Big Oil, Big Pharma, Big Obama?
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  • rkka

    “That depends on how you feel about big bureaucratic corporations taking over American health care”

    Have you been hiding under a rock the last 20 years?? The health insurance industry has been determining who gets healthcare in the US for a couple of decades.

  • Glen

    You’ve finally nailed the big conflict: huge rules-driven corporatist government/industrial complexes controlled from the top by elite groups of highly-credentialed experts vs. small, distributed groups of entrepreneurial specialists pursuing different and unique approaches to common problems and collaborating closely via leading-edge communications technologies.

    Which one of these futures will yield the highest value for all of society? And preserve the most liberty for all citizens? The answer, of course, is obvious…

  • Anthony

    Two key corporate sectors (health insurers and pharmaceutical industry) and their lobbyists appear to be main beneficiaries of health care reform act – whereas, the costly part of the act inures to everyone else.

    Health care reform in America warrants a more thorough and systematic public discussion.

  • Kris

    Is this what the social engineers who redesigned the American health care system really wanted to do? … Was that the plan all the time, or is it a side effect that the health law’s framers didn’t fully anticipate or understand?

    Surely you don’t mean to imply that there is such a thing as unintended consequences; all that matters is good intentions!

    Doctors are interested in healing and in making money. If their overhead (bureaucratic, regulatory, litigative, etc) becomes excessive, it is inevitable that they will form cooperatives of whatever kind in order to offload this extraneous burden.

  • aallison

    Prof. Mead,
    Is it not obvious that the trend upon which you report is a step toward the only logical outcome, namely single-payer insurance? It’s ridiculous that the health insurance companies are skimming off half-or-more of the premium dollar; almost as ridiculous as the shared with Medicare delusion that the solution to rising costs is to stiff the providers (of which I am not one).
    Logic dictates that the correct approach is that adopted by HMO’s, namely that prevention is better than the cure, i.e., healthcare providers should be compensated on the basis of their outcomes.

  • Luke Lea

    Back before Medicare hospital semployed radiologists and anesthesiologists on staff at, by the standards of other doctors, modest salaries. Under Medicare they lobbied to have this changed to a fee-for-service formula based on the number of procedures. Now of course radiologists and anesthesiologists are some of the best paid doctors doing some of the easiest routine work.

    Maybe if real cost competition is reintroduced into the system hospitals will be forced to go back to the old system. I have no idea whether so-called ObamaCare will do this; the law is too complicated and we’ll just have to see.

  • dr kill

    I find it impossible to feel sorry for those who insist on ignorance in matters of personal responsibility. Is anything more personal than personal health?
    Every man for himself.

  • Corlyss

    “Is this what the social engineers who redesigned the American health care system really wanted to do?”

    Pray, how can one impute design to something as chaotically wrought and constructed to please this or that Senator to win passage? Deliberation and thought seem uniquely alien to the process of which Dame Pelosi claimed, “You have to pass it to know what’s in it.”

  • Walter Sobchak

    “Is this what the social engineers who redesigned the American health care system really wanted to do?”

    It wasn’t the social engineers, it was the hospitals themselves wanted and they are getting it.

  • George A

    This transformation in American health care is not altogether new, nor a unique result of President Obama’s health care law. The number of individuals, organizations and government institutions, have long been interested in interrupting the “private” relationship between a doctor and his patient. In many ways, this is a topic with an interesting and deep history. The most authoritative texts that I have encountered include Paul Starr’s The Social Transformation of American Medicine and David Rothman’s Strangers at the Bedside. The latter is particularly instructive because it demonstrates the rise of bioethics–the entrance of theologians and philosophers into many of the end-of-life debates that occured, especially after Karen Ann Quinlan’s family’s decision to terminate life support when she was in a persistent vegetative state. The construction of a large bureaucracy and increasingly integrated health care systems has been a long time under development.

