Imagine a well-written book, on an important topic, that you can read online for free. Making a Killing: HMOs and the Threat to Your Health, by Jamie Court and Francis Smith (Common Courage Press, Monroe, ME, (www.makingakilling.org/?), paints a troubling tale of what has become of our health care system.
Jamie Court and Francis Smith have written a searing, well-documented indictment of "corporate medicine" as practiced by HMOs. American medicine, the authors contend, has been taken over by the avarice of the corporate marketplace. "The doctor-patient relationship and its concomitant social values of trust and confidentiality have been eroded by the search for profits," the authors write. HMO doctors are frequently overruled on critical medical decisions by utilization reviewers in distant corporate headquarters. These reviewers are often little more than what the authors describe as "clerks with no medical license."
Not only does the search for profits endanger patients (and the book documents some truly horrifying examples), it also results in a "colossal waste" of health care resources. The United States spends more, per capita, on health care and covers fewer people than any other Western nation in the world. Where does the money go? According to the authors, 20 to 30 percent goes to corporate overhead and profits.
Profits-before-patients is easily translated into corporate-dominated medicine. Greed and focus on stocks, stock options, and quarterly earnings rapidly degrade health care services. The professionalism of physicians and nurses is undermined by the juggernaut of commercialism über alles.
The critical relations of care and compassion between server and patient are replaced by categorical protocols imposed by corporate bureaucrats commanded by monetized minds at the top of the corporate hierarchy.
The exercise of judgment, discretion, and mercy at the server-patient level is relentlessly eroded by the forces of mammon the giant HMOs, their masterminding corporate law firms, and their political allies who safeguard their immunities and privileges in the face of growing public and professional outrage.
This was not the way it was supposed to turn out, at least in the minds of the pioneers of prepaid medicine. Commencing in the 1920s with Dr. Michael Shadid's mobilization of poor farmers around Elk City, Okla., to form the first cooperatively owned hospital in America, and then the Puget Sound and Kaiser Permanente health care plans, the ideal was to create quality health care with attention to preventive services within an affordable system of prepayment.
In the 1970s the federal government began encouraging the formation of health maintenance organizations whose nonprofit status and prevention orientation were believed to be well suited to curbing the excesses of the fee-for-service system, with its incentives to sell too much to patients. As costs annually far exceeded the general inflation rate and health care absorbed a greater percentage of the GNP, the alternative of "managed care" emerged as a way to control costs. A dominant format also emerged the giant, for-profit HMOs and their entrepreneurial billionaire bosses securing large clusters of customers and seeking more and more mergers.
A series of perverse economic incentives (gag rules, bonuses for not referring, and the like) were insinuated from top to bottom so as to seriously compromise the independent clinical judgments of physicians and other health professionals, often turning the pocketbook allegiance of the health care servers against the interests of their patients.
The giant HMO and its deepening swamp of commercialism over service, of profiteering over professionalism, of denial or rationing of care where such care is critically needed, of depersonalization of intensely personal kinds of relationships, are spreading without sufficient disclosure, accountability, and structural responsibility, to the detriment of life and health.
Workable alternatives are available. The underfunded Canadian universal health care system is still probably the best in the world, despite attempts by companies and corporate ideologues in North America to undermine and weaken it. For around 10 percent of its GNP, Canada provides health care for everyone from the cradle to the nursing home. Its administrative expenses are about 11¢ out of each dollar, compared with double that in the United States which this year may spend 14 percent of its GDP on health care, even as it leaves tens of millions of men, women, and children without coverage.
In Making a Killing, Jamie Court and Frank Smith make this story and its lethal consequences painfully clear. They searched and researched evidence, from inside the industry, the public records, the court judgments, and the documentation of personal tragedies flowing from HMO priorities, and they found patterns, not just episodes or examples. It is the system that swoops the savings from rationing and curtailment of needed care upward along the managerial ladders where the rewards grow larger and larger until they mock the very adjective "obscene." Venerable institutions and traditions in need of improvement are instead shut down and destroyed before the onrushing corporate Moloch.
This book moves from a description of corporations making medical decisions, the ensuing harm, the predictable frauds, and the shunting aside of community servers toward solutions for institutional reforms and suggestions for self-help by patients and their families. The authors know well that while information is the currency of democracy, it will take a stronger democracy to achieve the desired changes.
As the only Western nation without universal health care for its citizens, the United States is long overdue for a change, and this highly motivating book should help band together a critical mass of citizens who are aroused and determined to forge a health care system in which patients and health care matter.
Copyright © 2000 San Francisco Bay Guardian