He misunderstands the meaning of ‘profit’ versus pay. I am not talking socialism. I am talking about social concerns about societies members, not socialism

Everyone is entitled to fair pay for fair work, and fair pay reflects the skills and training needed to provide it. Pay, vacation, sick leave, etc, etc are all legitimate costs of doing business. They are not ‘profit’. Insurance company premiums include a portion for their expenses and a portion for the corporate profit, likewise pharmaceutical prices, equipment makes, etc, etc.

Human suffering is part of life, and caring for it is what physicans, nurses, and others
involved in health care provide, directly or indirectly. Profit, on the other hand, is an economic gain that does not go to the provider of the care, but to the shareholders in a
corporation.

I think it is ethically wrong to be generating an economic profit from human suffering. I think society needs to recognize that and rethink what parts of capitalism work (better than anything else in history) and what parts are not working, and rethink the system a bit.

peter glusker

I have a number of disagreements within his proposal which I shall address sequentially.

“it is ethically wrong to profit economically from human suffering” Why? It would be ethically wrong to *create* human suffering in order to profit. It is not ethically wrong to be paid for your services, particularly when they were provided to relieve human suffering. In fact, it is necessary if we want to have individuals and companies provide their services. When a roof is destroyed in a storm, is it ethically wrong for the roofer to profit from the repair? When your basement floods at midnight, is it ethically wrong for the only 24-hour plumber in your area to charge an extra fee for getting out of bed at 1 AM to fix your plumbing leak?

Dr. Glusker’s concern about profit being seen repeatedly in the value chain is somewhat misplaced in our society. Profit is what drives our economy – jobs and prosperity – without profit you cannot get goods or services. No owner or investor will create the jobs in the first place if they have no chance to be rewarded for their risk.

When discussing Medicare, it is important to acknowledge the growth of the program itself over time. Since the creation in 1965 by President Johnson referenced, it now covers chronically disabled, renal failure, electric wheel chairs and more. The promises made initially which resonated with the American public have been repeatedly expanded without the resources needed to fund such promises.

“This Health Board would require that all goods and services used for health care be derived from not-for-profit companies” – This seems untenable to me. It would require that there be non-profits effectively across all industries: steel, plastics, mining, manufacturers, service providers, etc. This would require an entire change in our capitalist system, which seems extremely unlikely.

Dr. Gasker states that non-gain objectives can enable the system he describes. Taken to its extreme, everyone would be paid exactly the same hourly wage because those who wish to do medicine will want to put in the extra effort for the good of humanity. I suggest that he read Freakonomics. This assessment of human motivation demonstrates repeatedly and convincingly that personal gain is our motivation. The gain can be as concrete as a car, less concrete as good public relations or as abstract as being rewarded in the hereafter. The ethical implementation of seeking personal gain is to do so in a way that you also meet the personal needs of others. At our base, we are organisms looking for every advantage to survive. We do so ethically when we choose to do things which benefit us that also benefit others. That is the nature of commerce and fair trade.

While many of us choose our career based upon our interests, what excites us, if we are not paid in some fashion, we do not eat, we cannot dress and we have no shelter. Profit is still required.

Therefore, rather than move to a socialist economy, I believe it would be a far better and more workable solution to provide a capitalist payment mechanism.

Peter Glusker

As physicians we all feel very passionate about our work and compassionate for our suffering fellow humans. But we will elect when we would like to provide our charity care, rather than an external entity forcing us to do it. In fact, we do just that every day – seeing patients with no guarantee of getting paid. Where is the compassion when we are denied our legitmate compensation on an ever-increasing basis? Compassion has to be a shared responsiblity in society, not just the domain of one group of professsionals….

Viewpoint

Issue Date: September 21, 2007

Universal health care that’s not-for-profit can work

By PETER GLUSKER

Universal health care provided by a single-payer system has been proposed as the most viable way to remedy the human, economic and medical problems created by the large number of medically under- and uninsured.

