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Corporate
Practices
The Way the Health Care Market
Operates
In early 2000 I collected pages
dealing with corporate practices together into this section
in early 2000. This page was intended to contain a broad
introductory review of the whole area. At present it
contains only brief outlines and links to the
pages.
I am not sure when if ever I will
get to rewriting and organising these pages as I struggle to
update and to meet each new crisis in health
care.
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General Reviews
of Corporate Practices
The pages on this
first section take a rather general look at the way
the health care market operates.
- Nay
Corporate
Medicine
This is a 600 page published article in
which I tried to encapsulate the essence of the
problem in corporate medicine.
- The
Health Care Marketplace
This page examines the health care
marketplace in the USA and explains how it works
to disadvantage those who seek care
- The
Story of Health Care
Reform
This page looks at the way in which economic
rationalist thinking has come to dominate
political processes. As a consequence market
thinking and processes have been introduced into
health care as "reform". The response to market
failure and at home control of market excesses
has been to globalise and try
elsewhere.
- Corporate
Medicine in
Australia
I wrote this review of Australia's response
to the application of economic rationalism in
health care in 2000. It looks at what has
happened in the USA and Australia and at
Australia's response.
- WELCOMING
MULTINATIONALS IN
AUSTRALIA
This page examines some issues surrounding
overseas ownership of health care in
Australia and looks at what has happened
here.
- THE
GREAT DIVIDE IN PERCEPTIONS about the CORPORATE
MARKETPLACE
This page looks at market failure in the
USA. It examnes the great divide between the
perceptions of market advocates when contrasted
with the way health professionals, patients and
most citizens perceive and experence the market
system in health care. It goes on to list the
red flags which should alert citizens and
regulators to the possibility of dysfunction. I
wrote this page in 2004 when Primary Health
induced the University of Wollongong to take a
page off the web site.
- THE
CORPORATE HEALTH AND AGED CARE MARKETPLACE
REVIEW OF RECENT
ARTICLES
August 2000
This is a review of 141 "recent articles"
which I wrote in 2001. An introduction puts the
articles in context. The material looks at
corporatisation of health care in Australia at
that time. It looks at what was happening in
managed care and nursing home care in the USA.
It looks at political influence and at what was
happening in Canada.
- The
Logic of Marketplace
Arguments
This page examines the logic of some of the
marketplace arguments and challenges
them.
- Joseph
Califano and the Market
Revolution
Califano was a health adviser to Reagan who
subsequently went to work for Chrysler. The
company was being crippled by health costs. He
saw the way in which the developing health care
marketplace was causing costs to spiral. Because
he saw this as a marketplace problem his 1986
book proposes marketplace solutions and more
market pressures. The adverse consequences are
now obvious.
- Introducing
competition in the public delivery of
health care
services
This is Graeme Samuel's speech to the world
bank in February 2000. He urges all countries to
adopt an even more market like system of
economic and regulatory levers than in the USA.
I criticised
this angrily and
some of these web pages resulted.
- PERFORMANCE
OF CORPORATE GROUPS : Profit versus
Care
This page gives an overview of the way in
which the pressures for profit have impacted on
care in the various sectors of the US and
Australian health care marketplaces.
- IMPLICATIONS
OF THE ENTRY OF COLUMBIA/HCA INTO AUSTRALIA
Part 1 :
Background
This page was written in 1997 when Australia
was threatened by Columbia/HCA. It was the
introduction to an examination of the
implications of Columbia's arrival. The page
examines the rise and rise of economic
rationalism and its application to health
care.
- Corporate
Medicine - Hospital licenses : Revising
the
regulations
In 1998 I used Columbia/HCA's own admissions
and its acknowledgment of the business practices
which lay at the root of its fraud and health
care failures to motivate for the banning of
these business practices in health care. This is
my submission.
- THE
MARKET --
MERGERS
(This page is empty. It was left behind by
events and has not yet been
written)
The driving force in the corporate market is
growth which is accomplished by takeovers and
mergers. The pressures generated are largely
responsible for the fraud and the failures in
care.
