The Profit Motive
At times I feel kinship with the Biblical quotation that I am “a voice crying in the wilderness, (John 1:23), particularly when talking about the role of money in medicine. To be clear, I understand “no money, no mission.” The issue to me has always been keeping a proper perspective. Thus, I am heartened by a new position paper from the American College of Physicians called “Financial Profit in Medicine: A Position Paper from the American College of Physicians.” As is typical for such papers, the language is quite detailed and I commend it to your reading, but their mission was to “consider some of the areas in which corporate influence and profit motive may have influenced health care.” Their “top-line” conclusion: there are insufficient data. They then go on to articulate principles they think are important, most of which echo themes I have outline here previously.
The accompanying editorial lays out the case concisely.
“We agree that profit should not be the paramount motive in medical care. The physician-patient relationship differs from business relationships in important ways and is grounded in the effect of illness on the patient. A patient with serious, new, or rapidly progressing illness may be unable to act as a savvy consumer in the market-place. Information about health outcomes and quality of care is imperfect, and the end result of any particular health concern is uncertain.”
While agreeing with the principles outlined in the position paper, they note the “quadruple aim” (improving patient experience of care; improving the health of populations; reducing the per-capita cost of care; and supporting health care workers to find joy and meaning in their work;) can be countervailing. Trying to maximize one goal may come at the expense of one of the other goals. This notion of balancing conflicting needs is one we have considered before in discussions of organizational resilience.
The editorialists believe the position paper could be strengthened by the addition of three more points. The first point is a recapitulation of the “no money, no mission” concept, although more elegantly stated.
“Second, ACP’s emphasis on the individual physician-patient relationship should be broadened to a population or community perspective, as the Quadruple Aim does…Additional modest steps would be helpful. Transparency regarding the salaries of executives versus median income of their employees would catalyze public discussion about how the hospital treats its workers in the community…”
Again, this is a topic we have considered in detail in discussion of staff turnover and its converse—team building. I don’t think the pay disparity is the only driver of discontent, but it certainly doesn’t help. As I said before, in the early days the “profit” went to the physician, now it goes to the executive.”
The last point the editorialists emphasize is the need for focused research, but admit getting these done is difficult, both intellectually and logistically. One of the problems with our preference for quantitative data is the ease of obtaining it when considering finance and the difficulty of obtaining it when considering human factors.
Having the American College of Physicians, an organization of which I am a Fellow, supporting some of the main themes I have articulated over the past seven years is encouraging in the sense I am not so alone, but I guess I am not feeling all that optimistic the paper will change anything.
First, expanding the physician focus from the individual to the group is difficult, at best, and a bad idea at the bedside. In my efforts to improve dialysis unit care, I found the only way to focus on the group was to set aside dedicated time in a conference room, not at the bedside (or chair-side in this case.) Since most physicians are still being paid by fee-for-service “productivity” measures, setting aside this time and paying for it is a necessary pre-condition. But even if pay is covered, it is still challenging to get physicians to shift gears from n=1, to n=x thinking. This is a skill that needs to be cultivated starting in medical school.
Second, in my optimistic moments, I believe the biblical Golden Rule should and can be applied in health care, both on the clinical and the business sides of the house. But in my more pessimistic moments, I believe the other golden rule—he who has the gold rules—carries the day. I doubt it is possible, or even desirable, to build a wall of separation isolating the practice of medicine from the business of medicine. On balance, I think the only way to constrain the profit motive is a degree of business regulation in healthcare that is probably un-American. However, I admit CMS is certainly trying. One of the issues, not addressed here, is the schizophrenia induced from trying to pursue profit on the insurance side of the business and to restrain profit on the government side of the business. But let me give the editorialists the last word
“In summary, the ACP position paper on financial profit in medicine provides an important critique of the profit motive in medicine and makes strong arguments for its elimination, reduction, or regulation. Concerns about profit in medicine as an end in itself, rather than a means to achieve ethically laudable health care missions, are warranted.”
25 October 2021
 Crowley R, Hilden D. Financial Profit in Medicine: A Position Paper From the American College of Physicians. Ann Intern Med 2021;174:1447-1449. doi:10.7326/M21-1178.
 Lo B, Grady D. Financial Profit: Not the Mission of Medicine. Ann Intern Med 2021;174:1466-1467. doi:10.7326/M31-3220.
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.
Capitalism in Medicine
Is capitalism, with its emphasis on markets, really the appropriate model for health care?
Conflicting Economic Models
Providers are being forced to take on financial risk for the cost of care as shown by recent news articles.
Meaning or Money
The question: is health care about money first or mission first?
More on Money in Healthcare
Hospitals account for the largest fraction of the healthcare dollar, but are usually hegemonic if not monopolies in their communities. Can Trustees call them back to their mission of patient care?
What Business Are We In?
All healthcare organizations have both a clinical and a business function. The proper balance is crucial for success.