of the huge amounts of money flowing through the health care system. Enlightened self-interest should rectify this managerial misbehavior. If it does not, then those managers should be driven from health care.
G. David Leveaux is an emergency physician.