Pages in other
sections which explore corporate behaviour more
specifically
Many pages in other sections describe the way
the market operates and the conduct of specific
companies. Tenet Healthcare (then National Medical
Enterprises - NME) gives a marvelous insight into
market thinking, market practices, and the thinking
of the market in Australia. It shows the
relationship between corporate managers, market
analysts and investors, (see the 1996 page
"THE
IMPACT OF FINANCIAL PRESSURES ON CLINICAL CARE :
LESSONS FROM CORPORATE
MEDICINE").
Tenet's involvement in a second scandal illustrates
the pervasiveness of corporate culture and the way
market ideology has insulated itself from community
perceptions and the consequences of market
practices (See Tenet
Healthcare Scandal in General Hospitals : The
Second Coming 2002.
For more about Tenet and NME see Tenet's
main access page).
Columbia/HCA (now
simply called HCA) adopted similar practices (See
Columbia access
page).
The particular corporate practices are addressed in
something I wrote after Columbia had
done
a mea culpa in
1997, and
in a submission I made arguing that some business
practices should be
forbidden
under hospital licensing
regulations
in health care. I had a year before lodged an
unsuccessful objection to hospital licenses for
Mayne Nickless, the Australian giant, because of
its adoption of these business practices. Later
Peter Smedley introduced even
more aggressive business
practices
into Mayne Health. Doctors revolted forcing profits
down, Smedley's resignation followed
and
all Mayne's hospitals were sold to a
Citigroup
subsidiary and two partners in 2003.
Aged care
illustrates the same problems (see overview
and the many
companies involved).
Sun
Healthcare
is particularly illustrative. A business
analysis describing
the companies prospects and an interview
with Sun's
chairman
are very revealing of market thinking.
HealthSouth
illustrates
another manifestation of market pressures -
accountancy fraud. This was essentially a
co-development with the frauds in the wider
marketplace on Wall Street and illustrates the
profound impact financiers and their advice have on
health care companies.
Corporate health
care should be seen within the context of this
wider corporate marketplace to which it owes its
ideology and its primary allegiance - an allegiance
in extreme tension with responsibility to the
community and a duty to care for its sick members.
The nature of the marketplace and its
imperviousness to the values of the community is
well illustrated by the defrauding of the community
by Wall Street financial giants in recent years.
The
Citigroup pages
explore the wider financial marketplace frauds and
their hidden involvement and influence on health
care (see page "The
Financiers and Health
Care").
Several of the pages touch on the power and
influence which corporate market leaders exert and
the nature of this marketplace (see
"The
Banking
Marketplace").
Another examines the culture on Wall Street and the
sort of people who succeed here (see
"Citigroup
Culture and People").
This page also looks at the rapidly unfolding
scandal surrounding the chairman of the New York
Stock Exchange who played such a vital role in
resolving the financial scandal without properly
punishing the financiers or making effective
changes.
If we look even
more widely we can see the pervasiveness of the
sort of practices and processes which we have seen
in health care. Examine what actually happened in
the torture of prisoners in Iraq. These aspects and
the processes are highlighted in the Australian ABC
Four Corners Program on 7 June 2004 (look at
http://www.abc.net.au/4corners/archive.htm
for a transcript). On this it was disclosed that
both the US army in Iraq and the CIA contracted the
interrogation of prisoners out to private corporate
interrogators. The companies were paid for results
and everyone turned a blind eye to how the results
were obtained. Torture became legitimate,
acceptable and even desirable - exactly as the
imprisonment of normal children in psychiatric
hospitals, and coronary artery procedures on normal
arteries, apparently became legitimate in some
Tenet/NME hospitals.
That this
marketplace, its thinking and its practices
permeate throughout every facet of health care and
affects each adversely is illustrated by
developments in other areas such as renal dialysis,
home care, managed
care,
clinical
laboratories,
and the drug
market
internationally.
In Australia we have the Scan
scam, the
Pan Pharmaceuticals scandal and the pressures
exerted on Australia's
unique system of drug control - the
PBS.
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Building on
Ideas
The following
pages continue to explore the ideas set out in the
pages on coming
to grips with health
care.