  • Johnnz

    Hello from New Zealand. You should do what we do. Provide healthcare for all citizens. No charge. Takes away layers of beauracracy and overhead, helps people, costs no more and is good for people.

    No one wants medical so there aren’t that many freeloaders. I have extra insurance because I can afford it and so I can get faster treatment. I don’t mind extra taxes for those that can’t afford it. Happy to help.

    A dude from New Zealand

  • Mrs. Davis

    Other features of the program — making it easier for young adults to stay on their parents’ plans — How much does it cost? Who will pay?

    The evil, selfish, greedy boomer parents whose premiums will rise.

  • WigWag

    It is a side note that is slightly off topic but I wonder whether Professor Mead is as skeptical about “credentialism” in health care as he is about “credentialism” in law, higher education and other fields.

    He’s already told us that law schools are pretty much a waste of money; instead lawyers, assisted by modern technology can do most legal work without spending three full time years in school. All they need is a few short classes, an internship program, a certificate indicating that they’ve passed a test proving they know their stuff and some help from some really “smart” computers.

    I wonder whether he feels the same way about medicine. Is medical school a waste of time? Should surgeons be permitted to operate on Professor Mead or me without having wasted all that time in a class room? Shouldn’t a surgical proficiency exam be enough before a surgeon is allowed to saw open a cranium to remove a tumor or crack open a breast bone to perform a by pass operation?

    There’s simply no question that one of the ways to lower medical costs is to insure that students who practice medicine aren’t weighed down by hundreds of thousands of dollars of debt incurred in purusit of their medical education.

    I am curious whether Professor Mead thinks we should allow doctors to simply learn on the job the way he believes that lawyers should.

  • John Skookum

    “Logic dictates that the correct approach is that adopted by HMO’s, namely that prevention is better than the cure, i.e., healthcare providers should be compensated on the basis of their outcomes.”

    Which would immediately ensure that the sickest patients would become even more of a hot potato to be tossed from specialist to specialist than they are already, while a stampede ensued for younger, healthier hypochondriacs.

  • Drs Hubby

    Last year we moved cities and after 25 years my MD wife had to look for a new medical practice. When she began in the 1980s new doctors often bought the practices of doctors who were retiring. For $100k they’d get the equipment, the staff, and the help of the retiring old guy at taking over his patients.

    My wife looked at a couple practices like that, and we ended up deciding that with the current level of government regulation it just wasn’t practical. One desperate old doctor offered to GIVE her his practice. After some soul searching she decided she didn’t want it. She didn’t think she could keep up with the regulations.

    She’s now working for a mega-healthcare company.

  • Adoc

    Commenter #10 is correct. Some of the other comments are simply loopy.

    Making MDs employees of vertically-integrated healthcare systems destroys the patient-doctor relationship because allegiance and duty are directed away from the patient, in favor of the employer or the “system”. Docs and patients who surrender liberty in favor of security shall have neither.

  • looking closely

    >>Hello from New Zealand. You should do what we do. Provide healthcare for all citizens. No charge.

    Let me guess. . .you’re a young healthy person.

    There’s a charge for your “free” healthcare; you just don’t see it because it doesn’t come directly out of your pocket, but out of your taxes. (Or, if you don’t pay any, from the taxes of someone else who does).

    My multi-national experience with “free” healthcare systems (In Canada, Europe and Asia) is that you largely get what you pay for.

    Costs are ultimately contained by denying services and/or choices.

    EG, you need an ACE inhibitor? Great, you can have Captopril. Lisinopril work better for you?. . .sorry, you’ll have to buy it yourself.

    Need your hip replaced? Get in line. We’ll get to you in 6-12 months.

    Need coronary bypass surgery? Sorry. . .you’re too old and our panel of highly credentialed experts has determined that after age 70, your life isn’t valuable enough to spend $60k of State money to preserve. Oh, you want to pay for it out of your own pocket? Sorry. . .we’ve prohibited physicians from taking private insurance, because allowing them to do so would destroy our gov’t monopoly on healthcare.


