Anything with “Big” in it means Big Money, whether it’s Big Pharma, Big Oil, or whatever. The Big industry will have skyscrapers, plush executive suites, and a battalion of managers with million-dollar compensation packages.
Big Healthcare is no exception, and it is important to understand just what healthcare is. The trillions of dollars of revenue sucked in by Big Healthcare are not just for medical care. “Healthcare” is mainly concerned with collecting and distributing the money. Perhaps half of the money gushing through the system pays nurses, doctors, orderlies, receptionists, or therapists, or buys medications, oxygen concentrators, wheelchairs, bandages, or x-ray machines. The rest is diverted to something else. It’s hard to figure out just how much because insurers may, in calculating the “medical loss ratio,” call a lot of things “healthcare” that you might call “administration.”
Big Healthcare makes money from the difference between insurance premiums, government payments, and other sources of revenue, and the outgo to workers and suppliers. This may be called a “profit” if distributed to shareholders such as your pension plan, or an “excess” if the enterprise is tax-exempt (“non-profit”). The non-profit can use it for self-promotion, executive pay, or a luxury condominium such as the one bought by the American Board of Internal Medicine for its dignitaries.
Big Data is an essential component of Big Healthcare. Most of Big Data, even if it is supposed to be about “quality,” is related to filing claims for payment. Big Healthcare has vast number-crunching and data-mining capacity, and is acquiring an excellent understanding of what is profitable what isn’t. This information is incorporated into “best practices,” “guidelines,” and the options that appear in the drop-down menus of the proprietary electronic health record.
Big Healthcare can identify low-risk enrollees and those likely to need expensive treatment. It knows which doctors are compliant about following the guidelines, and which care enough about their patients to think independently.
Big Data itself is a lucrative revenue source. It sells patients’ medical data to insurers, banks, government agencies, and enterprises of all types, to be used for scoring people—perhaps for targeted ads, perhaps for making employment decisions, perhaps for rationing or denying care. Do not imagine that the Health Insurance Portability and Accountability Act (HIPAA) prevents this. It in fact enables access by millions of “business associates,” researchers, law enforcers, planners, etc. HIPAA may prove an inconvenience to your family or doctor—but not to hackers.
Big Healthcare has one potential vulnerability: patients may figure out what is going on. They may ask themselves why they should pour thousands of dollars every year into “health plans,” where it is gone forever, instead of saving it to buy the medical care of their choice if and when they need it. Why should they see a “provider” owned by a health plan, who will plug their “protected” health information into the electronic health record and follow the health plan protocol? Why should they not see a doctor who is working for them, who cares about them, who will keep their data confidential, and who will prescribe according to his own best judgment?
Why not refuse to enroll? There is an ObamaCare penalty, but it might be much less expensive than the plan, and there are many ways to avoid it, including hardship waivers or joining a health-sharing ministry.
Big Healthcare is behaving like monopolies and cartels everywhere: trying to obliterate the competition, generally with the help of Big Government. The latest ploy, now being rammed through legislatures in more than a dozen states, is called the Interstate Medical Licensure Compact. The pretext is to solve the physician shortage and improve access to telemedicine. The effect is to create a special class of physicians, who meet the Compact’s nine criteria and will be licensed in multiple states. This will enable Big Healthcare to enforce narrow networks, forcing patients to accept telemedicine consultation from a remote specialist (who follows the plan’s protocol) instead of seeing a local physician face to face.
Once the independent physicians are gone, patients will have no choice. “The system will see you now”—or not.
Jane M. Orient, M.D. is executive director of the Association of American Physicians and Surgeons and president of Doctors for Disaster Preparedness.
