March 1984 V/7
ECONOMICS AND HEALTH CARE: THE DOMINATING VALUES
There are signs that the profession of health care is losing its sense of direction. The signs are plentiful. The American Hospital Association sponsors a "comprehensive conference on hospice care" and there is no mention of the purpose of hospice care, namely, to enable dying people to benefit spiritually from the experience of death. Rather, the agenda is devoted to reimbursement, financial management, payment and insurance issues. The Society of Hospital Planning holds its annual meeting and there is no word about quality patient care. Rather, the topics discussed are the competitive edge, commercial strategy, aggressive marketing and pricing strategies. Looking through the material announcing various seminars and workshops one is hard pressed to find anything that even mentions the purpose of health care, namely, the beneficial development of a human person by ministering to physiological or psychological needs. Nor does one discern any appreciation of health care as a profession, that is, an occupation which must stress caring and compassionate attitudes and values in order to be successful. However, one will be able to find any number of conferences that explain diversification, corporate revision, and cost per case management.
Recently a physician writing in the NEJM depicted the effect of this overriding commercial emphasis in health care upon the fictitious Doctor Z. (1) Though whimsical, the article is tragic as well. Doctor Z is stripped of his hospital privileges because "he refused to accept the guiding principles of the new medicine: that the encounter with the patient is accurately and completely defined by a disease diagnosis and that for every such disease there is corresponding technological treatment." Lest you sympathize with Dr, Z, realize he is the cause of his own downfall because "he was never able to think of medicine as an industry and view hospitals as a business.., he clings to the archiac belief that medicine is an ethical rather than a commercial enterprise."
Undoubtedly there are many who will respond to the cormmerialization of health care by citing the need for economy, cost effectiveness and surplus in the contemporary health care environment. The argument is often phrased thusly, "If there is no profit there will be no hospitals and health care." T agree with this statement. And I also agree that it is wise to discuss marketing, diversification and anything else that will contribute to economic responsibility. However, while discussing these items, unless people continually remind themselves of the purpose of health care there will be a strong inclination to make money the dominating motive of the health care system in the United States. History and our own experience demonstrate that the unsubordinated pursuit of profit brings out the worst in people. Such attitudes as avarice, selfishness and exploitation are more likely to dominate the pursuit of profit than are those person-centered attitudes which bespeak compassion and care. Care for the sick, whether they be rich or poor, requires skill, dedication and generosity of spirit. The qualities and attitudes that are required to care effectively for people are not the qualities and attitudes one needs to make a profit in business.
Hence, the question facing us is which attitudes, values and characteristics are going to dominate and influence the provision of health care: those which bespeak compassion and respect for the person who is in need of help or those which bespeak competitive pursuit of financial effectiveness? The growing tendency for the values and attitudes of commerce to dominate the provision of health care is found in the phrase, "The health care industry." Anyone who truly appraises health care as an industry as opposed to a profession is on the way to accepting the values of competitive commerce as the dominating force in health care. To appraise health care as a profession, on the other hand, does not imply that one approves inefficient or wasteful business procedures. However, it does mean that one places, as the ultimate norm for both patient care and business procedures, such values and attitudes as personal competence, humility, commitment and compassion. So bring on the MBAs, the accountants, the planners and the marketing researchers. But let them be well aware of the values and attitudes that should dominate their activities as they employ their knowledge and skills to improve the efficiency and effectiveness of those directly involved in the profession of health care.
Unfortunately, the nominal leadership in the profession of health care does not seem to recognize the question of which ultimate values will dominate people and programs that has developed in the last five years. When evaluating DRGs, for example, the AMA bases most of its considerations and observations on financial concern for physicians. At a recent conference on care for the poor, when "cream skimming" by for-profit hospitals was declared detrimental to teaching and public hospitals, a leader of the AHA could only respond, "Tension has always been there, but AHA has to be an industry-wide association." When the leaders of the health care profession refuse to acknowledge their responsibility and opportunity to care for:the poor, then health care is indeed in danger of becoming an industry.
What can individuals and institutions do then to foster and develop health care as a profession? First of all, an accurate mission statement must be developed, taken seriously, and used as the ultimate norm for every program, policy and action. The mission statement recently developed by the leaders of the SLU Medical School is an example in this regard. Brief and accurate, it places the health and well-being of the patient as the goal of health care and then discusses the values which should dominate the pursuit of this goal as well as the necessary activities, Of course, the proof of the mission statement will be in its utilization and application. Individuals as well as institutions may develop a mission statement. As a health care professional, how would you express your purpose? Developing a concept of purpose helps liberate one from the dehumanizaIng commercialism which infects so many involved in health care.
Whenever a group of people lose direction, the reasonable remnant must seek to stay on course until the other recover their senses. Thus, despair and recrimination are not in order. But there is a dire need for committed people to remember continually their purpose as health care professionals and their dominating values and to act accordingly,
Kevin O'Rourke, OP
1. "The Unfortunate Case of Dr. Z: How to Succeed in Medical Practice in 1984," New England Journal of Medicine; Vo1,310, N.11, March 15, 1984; p.729-30.
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