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Why is America's health system so expensive? Why do we get so little in return for the money that we spend as a nation on health care?
One answer may be that our health care system appears to have taken a clear turn toward a for-profit framework and away from service to patients. Is this shift good for the medical profession? And by association, is it good for PAs?
The fundamental issue is what some refer to as the commercialization of health care. Beginning in the early 1980s, perhaps coinciding with prevailing economic philosophies of the day, the health care sector, including medicine, appeared to shift away from an operational standard that placed a high premium on professionalism and service toward one where money and profit were paramount. Sociologist Paul Starr, PhD, in his Pulitzer Prize-winning history of the medical profession, The Social Transformation of American Medicine, was among the first to observe this phenomenon when he called the concluding chapter of his book "The Coming of the Corporation." By this he was indicating that he regarded the early 1980s as the time when the medical profession was moving toward a more business-oriented framework. 1
The Evolution of Health Care
Around the same time, Arnold S. Relman, MD, a Harvard Medical School professor and a former editor of the New England Journal of Medicine, coined the term the "medical-industrial complex" in a seminal paper he wrote in the journal. In that paper, he described the rise of a "huge new industry that supplies health services for profit" and worried that this trend would lead to the overuse and fragmentation of medical care and medical technologies. 2
This evolution of the medical profession and health care has been described in various terms including monetarization, 3 commercialization 4 and for-profit medicine. 5
In 1984, Columbia University economist Eli Ginzberg, PhD, described the rapid "penetration of the 'money economy' into all facets of the health care system." 3 Two years later, the Institute of Medicine commissioned a study to look at the implications of the for-profit trend in the health care sector. 4
The forces of commercialization in health care have not abated. Today, it is quite obvious that the health care system has become commercialized. A significant number of hospitals are now owned by investors, and both these for-profit hospitals and not-for-profit hospitals are operated as businesses. A similar mentality has crept into many private group practices and clinics. 6 Many people believe that health care is a commodity that, like refrigerators or toasters, can be bought, sold or traded and can be subject to advertising, promotions and for-profit motives.
Profit and Professionalism
These thoughts were in my mind recently when I heard Georgetown University bioethicist Edmund D. Pellegrino, MD, deliver an elegant talk titled "The Doctor-Patient Relationship." Pellegrino decried the seemingly inexorable trend of medicine toward accepting and adopting the for-profit mentality. Educational debt and a desire for economic reward, perhaps more than a sense of professional ethics, seem to drive medical graduates' decisions regarding specialty choices, he said. Graduates disproportionately select higher-paying specialties and subspecialties. Pellegrino wondered what had happened to the ethic of medicine, when entrants to the profession chose a career in medicine in order to serve the sick and professed to place the interests of the patient ahead of their own-the precise definition of a professional.
In 2007, when seemingly every occupation labels itself a profession and motives are predominately entrepreneurial, such notions seem quaint. In a reminder to again focus on the purpose of medicine, Pellegrino stressed three elements that have defined a healer since time immemorial:
Be competent.
Place the patient's interest above your own.
Have respect for the patient.
He sadly noted that professionalism, in its truest sense, seems to be waning among physicians and said that he was not sure if the average physician always places patient interests above his or her own.
The Healer's Role
What are the lessons in all of this for the PA profession? For most American health care institutions, facilities and providers, it would appear that the profit motive has become the standard. We all function in this now completely commercialized health care system and feel the same pressures regarding money and profits as our physician colleagues. We appear to take pride in the fact that our salaries have increased steadily, and that most PAs appear to be making a comfortable living. Yet, in this money-focused environment, it sometimes becomes more difficult for clinicians to maintain a sense of service and professionalism. In the quest for profit that seems to be so pervasive in the U.S. health care system, it becomes easier to lose sight of the true purpose of becoming a clinician?service to the patient.
PAs emulate physicians; thus the danger. It is important to keep in mind Pellegrino's thoughts about the fundamental role of the healer in society. One hopes that the trend of commercialization of the health sector will not erode the professional ethic for either physicians or PAs.
James F. Cawley is professor and interim director of the PA program at the School of Medicine and Health Sciences at The George Washington University in Washington.
References
1. Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982.
2. Relman AS. The new medical-industrial complex. N Engl J Med. 1980;303:963-970.
3. Ginzberg E. The monetarization of medical care. N Engl J Med. 1984;310:1162-1165.
4. Institute of Medicine. For-Profit Enterprise in Health Care. Washington, DC: National Academy Press; 1986.
5. Gray BH. The Profit Motive and Patient Care. Cambridge, Mass: Harvard University Press; 1991.
6. Relman AS. A Second Opinion: Rescuing America's Health Care. New York, NY: PublicAffairs; 2007.
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