HARVARD GAZETTE ARCHIVES

Conflict Seen Between Profits and Patient Care

By William J. Cromie

Gazette Staff

Health care in this country is being threatened by commercial health providers who are more interested in profit than patient care, say two Harvard faculty members.

Francis Moore, Moseley Professor of Surgery Emeritus, and John McArthur, Baker Professor of Business Administration, Emeritus, want to address the problem by creating a new private agency.

"We propose a new national agency to set standards for corporate medicine and prepaid health plans," Moore notes. "This agency must be independent of physicians associations, hospital associations, and corporate associations. It will deal with social dimensions, such as community responsibility and excess diversions of precious health-care funds to executive and administrative costs."

In yesterday's issue of the Journal of the American Medical Association, Moore and McArthur refer to the current "invasion of commerce into medical care" as "an epic clash of culture between commercial and professional traditions in the U.S." The quality and scope of medical care is being "overtaken by the commercialism ethic and by corporations seeking profit for investors from the care of the sick."

The threats they see include:

Diversion of funds for the care of the sick to such corporate objectives as dividends, advertising, and executive salaries.

Increased prices and/or decreased services could cause a rise in the level of the threshold income below which family costs of medical care must be borne by government or charity.

Exclusion of individuals and families from coverage because of prior disease, genes that raise the risk of disease, or high cost of treatment. Such risk avoidance denies care to those most in need and is not characteristic of national health insurance in other industrialized countries, Moore and McArthur maintain.

Downgrading of caregivers. Highly qualified but costly personnel are being replaced by others with less experience and lower salaries.

Managed costs versus managed care. Care may be managed to minimize costs and even maximize profits rather than to foster the welfare of patients.

Loss of free choice. Free enterprise usually leads to competition and increased choices for consumers. However, free choice cannot operate in rural areas, smaller communities, or inner-city areas where population and financial resources are insufficient to attract more than one health plan or HMO.

"Whether by voluntary self-regulation or by the passage of . . . legislation, minimum standards will inevitably be required to abate some of the hazards to society and abuses of patient care arising from commercial pressure on professional behavior," Moore and McArthur believe. Such standards for medical commerce "urgently require establishment of an entirely new sort of agency, ideally in the private sector, free of control by individual and institutional providers, government, insurance corporations, consumer advocates, professional societies, or hospital associations."

They suggest that the launching of such an agency might be supported by grants from national charitable foundations.

Existing Safeguards

Not everyone concerned with the issues raised by Moore and McArthur believes that a new bureaucracy needs to be established. "It is more to the point to redirect existing structures to suit the specific standard-setting needs of current commercialism," according to Linda Emanuel, formerly associate professor of medical ethics at the Medical School and now an ethicist at the American Medical Association. "New programs and initiatives have emerged in many existing organizations for the purpose of maintaining physician and service organization standards," she wrote in the same issue of the journal.

These organizations include the American Medical Association (AMA), the Joint Commission on Accreditation of Healthcare Organizations, and the National Committee for Quality Assurance.

Emanuel notes that "the Ethics Institute of the AMA plans to create this kind of accountability. It will establish a database on health-delivery organizations . . . to evaluate how well organizations permit the upholding of . . . previously identified professional and ethical standards of practice . . . This program uses market tools, leveraging the powerful effect of reputation for ethical or unethical conduct, to insist on professional standards no matter how aggressively commercial the business setting."

Moore and McArthur, however, want the proposed agency to be free of such organizations. "We are, of course, enthusiastic about the extensive work done by the AMA and others in ethical concerns at the patient-doctor interface. But we must move beyond that to a new independent agency that can speak for everyone."

The federal and state government also have a role to play, according to a recent report from the Institute of Medicine, part of the National Academy of Sciences. The federal government should monitor the effectiveness of quality assurance and accreditation, and promote improvement in the tools used to measure health-care quality, according to the report Managing Managed Care: Quality Improvement in Behavioral Health.

The report also cites a need for managed care organizations to provide consumers with a clear description of a plan's benefits, and should work to create straightforward grievance procedures for patients.