Wednesday, June 3, 2009

The Weakening of Professionalism and the High Cost of Health Care

I think that the Obama administration is correct that health care costs need to be reduced if we are going to improve our economy. We don't have the best health care in the world but we certainly have the most expensive.

This week's New Yorker has a great article about what drives up the cost of health care. The article by Atul Gawande, MD. Dr. Gawande compares the cost of health care in McAllen TX to nearby El Paso. The two areas have basically the same demographics and health statistics - so it's not the people. Yes El Paso's Medicare expenses are about half of McAllen's. McAllen has amongst the highest health care costs in the US. On the other hand Rochester, MN, home of the Mayo Clinic has one of the lowest.

I suggest reading the article but my take on this is very simple. The doctors at Mayo live up to the moral principle that created the social contract whereby society granted autonomy to professionals (classically health care, clergy and attorneys). Society created the social contract because it lacked the knowledge needed to properly understand and regulate the professions. The contract states that professions get the autonomy to practice as long as they subjugate the needs of the profession and professional to the needs of the patient, parishioner or client. The Latin phrase credat emptor replaces caveate emptor. The later, we all know means let the buyer beware. The former is let the buyer have faith. That is have faith that the recommendations that the professional makes are in the "buyer's" best interest not in the professional's.

Dr. Gawande's research shows that in McAllen and I suggest spreading around the US is an anti-professional ethic in health care to, as he writes, not leave money on the table. This means that one has made sure to bill for everything one can possibly bill for. I am a capitalist but I think this is a problem of values.

I've written in my ethics column in Dynamic Chiropractic about values. Below the lists of values from the Rokeach Value Survey. There are two types: Instrumental Values and Terminal Values. The former are those values that explain how we live our lives and the later are what we want out of life.

Instrumental Values
  • Ambitious
  • (Hard-working, aspiring)
  • Broadminded (Open-minded)
  • Capable (Competent, effective)
  • Cheerful (Lighthearted, joyful)
  • Clean (Neat, tidy)
  • Courageous (Standing up for your beliefs)
  • Forgiving (Willing to pardon others)
  • Helpful (Working for the welfare of others)
  • Honest (Sincere, truthful)
  • Imaginative (Daring, creative)
  • Independent (Self-reliant, self sufficient)
  • Intellectual (Intelligent, reflective)
  • Logical (Consistent, rational)
  • Loving (Affectionate, tender)
  • Obedient (Dutiful, respectful)
  • Polite (Courteous, well-mannered)
  • Responsible (Dependable, reliable)
  • Self - controlled (Restrained, self discipline)
Terminal Values
  • A world at Peace (free of war and conflict)
  • Family Security (taking care of loved ones)
  • Freedom (independence, free choice)
  • Equality (brotherhood, equal opportunity for all)
  • Self-respect (self esteem)
  • Happiness (contentedness)
  • Wisdom (a mature understanding of life
  • National security (protection from attack)
  • Salvation (saved, eternal life)
  • True friendship (close companionship)
  • A sense of accomplishment (a lasting contribution)
  • Inner Harmony (freedom from inner conflict)
  • A comfortable life (a prosperous life)
  • Mature love (sexual and spiritual intimacy)
  • A world of beauty (beauty of nature and the arts)
  • Pleasure (an enjoyable leisurely life)
  • Social recognition (respect, admiration)
  • An exciting life (a stimulating active life)

I think that the cost of health care is due to the elevation of "A comfortable life (a prosperous life)" over "A sense of accomplishment (a lasting contribution)". This might be the rebound or backlash of the “60s”. I started practicing in NYC when Jerry Rubin (Chicago 7) hippie became a yuppie. There is a nice discussion of how he debated his co-conspirator Abbie Hoffman in the Wikipedia article on him under the subheading post activism. When I was in NYC in the early 80s I used to go to Jerry Rubin’s networking parties at the Palladium where business people went to meet other business people. I found it a waste of time. Nevertheless, life, it seems, had changed to profit mattered more than accomplishment.

Or to put it another way professionalism matters because until the prevailing ethic amongst all health care providers stops being the health of their personal wallet and it properly is the patient's health and value they receive from our care no effort will reduce cost with increases in health and wellness.


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