by Daniel R. Hoffman, Ph.D.
The changes currently taking place in health care are huge, pervasive and irresistible. That's only to be expected as health care moves toward consuming 20 percent of America's GDP. As part of the process it's predictable that people with a stake in preserving or even reversing the status quo would respond with what psychologists call ego defense mechanisms. Predictable and understandable, yes, but that doesn't make their wails appealing. And as guides to public policy, ego defenses typically lead to chaos and disaster.
Two segments of health have been particularly egregious in this respect: a part of organized medicine and most of the pharmaceutical industry. Their respective approaches to health care dynamics have been the classic ego defense of scapegoating and denial.
A typical blast from organized medicine came last week in an article by Dr. Elaina George, published by the National Center for Public Policy Research. In essence her tract was a standard piece of rightwing boilerplate that combines half-truths and outright distortions into a vicious howl that portrays the Affordable Care Act (Obamacare) as Satan's handiwork.
Few of her claims withstand scrutiny. For example, Obamacare is not the major driver behind physicians selling their practices and becoming employees. Physicians prefer to become employees of hospital networks because, in that capacity, they can add "facility fee" charges onto their bills, something they can't do when they own their practices.
Nor does Obamacare cause the related process of hospital mergers. Hospital managers started that trend all by themselves as a means of obtaining leverage in their contract negotiations with third-party payers. As an administrator in a Midwest hospital system told us last year, "We made it clear to Blue Cross that without us, they won't have a single interventional cardiologist in this county."
George's claim that the 2010 legislation causes these consolidation trends and, thereby, lowers the quality of care by "creating long wait times" is, in the most generous terms, complete nonsense. Likewise, by stating that Obamacare's support for "best practices" and evidence-based care "lowers the standard of medicine," she ignores decades of contrary findings from Dartmouth's Center for Health Policy Research and other public health research centers.
Beyond George's rants and distortions intended to demonize Obamacare, there lies the sort of resentment the American Medical Association has shown throughout its history. Both favor imperious, sovereign physicians who want to hang out their shingles in small practices and operate as monarchs. Again, scapegoating and nostalgia for a more rural country provide poor guides to public policy.
What about the pharmaceutical industry's response to these trends? It is not an exaggeration to characterize it as, "If I close my eyes, maybe the bogeyman won't see me." This week a long-time owner of marketing research agencies, a man who has been a cheerleader for pharma's line managers over several decades, circulated what seems to be his frustration with the industry's failure to acknowledge some obvious developments. "What if all of the rules that have defined all of our careers for years suddenly changed?" he asked.
"Those of us involved in pharmaceutical marketing have focused our attention on 'persuading' individual, preferably 'high decile,' physicians to prescribe our products. What if that whole gig didn’t matter anymore. In a world of treatment protocols dictated by accountable care organizations and their standardized treatment protocols and formularies, it won’t!
"What if the notion of 'positioning' our product to gain more 'market share' than the 'competitive products' didn’t matter anymore?
"[W]hat if individual physicians’ perceptions of our product don’t matter anymore? Doesn’t 'marketing research’ as we have known it go poof? Who cares what 'a hundred randomly selected, high prescribing Primary Care Physicians' think in a protocol-driven world ... And who cares about 'segmenting' prescribers when increasingly, they are all told to do the same thing?"
Instead of reorienting itself to get out in front of these economic and social changes, pharma supplements its denial with the sort of nasty political and payoff game denounced last week by Dr. Marcia Angell, former editor of the New England Journal of Medicine.
"Over the past two decades the pharmaceutical industry has moved very far from its original high purpose of discovering and producing useful new drugs. Now primarily a marketing machine to sell drugs of dubious benefit, this industry uses its wealth and power to co-opt every institution that might stand in its way, including the U.S. Congress, the FDA, academic medical centers, and the medical profession itself."
The plaintive cries of physicians should remain low on everyone's sympathy list. Advanced nations will always needs their services, and they will be well compensated. In the future they may no longer be able to sustain an arrogant sense of entitlement and their medical degrees won't be as likely to produce seven-figure annual incomes, but no one will need to hold charity dinners on their behalf.
Likewise, the aging populations in developed nations will only increase the need for life-enhancing therapies. Companies that develop cures for Alzheimer's, diabetes and the various cancers will deserve handsome (but not outrageous) returns on their investments. Until that time, it is not too much to ask for some honesty, humility and an acknowledgement of reality from pharma.
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