Capitalism in Medicine
Podolsky and associates have reported on the impact of pharmaceutical marketing on medical practice. They start their discussion by reference to the lawsuit filed by the Commonwealth of Massachusetts and others against Purdue Pharma, the makers of Oxy-Contin, noting the suit is framed as an indictment of “unconscionable corporate (and individual) profit at the expense of the public’s health.” But, they note, marketing to physicians really started in the early 1950’s when drug companies began touting the benefits of new antibiotics for patient care. Pfizer, which was late to the game, hired an advertising firm led by psychiatrist Arthur Sackler, who was credited with creating most of the methods in common use today. In 1998, the Medical Advertising Hall of Fame, noted:
“No single individual did more to shape the character of medical advertising than the multi-talented Dr. Arthur Sackler. His seminal contribution was bringing the full power of advertising and promotion to pharmaceutical marketing.”
Despite periodic calls for restraint, pharmaceutical marketing amounted to $20.3 billion out of a total of $450 billion in revenue in 2016. Certainly, from the capitalist perspective, the pharmaceutical business is a great success—lots of products, lots of demand, increasing total revenue, and profit, all growing consistently.
Asch and associates have also taken a market-based perspective to the problem of medical care. In their analysis, the chief barrier to efficiency and productivity in the industry is the physician:
“The physician-patient encounter is health care’s choke point. So long as we continue to think of health care as a service that happens when patients connect with doctors, we shackle ourselves to a system in which increased patient needs must be met with more doctors.”
They argue that much routine care can be protocolized, therefore capable of being delivered by a bot, backed up by a nurse, and maybe, in exceptional cases with a primary care physician. “An efficient industry wouldn’t lead with primary care but would reserve it for cases for which lower levels of support haven’t been enough.” In making their case for “facilitated self-service” they note the need to abandon the legacy payment systems, which, in their view, persist because of fear of over-utilization. Secondly, state-based licensure and regulation needs to be abolished, to facilitate national competition for this self-service care, which will bring the price down. In their view, this would be an enormous improvement, even if helped only a small fraction of the current population of patients. Although not explicitly stated, the authors assume their analogies with other capitalist enterprises is appropriate and represent things medicine should adopt. I believe their analysis misses the challenges of medical care, where the vast majority of patients are not activated to take care of themselves, even with assistance from professionals. Their faith in business solutions seems likely to exacerbate the spread between the haves and the have nots, when it comes to medical care.
On 17 April 2019, my local newspaper reported 11 local medical professionals were indicted by Federal prosecutors on drug charges. Several have attorneys who are claiming publicly their clients are hard-working, essential health care providers. I have no knowledge beyond the reported indictments, though I know most of the physicians listed in the article. Perhaps they thought they were engaging in a capitalist enterprise—there is a market for opioids, and they were prepared to meet that demand. Of course, the same could be said of Mexican drug cartels and the Federal prosecutors clearly think these were not legitimate medical enterprises.
Taken as a group, these articles illustrate our current schizophrenic state of mind. If equipoise is defined as the ability to hold two or more contradictory ideas at the same time, it seems we don’t have it when it comes to healthcare and capitalism. If you own stock, or work for a large pharmaceutical company, selling drugs is good. If you are a licensed medical professional, selling drugs will get you indicted. The conflict between a “free-market, capitalist” approach and a “governmental, regulatory” approach is obvious. Yet we would argue that both are good. We complain about the cost of healthcare, but applaud the profit motive, except, of course, for providers.
I was talking to a group of financial professionals the other day and we got into a conversation about health care costs from a personal perspective. There are two problems with the capitalist mindset when applied to healthcare. First, we may or may not decide to buy a new car, depending on how much it costs, but when we are at risk of dying, cost becomes no object. Second, the people deciding what we need, including not only doctors, but everyone else, are spending someone else’s money in making those decisions. Thus, we have a system where demand is virtually unlimited and there are no cost mechanisms in place to restrain that demand. So, the market economy paradigm isn’t a realistic reflection of what goes on.
It seems to me the conflict between the long-standing professional (and fiduciary) obligations of the physician and the profit driven motivation of the large corporation, be it a health system or a pharmaceutical company, are being resolved in favor of the latter in ways that are bad for patients. This is not meant as a defense of the status quo, which is not sustainable, but really a call to look a little deeper at our assumptions and the sources of conflict. I suspect what everyone really wants—a humane, patient-centered, clinically and financially effective health care system—will not evolve without it. Is a market-based approach really the appropriate model for healthcare?
12 May 2019
 Podolsky SH, Herzberg D, Greene JA. Preying on Prescribers (and Their Patients)—Pharmaceutical Marketing, Iatrogenic Epidemics, and the Sackler Legacy. N Engl J Med 2019;380(19):1785-1878. (May 9, 2019.) doi:10.1056/NEJMp1902811.
 Asch DA, Nicholson S, Berger ML. Toward Facilitated Self-Service in Health Care. N Engl J Med 2019;380(20):1891-1893. (May 16, 2019.) doi: 10.1056/NEJMp1817104.
 The Jackson Sun, 17 April 2019, page 1.
Big medicine may be financially necessary, but it poses risks unless care is taken to become a real system, which requires putting the clinical enterprise at the center.
Equipoise can be defined as a state of equilibrium or counterbalance. We would do well to seek it both personally and as institutions.
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