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Confessions of a Health Care Hitman?


I’ve just returned from a conference on “pay for performance” run by the good guys in the US health care system. At the same time I’ve just finished reading John Perkins’ Confessions of an Economic Hit Man. The book is a great expose of the nuts and bolts of how corporate interests trampled over the interests of third world countries, and incidentally those of most Americans. I’m struck by how similar the story is to that of America’s healthcare system. Like the real story behind global economic development and empire, there’s a similar conflict in our health care system.

I’m also feeling shades of the personal conflict Perkins’ spends most of his book wrestling with. He made economic forecasts and consulted with the bad guys. He fully knew what he was doing. Using the big international agencies like the World Bank, he coerced and bribed the leaders of developing countries, until they put their own interests and those of their US corporate masters above those of their people. But while he claims he was knowingly initiated into the clan of economic hit men (EHM), most of his colleagues trying to modernize the third world were genuinely believed they were going the right thing. I’ve spent my career working with people in health care organizations, most of whom have had their hearts in the right place and have been trying to do the right thing. But in most cases their organizations were benefiting from some of the naked injustices inherent in the health care system, and were contributing to them.

As I said, most of the good guys in health care are working to try to improve the quality and efficiency of care delivered. Then there are those who deliberately destabilize the system and make money by pushing it in a worse direction. In Perkins world these are the EHMs who benefit from the system, and even worse the “jackals” who assassinate their opponents. Whereas in American health care the hit men and the jackals are the companies and their co-conspirators that hide behind well-funded think-tanks and use their market and political muscle to pass legislation that will be harmful to the poorest and sickest Americans. In this category I’d include the companies that promote underwriting and cream-skimming in the insurance market. But the vast majority in the health care system are working hard and conscientiously to do their best to make their little part of the system more efficient and more able to do good to more people.

Perkins’ book is a little too simplistic. There’s a story that Perkins’ anti-imperialist polemic doesn’t tell. It’s the story of how imperialism, aid and trade can be done right, and it’s the story of western Europe and Japan after WWII. In that story unstable governments with impoverished economies were pushed by their US funders and/or occupiers to conduct land and social reforms that helped create a stable middle class. In the end these policies created trading partners for the US that were a net economic good — if you believe in the benefits of global trade, which I do.

In the international system, there is a way out. If we were to promote fair trade, ecologically sensitive development, and policies that created sustainable growth, the rich nations could help create strong middle classes in developing nations. In the long run that would be better for us, as we’d end up with strong trading partners rather than getting blowback and promoting the conditions for terrorism and civil wars. And large corporations, if forced to by effective regulation (rather than buying off subservient governments in rich nations as they do now), would find that their long term prospects and opportunities actually improved — after all would they rather do business in Japan or Colombia?

I think the same is true in health care here in the U.S.. If we were to have a system that that covered everyone, which created regulated competition and that incented providers to do the right thing (such as promoting health care quality processes and improved management of the chronically ill), health care organizations would be able to do well by doing good. Instead we have a system that incents insurers to get out of the business of getting insurance to those who need it most, and, as leading clinical quality expert Brent James told my conference, rewards those physicians and hospitals who provide worse care with more money. That’s right, James’ hospital system (Intermountain in Utah) has significantly improved lots of its processes (such as reducing post-operative infection rates) and found that it lost money by doing this.

So the good guys in the system are starting to talk about changing this under the rubric of the term “Pay for Performance.” But the politics of health care is dominated by the hit men in the pharma and insurance business who do better by making the system worse overall for their own short term profits. And those of us who work with their organizations can either choose to believe that we are helping to make them see the light, or we can decide that we’re health care hit men too and that we’re deluding ourselves. And unlike Perkins, I genuinely don’t know which side those of us who try to tell the truth, but consult to the organizations that seem to have no interest in doing the right thing, are on.

Share  Posted by Matt Holt at 10:13 PM | Permalink

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