Written by Marc-David Munk
In a palliative medicine clinic in the suburbs of work in Boston, my colleagues and I tend to visit some of the sickest patients in the city. Through the windows, I could see the injured pulling into our squat building in a family car, wheelchair van and subsidized municipal cycling. Rarely drive themselves: Most diseases can make them too fragile or calm. I looked at patients who could hardly dress up and somehow arrived at their Sunday best clinic.
As their doctors, our job is to manage their pain and provide moral support and practical help, sometimes spiritual support, on things like rent and transportation. This is an important task and one of the highest calls in medicine. But while the work may be noble, our clinics are not starting to support themselves financially. These visits, as well as sick and vulnerable patients, would be exemplary if there is reason to be generously spent on patients and their needs. In fact, we did not receive enough payment from the insurance company to cover the cost of the complex work required. In fact, this translates to very few employees to help with dates, not enough follow-up calls, no one can help with insurance headaches or pharmacies shortages, no one answers the call. Our facilities were very tired. The easiest food – coffee, magazines, comfortable chairs in the waiting room – is long gone.
There is a “thin” feeling in the air. This is the feeling of being rationed. This is a lack of everyone except for the real necessity. There is no tolerance, lack of kindness. When my friend, an emergency physician at a major trauma center, shared photos of his breakdown ER, I saw meager: tables and chairs with medical videotapes, rooms, rooms with invalid equipment. Very scarce medical supplies, doctors hide stalls and coat bags on the table.
Managers would say these barren conditions are the result of financial shortages. There is not enough money to pay for skeleton support and maintenance outside. The hospital is operating a deficit and shrinking. Keeping the light is obviously a matter of saving penny in every opportunity. And, with each cut, the meager growth. On the surface, it’s all understandable until you take a step back and realize that it’s not. We know that health care in the United States consumes more money than per capita. Money is pouring into our healthcare system. Starting in 2023, home health insurance premiums have increased by 7% after another year. Now, the average family policy costs about $25,000 per year.
This makes me want to reconcile how money gets into the system and how much money is left with very little frontline care necessary. I know this is not a complicated answer.
I worked as a health care administrator for fifteen years, negotiated with payers and suppliers, and told me that our social health care funds had been transferred and phased out. In the wide health care landscape, intermediary costs have become so extreme, unregulated, so bad that there is nothing left to dripping anything but providing the most tragic frontline care.
In the United States, we specifically allow thousands of organizations (many found elsewhere in the world) to pass on unheard costs to ourselves. We have group procurement organizations (GPOs) and responsible nursing organizations (ACOs). There are medical service organizations (MSOs) and physician organizations (POS). Also hosts nursing organizations (MCOs) and health maintenance organizations (HMOs). The Physician Academician Organization (PHO) also needs to pay. Office with contracts, coding offices, compliance offices, certificate offices, case management offices and claim handling offices. There are many organizations that drive one outcome; others exist to drive the opposite. All are costs.
Our six health insurance companies share revenue, and if they are a country smaller than Spain but larger than Australia, will make them the 14th largest GDP in the world. They usually spend eighty-five percent of the expenses they collect on medical services…the rest is their expenses and profits. Driven by labor, medicines and equipment, and administrative costs, the United States spends nearly twice as much on care as other high-income countries. Drug manufacturers charge Americans most multiples of the same drug than other countries. In the United States, heart implant devices are priced at multiples higher than in Germany. There are more hip implants in the United States than in Canada. Malpractice insurance is crushing, with some doctors paying hundreds of thousands of dollars in liability coverage each year. Electronic medical records cost hospitals hundreds of millions of dollars in installation.
Here, regulators make themselves both expensive and essential. The U.S. Council of Internal Medicine received $90 million in 2023 (and 23 other professional committees). Last year, the Joint Commission’s revenue reached $208 million. Press Ganey, who owns the majority of the mandatory patient investigation business, reportedly earned hundreds of millions of dollars in revenue (before they stopped reporting revenue data after being purchased by private equity). The medical journal business is particularly shocking: Doctors write, edit and review articles for free, but these journals are locked behind a paywall. Elsevier’s parent company owns more than 2500 journals and generates £3.06 billion in revenue in 2023 with a profit margin of 38%.
Good luck, not all of this. We are trapped. The doctor has no choice but to get board certification. The hospital must be investigated. Expensive licenses and permits are not negotiable. We give what they ask for, year after year. In these cocoons, we have few demands on poor value, few bargains and few consequences. In my early years in medicine, I felt at least one huge finish. Today, I look at our clinic and our patients who respond with dignity because I explain that their insurance company has once again turned down a $15 prescription for painkillers.
I wonder when we admit that we are at the point where we are at the point of passing regulatory and administrative games, policy distortions and oligarchs’ behavior, opportunists finally kill the Golden Goose. I wonder when in an environment of clinician perseverance and heroic commitment to patients, we will know that we have reached a turning point, which is no longer a trivial environment, but an environment of deprivation, one of which deprived the ball, and people are truly suffering.
With so many deeply ingrained interests, it’s hard to imagine how this is solved. For thousands of years, when it is most important, the work of doctors who care about patients one-on-one is irreplaceable. Still not. But around the best parts of American medicine, we have set aside for Rube Goldberg-like equipment, the institution that primarily keeps itself alive. It draws real losses from real people. It’s a unique shocking, unique ridiculous, unique American.
Marc-David Munk is an academic palliative physician and is a former healthcare director for several private and VC-supported healthcare provider organizations.
