Mercenary Medicine vs Mercy Medicine

Morass of the masses

Medic of the moment

Mallet, musket, or missile

Morality is of little measure

Money is what matters

Medicine is not a medicine

Modus of the movement

Mists of memory

Minister, meaning, mending

Mother is the model

Mercy is who moves

A lesson from 30 years of trying to figure out how to substantially move healthcare toward what it could and should be. This is the foundational lesson and the hardest: both the problem and solution is us.

Context

They say a picture is worth a thousand words:

Can someone please explain how any of the things we are talking about doing toward getting to sustainable healthcare are going to solve this problem? There is no sustainable point on these curves. And all the efforts toward sustainability of the last 20 years have not changed the direction we are headed. Why do we think our current similar efforts are now going to make a real difference?

It is not hard to understand why these trends have not curved down but only accelerated upward when we "follow the money" around those who make the rules and govern:

In 2023 approximately $824M was spent on formal lobbying of the U.S. government by healthcare entities, making up nearly 30% of all lobbying. Healthcare lobbying is far bigger than "big oil" or "big tech." The numbers are expected to be higher for the 2024 election year. When we look at the data by year, healthcare political spending has exploded over the last 25 years. This is just the formally recorded lobbying, and does not include campaign contributions and the very large amounts of "dark money" flowing from industry into political super PACs and similar channels of influence out of public view.

He who has the gold makes the rules.

The Problem Crystalizes

By this point around 2019 I had spent a quarter of a century trying to make a difference, finding a way to make a difference in one way but then discovering there were deeper layers underlying the present layer. If we were to build something enduring and of substance, we needed to find what the present layer was built upon. Repeat.

Stanford Medicine X conferences had been part of my lab and classroom on this journey for a number of years at this point. The mix of patient activist influencers, healthcare CEOs, massive social media engagement, partners from international design firms, innovators and entrepreneurs from Silicon Valley and internationally – I loved the dynamic mix that made up this cutting edge, with its palpable potential for something transformative. I did talks several years. And learned a lot from many different people from all these realms of life.

In the latter portion of this time, after working with several tech start-ups on a semi-formal basis, the foundation of all things in the healthcare space sharpened into focus. The greatest, most cutting-edge innovations, that could help patients "treat the cause" and not just the symptoms, and save the healthcare system money, were resulting in what? The definition of success was to build one's start-up into a viable product and then sell out to the highest bidder. And who were the highest bidders? Ultimately, the current "big boys," the ones with the large marketing budgets to sponsor things like Stanford Medicine X conferences: insurers, pharmaceutical companies, etc. So they could continue to dominate and control the healthcare space. And make ever-increasing profits.

Light bulb: All the best innovation, even from the outside, just feeds the beast.

There was our problem. Of course it had been there the whole time. But obscured, in the mists. Now it was naked. No clothing. No fog. No layers of systems and chaos to obfuscate. Our problem was us. Our greed. Our values. Our mercenary healthcare space.

How did we get here? It felt like we were the frog in the water that had been slowly increasing in temperature. Our goose was about cooked. But we were used to it. We thought it "normal." Like it is "normal" to have diabetes, heart disease, and obesity.

The Illusion

We always talk about "sustainable" healthcare, saving the system money with better care, the triple aim, quadruple aim, quintuple aim, etc. Money is always central. But we assume it is supposed to make sense for society, for all of us.

There was the East Coast guy I met many years ago who was building a $20M wood and glass scandinavian-themed high-end fitness center as a hobby and something he thought was cool. He had come to our lifestyle medicine clinic to get acquainted and talk about the lifestyle space. Where did he get $20M to throw at this recreational pet project? His wife called it "legal spying." His company would be hired by a pharmaceutical company to spy on their competitor pharmaceutical companies. Pharma talks a big talk about R&D expenses to come up with breakthrough products for patients. Their primary objective is to break through their last profit record to the next one.