  • looking closely


    I’ll make it even simpler.

    Start to treat physicians like intermediate level corporate employees, and (surprise!) they’re going to start acting like them.

  • Biff

    I’m in the healthcare field, and I’ve been both amused and appalled by the attitudes of so many involved with healthcare reform. On the one hand, they regard small practices – especially solo practices – with thinly veiled contempt for their “inefficiency” and focus on the bottom line, while on the other hand, they idolize the small town general practitioner, struggling mightily to understand why there is such a perennial shortage of general practitioners.

    A marketplace of small practices, each a small business, is chaotic, messy, and inefficient, while large organizations are seen as less prone to variability, more fair, more manageable (perhaps “more controllable” is a better way to put it), more efficient, etc.

    Despite lip service, “innovation” is not on the menu. Control and bureaucratic “fairness” are.

    This trend predates the Obama presidency by quite a few years, but it’s clear that the healthcare reform law has dramatically accelerated the process.

    Harvard Prof. Clayton Christensen considers the inverse relationship between healthcare regulations and healthcare innovation in his recent book, “The Innovator’s Prescription”. Worth a read.

  • Rob Crawford

    Fewer offices means fewer zampolit are needed to keep them in line.

  • GJB

    Another way ObamaCare is squeezing private groups out of existence is by reimbursing them differently than hospitals for the same procedures. My wife works for a group of cardiologists and the local hospitals get paid more by Medicare for performing some of the exact same tests they do in the office. This is forcing some of the groups to be bought out by the hospitals as they can’t survive on the lower reimbursements.
    It’s obvious that the gov’t feels it’s a lot easier to control a small number of large organizations than lots of small independent practices.

  • Rob Crawford

    “Hello from New Zealand. You should do what we do. Provide healthcare for all citizens. No charge.”

    Are you really this naive?

  • Joe Blow

    But… Occupy Wall Street says that we need more government involvement in our lives in order to smash corporatism!

  • Been There

    Also remember the image of herding cats. Government would look stupid going after thousands of solo doctors.

    Solo practitioners and very small groups pose a great difficulty to those wishing to impose “guidelines”. As you coerce the solo practitioners to form groups (by way of payment negotiations-both public and private), then force the groups to form multispeciality clinics, you reduce the number of interactions required to force your changes. The multispeciality groups are bought out by the 800 pound hospital gorillas and then the government has the providers under their thumb. Huge noncompete clauses force dissenters to leave town or pay large fines. Hospital administrators then become the watchdog of the government.

    It’s then easy enough for the unscrupulous government types to impose centralized planning on a handful of hospital chains than tens of thousands of solo practitioners.

  • JimGl

    I can only applaud the last few articles by Via Mead. What it is is “Progressivism”, Big Government, Big Business, Big Labor. It’s been around at least since Mussolini. Essentially the end of the middle class, and the Big three will come together and decide what’s best for us. It was popular during Roosevelt’s administration at least till Italy went to war with us. It never dies

  • Jesse Cole M.D.

    Yes, this is by design, not accident.

    Medicare now reimburses a hospital for more money when it’s employed physician bills for a service than an independent physician.

    The government figures it is easier to control 5000 hospitals with half a million employed doctors, than 500,000 independent physicians. In addition, doctors will answer to hospital CEO’s, who have a fiduciary responsibility. This destroys the physician patient relationship.

    The push for an Electronic Medical Record system is not to improve patient care. Rather, it is to apply population based guidelines to the provision of medical care. Within 5 years, it will be illegal to order any diagnostic test or prescribe any medication, or provide any health service outside of an Electronic Medical Record system.

    This means that if you are 68, and your physician orders an MRI, the EMR may deny it arbitrarily, based solely on your age and population guidelines, instead of best medical practice.