Examples of universal health care systems include the Veteran\rquote s Administration model, the Canadian model, or the systems of European countries. None of them offer a viable model for good-quality health care for our entire population because their costs are too high. In each of them, health care delivery is ineluctably dependent on economic profit.\par

All goods and services used in health care, from a simple Band-Aid to a brain scanner to insurance policies, are produced by companies that require a dollar profit for their shareholders. The profit portion is added to the actual dollar costs of production.

There are two things wrong with this system. First, it is ethically wrong to profit economically from human suffering. Knowledgeable friends tell me dryly that economics is not concerned with ethics. They are right, and wrong. Economics is one of society\rquote s tools for making the rules we use to govern ourselves. Law, education and care for our elder and disabled members are others. Economics is used to understand societies\rquote exchange of goods and services, but it\rquote s not necessarily just about dollars. Ethics can therefore be said to be included in economic issues, particularly health care.

The cost of the profit segment in each of the examples noted, at each level of production, creates additive real dollar costs. The cost when purchasing a Band-Aid includes a profit for each of its parts — the plastic, gauze, adhesive, packaging and marketing that are required to be paid by the Band-Aid company before it can sell its product and make its profit. Costs can be broken down further: for example, the source of the plastic, a byproduct of oil or another chemical industry, or the farmer growing the cotton. The profit portion is ubiquitous and multiplicative.

Any single-payer system we know is paying all these profit costs, which continue to grow as medicine and its tools become more complex. Detailed economic analysis of the real cost of any given health care item, extracting the profit taken at each level, is complex, but a rough estimate would put it at a minimum of 30 percent of the current cost of health care.

When Medicare benefits were initiated in 1965, President Johnson stated: “Since World War II, there has been an increasing awareness of the fact that the full value of Social Security would not be realized unless provision were made to deal with the problem of costs of illnesses among our older citizens. … Compassion and reason dictate that this logical extension of our proven Social Security system will supply the prudent, feasible and dignified way to free the aged from the fear of financial hardship in the event of illness.”

We have come to another critical crossroads, this time concerning health care for all of our citizens. We need to establish something like a Health Board, analogous to the Social Security Board. This Health Board would require that all goods and services used for health care be derived from not-for-profit companies. This board would certify that only the actual costs, including salaries, research and development, and so on, are charged for any item. The Health Board legislation would exclude shareholder profit from any health care item or service. The savings for existing programs such as Medicare and Medicaid would be large. In fact, the amount saved would probably be more than enough to pay for the actual costs of care for the whole population.

An argument against this concept of nonprofit production contends that no company would be interested in the development of new pharmaceuticals or technology without profit. Except where health care is involved, profit is certainly a legitimate goal, but it is hardly the only motive for our individual, corporate and social actions.

Our corporate-oriented society has lost sight of this fact. The overwhelming majority of scientists I have known in my professional career pursue their work mainly because of their intrinsic curiosity, not because of economic profit. We invent new technologies and therapies because of our insatiable human drive to know, to understand and, indeed, to care for our fellow human beings.

We must take the next socially responsible step to provide high-quality health care for all our citizens at an affordable price. The human cost of creating a profit at each step in health care is too expensive. The ethical cost is unacceptable if we are to survive and thrive as a society. A healthy population is more important than profit.

Peter Glusker is a physician and adjunct clinical assistant professor in the department of neurosciences at Stanford University Medical Center in Palo Alto, Calif.

National Catholic Reporter, September 21, 2007
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I generally agree with Mr. Cavale’s comments, particularly his points emphasizing the disconnect between our socialist payment structure and our capitalist cost structure, and the need to pick one economic construct for both payment and cost.

One statement is worth discussing further. If we choose the socialist structure, he suggests that physicians should “volunteer” with the knowledge of the system they are entering. There should be choice. Many are unaware that physicians may currently be seen as indentured servants by Medicare, limiting their ability to become “out of network” for Medicare.