There was the West Coast guy I met as a social event. As we chatted I discovered one of his hobbies was his racing yacht, for which he paid a full time crew. He was exceedingly wealthy. He was on the board of one of the Blues in his state. What a great opportunity to talk to someone in a decision-making position about the potential financial benefit of lifestyle medicine – treat the cause and it would save a lot of money. I cringe thinking of how naive I was back then. He started laughing. At me. Not with me. "Let me tell you how this works," he said, still chuckling. "They present the figures on the highest charges allowable by law that year. We vote to accept them. And we are done." I was stunned. He wasn't trying to be mean. But I was being schooled.

It really is all about the money. The powerful's money. Not our money.

The Confusion

There have been many lessons learning how backward and nonsensical the actual mechanics of the healthcare space are. They are not at all logical from an outside patient or clinician perspective.

There are the insurers. The medical directors look at the science and say this lifestyle program to reverse killer diseases has good solid evidence and would be great for our patients. But they are not the decision-makers. The CEO or other business executive looks at the business dynamics and how the cardiologists may be upset and tell their patients that life-saving care is being denied to them. The patient-employees will complain to their employers that they are being cheap on their healthcare. And the employers may then purchase next year's insurance from a competitor. Superior, evidence-based care does not get to patients. But the dollars keep flowing. Which is what matters most.

The reality is that there are many, many misaligned incentives in the healthcare space. They make someone in the middle money in the short term, but cost the rest of us and patients sustainable quality care. Our costs keep going up, for less and less.

The easiest way to understand this chaos is this: the more money that flows, the more potential there is for more profit. It is not a simple sell-for-more-than-you-buy transaction formula. Patients and clinicians don't understand this hidden chaos of many misaligned incentives. Sometimes those involved in the business and operations deeply enough for long enough actually state what is happening, like Shawn Martin, CEO the American Academy of Family Physicians, at the recent ACLM 2024 conference. He essentially had to admit that he didn't see a way to substantially change things because of the many misaligned incentives throughout all of healthcare. Keeping it messy makes money.

It is keeping the realities of the money flow hidden that allows all this to continue.

The Bottom Line

Humanity. Humanity is the bottom line. The problem. The solution. Our values. Who we are. Are we mercenaries? Or are we caring fellow citizens? Do we continue to participate in this modern phenomena of taking advantage of fellow citizens who are sick? Or does mercy move us to get out of the near boiling water and back into the sustainable pond of mercy that has been our motivation for healthcare for most of human history? Will we do something about it?

When I talk with other leaders in healthcare about the dominating foundational profit motive underlying healthcare, I get one of two reactions:

A. I must have five eyes and three heads to think of challenging the its-all-about-the-money motive. "Good luck with that!" "I want to accomplish something in my lifetime." To think of getting out of the boiling water is...unthinkable. There is nothing else.

B. Discouragement and depression. They recognize that we are fundamentally stuck and all our good intentions and best efforts are building sand castles on the beach–cute for the moment but soon to wash away. The problem seems overwhelming and insurmountable.

We usually just don't talk about this scary reality. We definitely don't seriously challenge the status quo. On rare occasion someone will dare to say that patients must take priority over profits, like Dr. Wayne Jonas at the 2024 ACLM conference. As correct as he is, it is like shouting at the clouds. There is no tangible next step or action to be taken.

The reality is there is only one path that leads to sustainable healthcare. It is not the path we are on. We must deal with human nature. There is no alternative. We must rediscover our compassion. And put it into action. We choose the nature we will manifest as a country and a society. Killing healthcare CEOs is not the answer. But it is the kind of thing that will increasingly happen, until we change course. Radically.

Mercy medicine is worth living and dying for. Mercenary medicine is...just dying. A very few with a fistful of dollars, and many, many with empty hands.

Will our medicine be a medicine? Who are we?

#Sustainable Healthcare #HealthcareInnovation #HumanCenteredCare #ProfitVsPatients #MercyMedicine #HealthcareTransformation