    As a result, hospitals are already pressuring doctors to practice according to their guidelines…not best medical practice…or threatened with terminiation or bad reports to the National Practitioner Data Bank.

    This is government/corporate medical practice. The insurers are along for the ride, but not the prime movers in this. It will end badly if not reversed, which is why Obamacare must be repealed.

  • Elizabeth

    People in favor of adopting a single-payer system tend to think of it as “Medicare for all” — unlimited healthcare, nearly free. How about “Medicaid for all”? What actually happens in other countries is very often that the negatives of “free” healthcare mean that the middle-class and above buy health insurance anyway.

  • Robert Sendler

    So Johnnz brags about a system that he pays extra money to avoid having to use…

    Bueller? Bueller?

  • ACS

    Of course it’s intentional. Democracy and human liberty is a blip on the scope of human history of power, control, domination, and tyranny. Modern “liberals” may employ the facade of freedom, security, and care, but they only mask the real intention of amassing power. It’s human nature, corrupt that it is.

  • I stumbled across the website of a general practitioner in southern California the other day. This doctor was offering specialized service to her clients. She was available 24 hours a day via cell phone or e-mail, she reponds herself within 20 minutes of a message, and she provides house calls. I have no idea what she charges, or how she factors her services into insurance requirements (if at all), but what a great idea. We need small business operating under the minimum necessary regulations. Small business is the heart of America. This includes health care, plumbing, food service, you name it. Small business is the foundation of a robust, innovative society.

    Doug Santo
    Pasadena, CA

  • LarryD

    The Progressive goal has always been single-payer, which ultimately implies that the entire medical industry works for the government, and if any insurance industry is left, it’s working for the government also.

    Krugman assures us the the horror stories about such systems are false. I say he lies.

  • Steve W from Ford

    If you like the direction of education in the US with its federal rule making, its sclerotic bureaucracies and its teachers unions and their take no prisoners approach to protecting turf, then you will LOVE the new health care system that will inevitably emerge from this top down overhaul.
    The saving grace in all this is that those most vulnerable to the depredations to come will be those souls unlucky or un-nimble enough to avoid the inner city school systems and thus too uneducated to understand the cruelty that has been perpetrated upon them in the name of “compassion”.

  • werbaz neutron

    My son has sold his medical practice to the local hospital, will go on salary and a 40 hour week or less, has gone back in the military reserve as their M.D. and got a big sign up bonus plus all sorts of perks through old age. He feels there is no future for him in private medicine any more. The hard left he feels has set out to demonize him and his peers and so he is doing a John Gault.

  • You wrote:

    “at the expense of large firms”

    Don’t you mean:

    “to the benefit of large firms”

    I think this must be a typo, no?

  • PTL

    One of the first acts of a Communist/Socialist regime is the destruction of the middle class. This has been going on since 2009 and progressing apace.

  • This is simply elimination of the “kulaks” in the medical field. Onto the collective farm for all of them!

    God help them if they refuse to heal on command.

  • It’s happening even faster than I expected — the demise of smaller entities in the health-care/health insurance sector as a result of Obamacare.

    And it will continue, if Obamacare is left in place, because our elected leaders will treat it as political candy … adding more and more “benefits” to it to buy votes, just as they did with Social Security … benefits that only the “public option” can provide, because it is not subject to the bottom-line discipline of the private-sector.

    Then the same elected leaders will mandate that ALL plans carry at least some of those “benefits” … even though it is financially unsustainable for them to do so.

    The endgame … the public option becomes the ONLY option; there will be NO private-sector insurance options left … and no alternatives or work-arounds to the judgments of the Powers That Be.

    Single-payer health care makes the PATRIOT Act look libertarian, with respect to its potential to threaten our liberty.

    Soft, cuddly, fascism.

