Capitalism Versus Compassion: Can Healthcare Do Both?
Adam Brown, MD MBA
Founder @ABIG Health | Healthcare Business Strategist and Professor I Healthcare Executive I Marketing and Communications Expert I Chief Medical Officer
Originally Published in MedPage Today at https://www.medpagetoday.com/opinion/prescriptionsforabrokensystem/104139
I’m the only physician in the ER. There are still several patients to see. The waiting room is overflowing, and the mountain of paperwork grows.?
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I know there are consequences if I don’t document what I’ve done, what I’ve seen, thought, heard, and who I’ve talked to.??
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But then a patient’s family member knocks on the door and says “Doc, can we talk about my mom? I’m worried.”
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I want to talk with this person. I want to talk about her mom’s prognosis and how her family should prepare. But I have other patients, and there is that mountain of paperwork. I speak with her, but I'm in a rush. She senses that.
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She is upset. But so am I. This family doesn’t feel like I’ve listened to them. And it’s extremely important that I do—for the sake of their mother’s health, but also to my mental well being as a caregiver.
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The simple act of taking time and listening is one of the most important components of patient care. But as physicians we feel we do not have time to listen, much less harness and demonstrate compassion. According to a University of Chicago study from last year, it would take a primary care physician 26.7 hours per day to see their average number of patients.
These facts have consequences. According to a survey by the National Partnership for Healthcare and Hospice Innovation, more than 82 percentof Americans believe the U.S. healthcare system puts profits over patients.
Healthcare workers enter the field to help patients. And patients expect us to help them. They want to be heard. They want us to listen. They want to be treated equitably, with compassion, and ultimately, to feel better. Compassionate care involves acknowledging and understanding the emotional distress and suffering of others, along with taking action to improve their situation through motivation and relational efforts.
That is not happening in the United States today — even though we spend so much money.
High Costs, Low Quality
According to Centers for Medicare and Medicaid Services, healthcare spending in the United States increased 2.7 percent to $4.3 trillion in 2021. That number represents $12,914 per individual or 18.3 percent of the nation’s total economy. And yet, despite the highest cost per person for healthcare, the United States has some of the worst outcomes for patients.
Care is not administered evenly throughout the country, and, according to The Commonwealth Fund, Americans experience worse health outcomes than their peers around world. U.S. life expectancy at birth was 77 years in 2020, three years lower than the average for other industrialized countries.
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Physicians?and nurses attribute burnout to the increasing corporatization of medicine, where companies prioritize profits over patients. Half of nurses are considering leaving the profession. Activists have criticized hospitals, both for-profit and not-for-profit, for shutting down their services in underserved communities. Patients and doctors are unhappy with the exorbitant prices of medications and prior authorizations. Meanwhile, insurance companies earn massive profits. In 2022, UnitedHealth’s revenues grew $36.6 billion or 13 percent from 2021, while hospitals and physicians face decreasing reimbursements.
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Blame for what ills the U.S. healthcare system flings far and wide. Maybe it is the influence of private equity. Or perhaps it is too many hospital mergers. Or maybe fault lies physician staffing firms, insurance companies, or pharmaceutical giants.
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There is a lot of anger. Still, nothing changes.
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Why are we here? Because profits, not compassion, drive our healthcare system.
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Are Capitalism And Compassion At Odds?
The truth is, the U.S. system is doing exactly what it is supposed to do: generate profits. Capitalism is founded on the ownership of private property, self interest (not common interest), competition, freedom to choose, and limited government. Adam Smith famously said, “It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest.” Now, replace butcher, brewer, and baker with investment firms, insurers, and pharmaceutical companies. Is it not the same?
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Of course it is.
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Which is why there are winners and losers. Those with greater scale ultimately win and those with less, over time, lose.
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Right now, based upon the levels of burnout and healthcare outcomes, it is providers and patients who are losing.
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Let’s look at private equity. Private equity has become increasingly popular in healthcare due to a straightforward strategy: buy a struggling practice or hospital, improve their performance, and sell them for a profit typically in four to 10 years. But what does it mean to “improve performance” in healthcare? Does that mean quality performance, physician satisfaction, or financial and operating performance? For private equity firms, it is the latter. In healthcare, this means optimizing operating efficiencies, reducing workforce needs, providing capital investments for innovations, and even reducing salaries in an effort to pad the bottom line. Quality improvement is important — only if there are financial reimbursement mechanisms attached.
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Is that bad? No, that is just capitalism.
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The same is true with private payers, hospital corporations, and pharmaceutical companies. Mega-health insurers (CVS Health, UnitedHealth Group, Anthem, Humana, and many others) are all stock traded. The same is true for pharmaceutical companies like GSK, Gilead, Bayer, Sanofi, and AstraZeneca. Even some hospital corporations are stock traded. And their financial goals are simple: generate returns that outperform the initial purchase price (i.e., make profit).
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To be clear, many of the people who work at these companies do so because they want to improve care. That is their mission, but despite their good wishes, the company’s reason for being is to make a profit.
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So should we, as physicians, nurses, and patients, be angered or blame the players in the capitalism game if they follow the laws and regulations? Should we expect them to have benevolence as their primary motivator when benevolence is not traded on the stock floor??
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The answer is no, but that does not mean we cannot change the system, or make it more compassionate.
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Policymakers can change regulatory policy, enhance financial support for the underserved, and rework laws so that financial incentives, market dynamics, and outcomes change. We need a balanced approach where:
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Capitalism clearly has significant benefits for healthcare. But capitalism without appropriate levels of regulatory control results in unequal treatment, hospital closures, clinician burnout, ignored patients and families, and an erosion of the social contract.