They link to actual developments and events. Pages
2 and 3 were written in some disgust in response to
Samuel's speech. Some pages are repetitive and need
modification.
- CORPORATE
PRACTICES : INTRODUCTION to Analysis and
Criticism
This is an introduction to this section. It
looks again at the conflicting frames of
understanding which are at the heart of the
problems with market medicine. It examines the
nature of social criticism. It looks at the use
of our understandings in a reflective way and
the difficulty in doing this in a society under
pressure.
- STARTING
POINTS
This picks up on Samuel's advocacy of
marketplace "starting points" in health care to
revisit the theoretical frames I developed in
the introductory pages in a slightly different
way. I attempt to show how community and market
starting points and so understandings differ and
so have different consequences. I link starting
points and understanding to identity. Samuel
clearly understands these ideas. Where I have
advocated a broad approach fitting starting
points to context, Samuel seeks to convert
others to his belief system and create tension
in order to do so.
- A
CLASH OF
WORLDS
This page follows on the previous one by
looking at the world the rest of us live in when
we examine the health care marketplace and
contrasting it with the world health market
advocates like Samuel and Wooldridge live in
when they advocate market medicine. It
summarises corporate conduct in health care and
suggests that some of us are living in an
imaginary world and it is not the rest of
us.
- ANALYSIS
OF CORPORATE CULTURE AND PRACTICES(Sun
Healthcare as an example) ::::: Lessons for
the Future
This page uses Sun Healthcare and its
founder Andrew Turner to explore some of the
understandings developed in the theoretical
section reached from the initial
map
and explored again above.
- Quotes
and Extracts : the new corporate world of
medicine
By mid
1997 Columbia/HCA had gone but Sun Healthcare
was in Australia. I had vast quantities of
material and the comments of many advocates and
critics. I could not circulate all this so I
made a collection of quotes to send with my
material. They illustrate the conflicting belief
systems.
- Lessons
for the Future
I have
written a page in which I suggest the way in
which we can use these ideas to guide us in
developing a health service which gets us from
where we are to where we would like to be and
should be. We are currently moving to a
situation we should not want to be in and where
we should not be.
Other
pages
More pages along these lines dealing with
specific companies can be accessed from the pages
on coming
to grips with health
care.
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Words and Ideas
in the Marketplace
A number of pages
contrast the market's culture with that of
community. They look at demand, need, quality,
altruism, probity, equity and similar ideas. They
often acquire different meanings in the
marketplace.
- The
Market, Demand and
Value
This page looks at the way the corporate
groups use marketing and education to induce the
community to value what they sell and so create
demand for health care which the taxpayer may be
expected to pay. The market then exploits this
demand for profit. This is contrasted with what
the community needs in the form of health care.
An example is given to illustrate how this led
to the misuse of children for
profit.
- COMPETITION
IMPROVES
QUALITY?
This page examines the myth that competition
and market forces improve quality in health
care. It suggests that "quality" is a word with
associative meanings. These encourage the
creation of illusions and support fuzzy logic.
"Standards" is a better and more precise word -
one which we seldom hear in the
marketplace.
- Quality
in the Health Care
Marketplace
This page examines how the word quality has
been interpreted as meaning profitable by health
care corporations. It shows how accreditation
and oversight have failed to identify and
address the serious problems in these company's
facility.
- Quality,
Profit and Type of
Provider
This page examines the differences in the
way in which patients and doctors experience and
understand the health care encounter. It looks
at the issues of responsibility, pressures on
doctors, and public education in relationship to
the market and to professionalism. It suggests
that the problems would be best addressed by
cooperation between doctors and the community as
contrasted with competitive market
solutions.
- Cultural
Conflicts :::
Altruism
The page looks at altruism as an integral
part of professional culture, rather than as
ostentatious public donations by corporations.
It looks at the impact of marketplace medicine
on this.
- Some
thoughts about
Probity
Probity is not a consideration in the US
marketplace but is a repeatedly ignored
requirement for licenses in health care in
Australia. This web page examines probity and
its importance for health and aged
care.