  • jaed

    One point that has to do with Obamacare’s encouragement of this trend is that after doctors have been corporate employees for a while – when they are answerable to an employer’s policies, not to the patient and not to personal ethics – it will be far easier to slide over to making them answerable to government departments in their medical practice, in the treatments they recommend. The best interest of the patient, and the patient’s priorities, matter less than following the required policies and procedures, set by experts at the top with an eye to the greatest overall monetary efficiency and without regard for the particular patient.

    This pattern is devastating when applied to, say, education. Applied to medicine, it kills people. Doctors, like anyone else, have to live with themselves, and the way you live with this kind of situation is to withdraw into the emotional stance of a bureaucrat:

    “I’m sorry, but the National Practice Guidelines don’t allow for this procedure for someone of your age and BMI category.”

    “The computer system isn’t allowing me to order that test. But I can offer you a handful of pain pills.”

    “But you have to take this medication to alter your test values, even if its side effects mean that ultimately it will harm you. My ten percent quarterly bonus depends on all my patients scoring well!” (That last one not to be said out loud. But the financial incentive will profoundly affect the doctor’s conduct.)

    This happens already. As medicine becomes more centralized it will happen more often. Eventually there will be no escape from it.

  • Taco

    The bottom line is Obama is getting exactly what he wanted, even if the ‘law’ fails.

    Think about it.

  • Aggravated DocSurg

    To quote the estimable Prof. Reynolds, this is “a feature, not a bug” of Obamacare. It’s a whole lot easier to deal with (i.e., mandate levels of care, or lack thereof) physicians who are employed by large corporations, rather than independent practitioners.

  • Rick

    The heart of the healthcare plan was based off of laws from states that carry the highest health insurance costs in the nation. It did nothing to really decouple the insurance from employment paradigm which keeps costs very high for those outside that system, and forces those inside it to become far less mobile in order to keep personal costs low. It was over a 1,000 pages long…but why? Were the true goal to just expand access why that much (poorly defined) legislation and why an opening of the regulatory floodgates in a super regulated field? This was a conscious turning away from everything to do with the market and personal healthcare choice. It was a law to make the Vogons blush and added to it were an unknowable amount of new regulatory controls. This seems less and less like a law designed to save health insurance and more and more like one designed to hasten the end of private healthcare by destroying all the aspects that can drive costs down and increasing the bureaucratic entanglements exponentially. All at a time when we’re not training enough general practitioners already.

  • Laura Blanchard

    Given the direction that health care is going, my personal health care strategy is to eat right and keep fit until I come down with something awful and then drink myself to death with the highest-quality hooch I can afford.

    At 63, I expect the government health care money to run out (and private insurance to be completely unaffordable) about the time I become one of those “frail elderly,” so it shouldn’t take too much hooch.

  • Bonfire of the Idiocies

    Obama and the Democrats in Congress think “unintended consequences” are right-wing code words for conservative plans to kill their magical unicorns. They have such belief in their own “brilliance” that when their poorly-constructed plans fail, it must be due to sabotage. Sabotage = what the rest of us call “reality.”

  • Colin Elliott,MD

    I’m in solo practice.Because I do some things very well (I have 3 drug companies that want me to do clinical trials on some findings ) I can really low ball my general medicine fees. My office mgr has told me as of Jan my expenses for EMR and scrips will plummet my income.Now, I can make this up. I saw a patient who has sever RA yesterday for $20 bucks. The steroids I inject cost more than that.Another patient for very bad T2DM. He’s under control.Hasn’t paid in the last 8 visits. If I need to make more money for the overhead,it’s easy. But,bad for my charity patients

  • Iron Mike

    While I largely agree with the approbation heaped on Obamacare, it was actually Title 2 of HIPAA, passed under Clinton in 1996 that started the decline. I have been in private practice and employeed. Employeed is much easier, you work fewer hours and don’t have to run a business on top of seeing patients. But the administrators are getting more and more, well, uppity, considering they don’t bring in a dime of income and are really dependent on the physicians bill. Our medical staff has been forced to stand together to fight a lot of arbitrary demands. We are having some luck working with the board of trustees to curb administative power. Administrators tend to spend a lot of money on themmselves, money they did little to earn.

