Few punches are pulled in California Newsreels’ documentary adaptation of Maggie Mahar’s 2006 investigative book Money Driven Medicine. This physician-centered film exposes the infrequently examined ways in which a privately controlled health care system impinges on the relationship between doctor and patient. As Dr. Andrey Espinoza argues in the film, there are many entities in the examination room besides the patient and the doctor – private insurers and employers often shape the type and amount of care that is delivered.
One of the important offerings in Money Driven Medicine is a clear timeline of the development of the private health care system in the United States (US). The first key moment comes after World War II as many other nations shift to public insurance and publicly controlled delivery of care. In the US, doctors played a key role in preventing the creation of such a public system by asserting their right to determine care. But this physician-centered care was displaced in the 1970s with the rise of Health Management Organizations. “M.D.’s,” Mahar states, “were traded in for MBA’s.” As this business-centered system failed in the 1990’s, private insurers tried to reign in costs by denying costly, but often medically necessary, medical procedures. Backlash ensued and since the late 90s, insurers have liberally approved procedures while jacking up premiums to defend their profit margins. Costs have skyrocketed.
The result is a bloated health care system which rewards specialists who perform multiple procedures instead those who provide good preventive care. A critical assessment is, therefore, offered about the myth that America has the best health care in the world. When it comes to what Donald Berwick of the Institute for Healthcare Improvement, calls “rescue-care” the system performs quite well, but what most people need is open access to simple preventative care. Here Berwick argues, “We are nowhere near the best and it is reflected in outcomes.” The health care system in US pays for doing things not healing patients.
In fact, as studies conducted by the Dartmouth Institute prove, doing more has little impact on positive outcomes. High-treatment states such as New Jersey, which spends 20% more than the average for Medicaid, have equal or worse outcomes than low-treatment states such as Iowa. Physician interviewees in the movie spoke openly about a health system that has been commodified, industrially produced and, finally, is not designed to improve people’s health.
This leads to the second key argument in Money Driven Medicine. The problem with health care is not just lack of insurance; it is an overall lack of access to the kind of care people need. The fee-structure described above has consequences that have filtered down to the training of doctors resulting in a scarcity of primary care physicians. Medical student Krystal Irizarry called primary care, “A burden compensation wise.” Consequently, the film presents multiple patients who have no “medical-home” – no single primary care physician – and are reduced to emergency room visits when minor conditions turn into chronic illnesses.
It is no wonder then, that Mahar found plenty of willing subjects for her study. Five out of six doctors she solicited responded. Most described a health care system slipping out of their control. This idea is brought home powerfully when Dr. James Weinstein describes the story of his daughter Brianna who was afflicted with childhood leukemia. After multiple protocols of chemotherapy, Weinstein objected to continued treatment – viewing the proposed cure as more damaging than the disease. Brianna’s doctors insisted on continuing treatment and threatened Weinstein with a lawsuit if he resisted. The doctors in this case feared a costly lawsuit. The result? Multiple, and ultimately futile, treatments which had no medical justification other than avoiding litigation.
The experience allowed Weinstein to realize that most doctors are not really trained to provide useful information to their patients. What’s needed, the film then argues, is a shift to a more unmediated relationship between doctors and patients. As Weinstein and Berwick and others emphasize, such a relationship need not be unbalanced – with physicians lording over patients. Berwick points to studies which indicate that when provided with the proper medical information, patients tend to make more efficient and frugal choices about their health care. Removing profit-motive from medicine will allow doctors to act like doctors – to place their ethical commitment to patients ahead of bottom-line calculations – and patients to make informed decisions.
Some reservations can be noted about the film. Mahar is an investigative journalist who relied primarily on interviews with medical practitioners to piece together her narrative. Some of the history presented in the film could use a broader contextualization. For instance, the post World War II turn away from a public system occurred, not coincidentally, with an intense witch-hunting of socialists and communists. Aspiring politicians such as Ronald Reagan made great currency as both anti-communist hunters and as spokesmen against socialized medicine. Similarly the 1970’s pivot toward HMOs occurred in a moment of transition for Corporate America away from the post-war production model and toward a neo-liberal strategy of lean wages and slim benefits. These broader developments informed changes in the health care industry.
Ultimately, Money Driven Medicine offers perspectives essential for Americans evaluating proposals for health care reform. As stated in the film, the goal is not to tinker with this or that part of the market system, but to totally re-think the relationship between doctor and patient that has developed under a privately owned system. Undoubtedly, although the film does not state this explicitly, a single-payer national healthcare system offers to best hope for reclaiming the doctor-patient relationship. Unfortunately, the trajectory of the health care debate in Washington seems to be bending more toward the tinkering side. Money-driven medicine in America may be able to survive another attempt at reform.