- The
Market and
Equity
This page examines the failure to maintain
equity in market systems and when using
contracts.
- EQUITY
This page examines equity in the USA and in
other countries. It examines the impracticality
of ensuring equity through regulation or by
contracts and looks at alternatives. Prof
Stephen Leeder gave an excellent address on
equity to the Australian summit on health care.
This is published in the Autumn 2004 edition of
New Doctor. He refers to the difference between
US (i.e. market) ideas about equity and those in
Australia.
- Access
to care and the
Marketplace
This page looks at Samuel's claim that the
market improves access because of increased
efficiency. The evidence shows that it reduces
access under a capitation or managed care system
and increases it under an item of service system
resulting in under or over servicing. Many don't
get what they need and others get care they
don't need.
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Trust,
Professionalism and the Attack on
Professionalism
Professionals
control the treatment given and so the utilisation
of health services. Corporate profits flow from
their signatures. The response ranges from an
attack on professionalism to attempts to secure
their compliance with corporate programmes using
marketing, incentivisation, coercion and simple
bribery (various legal and illegal forms of
kickbacks). Non-compliance by individuals is often
viewed as disruptive. Marginalisation, social
isolation and punitive action often follow.
Professionalism has bent before these pressures and
there have been serious failures.
- Trust
: The Market and
Professionalism
This page examines the the importance of
trust and trustworthiness for success in health
care and in professionalism, contrasting it with
the importance of distrust for the success of
the market. It examines the failures of
professionalism to meet that trust and the role
of the market in this.
- Professionalism
- response to economists
criticisms
This page looks at the impact of market
forces on professionals and indicates that
professionalism has buckled under market forces.
Given the way humans behave this is what we
should have expected. The page argues that
market forces are extrinsic to health and
professionalism. They were developed elsewhere
and are essentially destructive of
professionalism. Professional values and ethics
are intrinsic to professionalism and health
care. They are sound but need reaffirmation and
social support to survive.
- Quality,
Health Professions, Patients and the
Market
This looks at the different way in which
each of these groups sees and experiences health
care and quality of care. It looks at the issue
of responsibility for the market and for
doctors. It examines the impact of the market on
public education and preventive
medicine.
- Professional
Independence
This page looks at the role of professional
independence as a thorn in the side of
ideologies. It compares doctors under economic
rationalism to those under apartheid. There are
problems with professional independence and
these are acknowledged. They are not explored on
this page.
- THE
CONSUMER, THE PROFESSION AND THE
MARKET
This looks at the misuse of consumers and
the perspective of the profession and of the
marketplace. It looks at professional
responsibility and the allegation that care is
organised for the benefit of doctors rather than
patients.
- Professionalism
and
Regulation
Professionalism is built around and driven
by intrinsic values and ethics directed to care
and the community. There is consequently
pressure towards self correction when it
responds to external pressure and goes off the
rails. The market in contrast is profit driven
and external regulation is essential to make it
work for society. The pressures are away from
care and so not self correcting.
- A
CALL TO
ACTION
This is the text of a message initiated by
the "Ad Hoc Committee to Defend Health Care" and
circulated to health care professionals in the
USA in late 1997. It resulted in the publication
of an article in the JAMA signed by thousands
and in the formation of Physicians
for a National Health Program
(PNHP)
which is now a powerful force in US politics. It
calls for universal health insurance in the USA
holding Canada up as an example.
- Controlling
the Utilisation of Health
Care
This page addresses the question of who
controls the utilisation of health care services
in the marketplace. Investigation and treatment
is approved and is signed for by doctors. Those
who control the pens of the doctors succeed,
those who don't fail.
- The
Market, Teaching and
Research
This page explores the relationship between
the market, universities, research and
education.
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Accountability,
Regulation, Surveillance, Retribution and
Accreditation
A host of costly
government and community structures seek to exert
control over this marketplace to ensure that
patients and the community are not short changed.
They have simply pushed up costs and failed to
protect citizens. The issues are
explored.
- Accountability
This page documents the failure of internal
corporate structures , external oversight bodies
and disciplinary processes to hold health care
corporations accountable for their
conduct.