  • Kris

    Bonfire (#43) reminds me of this disquisition on Obama’s “America has gotten lazy” comments.

  • What this means is that being a doctor is no longer a “profession” but a job. Patients are treated by protocols, and docs are required to process a certain number of them per day. Efficiency means you don’t have time to be friendly and chat. Cold and efficient.

    Rationing will be done for the good of the people, not because a death panel denies you medicine.

    And most folks will get their aches and pains treated by chiropractors and self proclaimed practitioners who know little about scientific medicine but a lot about the art of medicine and caring for people.

  • “Is this what the social engineers who redesigned the American health care system really wanted to do?”

    Wrong question.

    Right question:

    Is this what the lobbyists for the pharma and insurance companies really wanted to do?

    Hell yes.

    Obama and Congress abdicated, the sharks circled, sniffed, smelled blood, attacked, bit, and are now eating.

    Bad guys win. Not complicated.


    “The rise of enormous, super-empowered HMOs closely tied to government regulations suggests we are headed further in the direction of building a corporatist, medico-industrial complex whose powerful lobbies will fight reforms, abuse monopoly powers and further congeal the American health care system into an unmanageable and unaffordable form that will undermine living standards while providing ever-less-satisfactory care.”

    This is the fascist-corporatist Hell-world Obama and his crony capitalist allies, enablers, campaign financiers, public sector union allies and the whole rest of the Blue World Evil Empire want to make us live. Everything you touch, see or deal with will be the public rest room at the Registry of Motor Vehicles, forever, unless you are in Tim Geithner’s armored limousine driving through the slum he and his pals are turning us into.

    The hour is late.

  • Walter,
    Forcing ever larger health care providers…is a feature, not a fault (at least too ObamaCareites). After all, when there are only a few very large, very expensive health care providers around, it will be much easier for the government to take complete control.

    Rich Vail
    Pikesville, Maryland
    The Vail Spot dot Blogspot dot Com

  • I distinctly remember the exact same phenomenon occurring when Hillarycare was working its way through America. It was in the press and I noticed it here locally and discussed it with a couple of my physicians. Then within a few years of its failure there were more stories of the doctors separating into smaller groups and practices, and again I noticed this here locally. Every physician I have spoken to have stated that their patients received lesser quality of care under the large practices. Another “unintended” consequence of large government.

  • richard40

    “Is this what the social engineers who redesigned the American health care system really wanted to do?”

    Obamacare is supposed to fail, spectacularly, but while failing is also designed to destroy any remnants of a private medical system before it completely crashes. That way the only viable alternative is single payer socialized medicine. Obama himself said as much, that any interim plan would be a stalking horse for single payer, to small leftist groups, before he was elected, but of course that was not widely reported. We have about 2-3 yrs left before his plan succeeds. Obamacare is not incompetant, it is brilliantly competant, if your goal is to destroy any possibility of a private US health care system.

  • AlbertG

    Having only large organizations to deal with also makes gathering bribes and payoffs, also known as “campaign contributions”, much easier…

  • Ladyantifarma

    There are many ways to reign in healthcare costs but the Special Interest Lobbyiests seem to get in the way. Every step you make in DC, one trips over a Pharma Lobbyiest. Just go to their PAC websites and look at the money they give each and every politician. Two of the larger companies are members of ALEC, which is a group of sleezy legislatures who get wined and dined by industry in order to go back to their states to sell Pork.

    Medicare needs to be able to negotiate prices with pharma, lab and devices companies. But the argument from pharma, for example, invokes fear. Well if I were the big pharma lobbying person making 2 million dollars a year, I’d fight for my job too.

    Stop picking on the physicians and get to the real root of the problems.

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