The corporatization of medicine: Part two

2016 was in fact the first year in which fewer than half of physicians had an ownership stake in their practice, based on a survey by the American Medical Association.[i] The pace of acquisition of practices by hospitals and health systems during this period was astonishing. From 2014-2018, just four years, corporate ownership of practices increased from 24.1% to 45.6% of all physicians in a nationally representative sample. After selling out, physicians actually experienced a reduction in their income.[ii]

The evidence that increasing concentration of medical services is associated with higher prices is consistent and extensive.[iii] This includes horizontal consolidation among hospitals[iv] and physician practices,[v] and vertical consolidation, i.e. purchase of physician practices by hospitals.[vi]

Quality in medical services is difficult to measure, but at least from the standpoint of physicians, the growing corporatization of Medicine is widely experienced as compromising their ability to meet the needs of their patients. It is widely understood that the Covid-19 pandemic imposed enormous stress on the medical workforce.[vii]  However, what is commonly called “burnout” – a psychological state characterized by “overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment”[viii] – was common before the pandemic, and a matter of widespread concern. 

Simon G. Talbot and Wendy Dean argued in 2018[i] that a better term for the problem was not burnout, but moral injury, a concept previously applied to combat veterans who have had experiences such as “Perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations. This may entail participating in or witnessing inhumane or cruel actions, failing to prevent the immoral acts of others, as well as engaging in subtle acts or experiencing reactions that, upon reflection, transgress a moral code.” [ii]

As Talbot and Dean put it, “The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.” They argue that the corporatization of medicine, and the evolution of the physician’s role from that of an independent professional to an employee whose services are valued principally for the profit they can produce, has put many physicians in the position of being unable to fulfill what they experience as their ethical obligations to their patients. Dean has since expanded these observations into a book,[iii] which describes many ways in which corporations driven largely or solely by financial gain ill serve both patients and clinicians, and illustrates these with detailed stories about the careers of individual physicians.

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[i] Simon G. Talbot and Wendy Dean. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat. July 26 2018. Available at https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/ [Accessed June 27, 2023

[ii] Brett T. Litz, Nathan Stein, Eileen Delaney, Leslie Lebowitz, William P. Nash, Caroline Silva, Shira Maguen. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review. 2009. 29:8; 695-706

 

[iii] Wendy Dean (with Simon Talbot). If I Betray These Words: Moral injury in medicine and why it’s so hard for clinicians to put patients first. Steerforth Press, Lebanon, New Hampshire. 2023.

 

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[i] Carol K. Kane. Updated Data on Physician Practice Arrangements: Physician Ownership Drops Below 50 Percent. American Medical Association Policy Research Perspectives, 2017. Available at https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdf. [Accessed June 19, 2023]

[ii] Christopher M. Whaley, Daniel R. Arnold, Nate Gross, and Anupam B. Jena. Physician compensation in physician-owned and hospital-owned practices. Health Affairs. December 2021 40:12.

[iii] Martin Gaynor. More Than 20 Years of Consolidation Have Led to a Dysfunctional Health Care Market. Promarket, June 2021. The Stigler Center for the Study of the Economy and the State. Available at https://www.promarket.org/2021/06/02/consolidation-dysfunctional-health-care-market-prices-competition/ [Accessed June 21, 2023]

 

[iv] Martin Gaynor and Robert Town. The Impact of Hospital Consolidation: Update. Robert Wood Johnson Foundation, The Synthesis Project. June 2012. Available at file:///C:/Users/ml117/Downloads/rwjf73261.pdf [Accessed June 21, 2023]

[v] Laurence C Baker, M Kate Bundorf, Anne B Royalty, and Zachary Levin. Physician practice competition and prices paid by private insurers for office visits.  JAMA 2014 Oct;312(16):1653-62

[vi] Cory Capps, David Dranove, Christopher Ody. The effect of hospital acquisitions of physician practices on prices and spending. J Health Econ 2018 May;59:139-152.

[vii] Tait D. Shanefelt, Colin P West, Lotte N. Dyrby, Hanhan Wang, Lindsey E. Carlasare, Christine Sinsky,et al. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic. Mayo Clinic Proceedings. Sept. 13, 2022.

[viii] Christina Maslach and Michael P. Leiter. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016 Jun; 15(2): 103–111.