Here is one brief example. I disagree with providing unneeded non-public data to get a National Provider Identifier (NPI – https://nppes.cms.hhs.gov/). I have been working with CMS for 9 months to get the NPI data collection form revised (still ongoing). To bill Medicare, I am being told that I must have an NPI, even though as a non-covered entity I am not required by HIPAA to have one. I support the *concept* of a universal identifier, but not this intrusive implementation which increases all physicians’ risk of personal identify theft. Until the NPI assignment process is fixed, I do not plan to obtain one. It appears that leaving the Medicare system is my only option. In order to leave the system, I must sign an affadavit stating that I will continue to bill Medicare for patients seen in an emergency according to their rules. I do not agree to do so.

The NPI issue is not the primary point, it was simply the catalyst. Have physicians lost our liberty? Will Medicare insist that I must remain a Medicare provider because I refuse to agree to their rules? I am trying to leave Medicare explicitly because I disagree with their rules.

I have always wondered why the SGR targets physicians exclusively for yearly cuts. Why do hospitals, nursing homes, DME providers, etc. not come under the same formula, if the same finite Medicare dollars have to be divided among all these providers?

And finally, I still cannot understand why Medicare and other insurers cannot get into a 21st century way of thinking. Modern practice cannot be sustained in the traditional “episodic care model”, especially for the ever-increasing array of chronic diseases, such as diabetes. There are well-documented methods of providing cost-effective and highly clinically effective care for chronic diseases by utilising technology and providing non face-face, “continuous care”. This will involve paying smaller amounts for ongoing care, which usually prevents “episodes” of emergency care, thereby saving the entire system vast amounts of money. This not only encourages patients to be more direclty involved in their own care but also allows for minimizing loss of productive work time needed for conventional office visits. I hope the Center for HSC picks up this challenge.

One point is worth emphasizing in regards to private insurer payments. As the oligopoly of insurers has contracted and anti-trust rules preclude providers from negotiating with the insurers as group, the insurers have used the physicians’ fear of possibly being unable to pay their bills (if they withdraw from a plan contract) to force non-negotiable contracts with ever smaller payments (and increasing administrative burdens). It is worth noting that some contracts are indeed tied to Medicare rates, some a percentage above Medicare rates and some 95% of Medicare rates or below.

Of the bullet items, I don’t think the first two would be beneficial. Perhaps looking at the constellation of Medicare payments there are some which pay better than others on an hourly basis, however, *none* would be considered “overly profitable”. Paying for “care management” simply creates another layer of bureaucracy, effectively removing more dollars from the system. Care management is what physicians generally do now. There are some circumstances where there are so many physicians treating a patient that responsibility is unclear, but this is much more a communication issue than it is a payment issue.

The third item is important. There may not be enough incentive for patients in the system. More importantly, perhaps, there is no disincentive for families, friends and caregivers to request unnecessary care or treatment which offers limited value. Factors outside of healthcare make it difficult for physicians to appropriately provide less care when that course is warranted. Since we spend approximately 20% of our budget in the last 30 days of life, it might make sense to focus on how we can ethically and appropriately reduce that number. Education about futility and the inevitability of death combined with appropriate financial incentives might help significantly.

The last bullet, I believe is the most important. Data about effectiveness is sorely lacking in the medical literature when it comes to cost. Sure, we have good data that aromatase inhibitors are more effective breast cancer fighters than tamoxifen. We have precious little data on how much more we spend to gain that advantage. Is Tamoxifen 85% as good as the best drugs but only 25% of the price? Do we care? We ought to care if we want to make policy decisions which optimize our limited healthcare resources.

With knowledge about cost effectiveness we could ensure that the most cost effective therapies were widely available. Perhaps the least cost effective therapies would still be obtained by individuals who choose to spend their own money, rather than our communal money, on their costly or low benefit treatment choices. This point may sound harsh to some, but why do we permit individuals to choose least cost-effective therapies now which limit our ability to provide more, cheaper care that saves more lives? I hope that we would choose to save more lives at lower cost once we have the data.

Ultimately, we will only spend what we choose to spend on healthcare. The budget is a fixed amount. Rationing tends to occur when demand is unlimited but resources are limited. Currently we have irrational rationing of Medicare resources. We simply cap spending and let the randomness in the system determine who gets services. We must move to more rational rationing and decide how we best distribute that budget more fairly among the patients so that each receives a comparable level of service from the system.