- GOVERNMENT
CONTROL OF HEALTH CARE : A sorry
tale
This looks at governments ineffectiveness in
controlling the corporate marketplace and the
indebtedness of many politicians to
corporations, particularly those health and aged
care, for campaign funds. The two are
linked.
- Surveys
fail to Protect Nursing Home Residents from
Abuse
This is a 2001 article reproduced from a
Wisconsin web site which examines the failure of
regulatory authorities to address failures in
the care of the aged.
- Why
Regulation
Fails
This page looks briefly at why oversight and
regulation are so ineffective in health
care.
- Government
Oversight : Regulation and
Surveillance
This is another page examining the repeated
failure of government regulation and oversight
of the health and aged care
marketplaces.
- The
Collection of
Data
This page looks at the difficulty of
obtaining data and the paucity of data from the
competitive corporate marketplace. It looks at
how data can be obtained and at how most of the
material on this web site was
obtained.
- Monitoring
Developments in the Healthcare
Marketplace
This is another page looking at the
collection and interpretation of data more
generally in the health care marketplace. It
looks at what might be accomplished in an
integrated cooperating not for profit
system.
- Regulation
in the USA
This page examines the failure of regulation
in the USA and gives a number of
examples.
- Regulation
in
Australia
This page examines the way in which
regulations which protect citizens from
unsuitable, even criminal corporate health care
corporations have been undermined in the
corporate interest.
- HOSPITAL
ACCREDITATION
This page looks at the track record of
accreditation and why it fails as it has in the
USA.
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Structural
Aspects
These pages look
at the need for a stable health system and at
structural aspects. They examine choice, not for
profit care, efficiency and integration
- A
Stable Health
System
This page examines the stability of the
corporate health system in the context of
affordability. What is likely to happen to a
corporatised health system when health care is
no longer profitable or when money is short and
there is less to spend on care.
- The
Corporate Marketplace and
Choice
Choice in health care is a very different
process to choice in the marketplace. Potential
patients are vulnerable to manipulation, misuse
and abuse. While advocates of a health care
marketplace claim that the market provides more
choice, it is not in the interests of
corporations to provide this. In practice they
have a very poor track record.
- Not
for Profit Health Care and The
Market
This page examines the behaviour of not for
profit community services when they are placed
in a competitive marketplace and have to compete
with groups whose primary focus is competition
and market dominance.
- Structure
of the Health
System
Health care in Australia is currently
structured along lines of funding. Graeme Samuel
in his speech to the world bank has suggest it
be structured in terms of an economic theory. I
suggest that it be structured along the lines of
the services provided so that these can be
brought to patients balancing efficiency against
need and service.
- The
Cost of
Efficiency
Efficiency in the corporate marketplace is
used to rationalise and justify substandard
care. Decisions are made in board rooms in order
to enhance profits. This is contrasted with the
opportunities presented for efficiencies and
humane care by those at the coal face trying to
stretch resources for maximum
benefit.
- Competition
and the "efficiency
dividend"
This page examines the claim that
competition results in efficiency. It examines
the difference in efficiency originating in the
board room and efficiency originating at the
bedside.
- INTEGRATED
HEALTH
SYSTEMS
This page looks at integration for profit by
the large corporations, at the use of flagship
hospitals as the hub of an integrated system,
and at gate keeping in managed care.
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The
Consumer
Some pages
examine the plight and role of the patient and the
community. This is fashionably called the consumer
so as to hide their vulnerability and suggest the
power of a market customer without claiming
it.
- MARKETING
AND
EDUCATION
Marketing and education have been used by
corporate health care companies to build the
bottom line. They have misinformed, deceived and
even restricted information. Instead of
facilitating and encouraging choice they have
restricted it.
- Declining
Community
Satisfaction
Market advocates claim that patients, now
called consumers are dissatisfied with the
health system and that the market solves this
problem. The former is partly correct. The
latter is not supported by the evidence. The
page examines dissatisfaction under different
systems.
- Health
Care and
Empowerment
This page explains how paternalism has given
way to an ethic of empowerment. It looks at the
benefits and problems in empowering and shows
how difficult this is in a market place
context.
- The
Consumer in Samuel's
Model
This page examines the lack of power of the
marketplace health care customer (or patient),
and the ruthlessness of the market when large
sums of money are involved.
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Politics
The link between
the market and politicians is a close one. Many
believe it is the reason why health care
corporations have been so successful in resisting
reform and have been treated so leniently. The
relationship is cemented by the vast sums spent on
political donations and lobbying
Politics,
Markets, Health and
Democracy
This page is a 2004 rewrite of three previous
pages. It examines the way we conceptualise the
nature of democracy. It suggests that the
inappropriate relationship between corporate
interests is the consequence of a democracy which
emphasises the right of all individuals to pursue
their own self-interest. This is contrasted with a
democracy which emphasises the responsibility of
citizens for society and the well being of all. The
financial relationships which cement the links
between the market and politicians are documented.
These largely disenfranchise citizens. The roles of
politicians in the USA and Australia are examined.
The importance of this for health care is
illustrated by many examples. Many links are
provided.
Other
pages
There are sections on the individual pages
describing political links, donations and lobbying.
The
Banking
Marketplace
looks at the power of the large market
institutions. There is more about Citigroup
lobbying.
The Frist
family
running Columbia/HCA was a political dynasty.
Bruce
Lumsford
(Vencor
's founder) was close to state governemnt. His
attempt to run for governor was torpetoed by his
track record in aged care. Integrated Health
Services (IHS) was notorious for
its
political dealings.
The intense
lobbying
as nursing home chains sought to block the damaging
litigation in Florida is representative of what
happened in most major health care crisis.
Managed
care
groups and pharmacy
giants
have been particularly active.
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Whistleblowing
and Dissent
The vast majority
of corporate prosecutions have arisen from
whistleblower initiated actions and not from
regulation or oversight. Without them most would go
undetected.
- Whistleblowing
in Health
Care
I have always wanted to write about whistle
blowing in health care. I got as far as writing
some initial thoughts in 2000 and became lost in
conjecture. I never got back to it but hope to
do so. It badly needs rewriting. Whistle blowing
has succeeded in the USA where regulation has
failed.
- Olivieri
empty
page
This page is still empty. Dr. Olivieri
blew the whistle on a drug company in Canada.
Her experiences are illuminating.
Other
pages
My own efforts at whistle blowing can be
accessed from the Initial
Map.
There are accounts of whistle blowing on some of
the corporate pages.
James Alderton
and others for examole blew the whistle on
Columbia/HCA. In Tenet/NME
in 1991
and in 2002 it was patients who realised what was
happening and acted. In Vencor
it was patients and staff.
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Miscellaneous
and Obsolete
A number of
blanks or short outlines of planned pages were put
on the site to temporarily receive links and are
still there. When I will get to write them I don't
know. Most will go in time. They are here so that I
don't lose them.
THE
LEGAL STORIES
This page was written in outline only in 2000.
I never got to complete it.
Organisation
(still
to write)
Outline for a planned page in about 1997 -- never
written
The
Processes at Work
-
This page written in 2000 simply supplies
links to other pages. I planned to summarise the
psychological, sociological and political processes
at work in the corporate marketplace but this is
probably irrelevant now.
MARKET
REFORM : Cognitive Processes
and Change
This page describes social, psychological and political aspects
to the process of change. These create pitfalls and challenges
which are seldom confronted. The manner in which marketplace
ideology has been imposed in health care illustrates many
of the problems and the unfortunate consequences.
Linking
Funding to
Care
This is another April 2000 page started after
Samuel's speech which got lost and was never
finished. It contrasts market and professional
ethics and then comments on capitation and fee for
service. It needs fixing or scrapping.
Corporate
Medicine Site : (alternate entry
page)
This is a redundant out of date page and will
be removed.
Further
Developments in 1997
Overview
This page is simply a set of links to material
I wrote during 1997 as details of Columbia/HCA's
many unsavoury practices became public in the
USA.
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