Pharmacy & Therapeutics - April 2008 - (Page 193) EDITORIAL Slaves to Medicine David B. Nash, MD, MBA I n a provocative new book,1 George Beauchamp, MD, claims that physicians are “slaves to medicine.” He explains that this is partly because “when most people go to see a doctor, both the services the doctor provides and the fees that insurance companies allow him to charge are largely predetermined by parties other than the patients and doctors.” Most patients, in turn, feel completely powerless when the time comes to submit a claim to an insurance company. They are stuck with fees that have been negotiated by a higher authority, and they are not given an opportunity to have a voice in the matter. They are slaves to a master just as people were in 350 B.C.E. (Before the Common Era), when Plato first described “free men” and “slave doctors.” I grant you that the author’s thesis hit me hard, and I thought it would interest our readers. Dr. Beauchamp claims that the central truth about health care (one that we often overlook) is a relationship based on trust. Without this special trust, the nature of the profession and its valued outcomes are inevitably perverted. He states that trust erodes when market forces, political control, and third-party interests collide. To regain the trust we have lost, physicians, nurses, pharmacists, and others must once again be placed in positions of authority, creating a morality or, in the author’s words, “a quality of care based on competence.” Finally, this trust can be sustained only when caring professionals subordinate their interests to those of patients. This is heady stuff. The heart of this new book is the idea that values—not power—should be the drivers of health care and that only two health outcomes matter: quality of life and longevity. Well, so far so good. I could certainly agree that values, not power, are critical and that quality of life and longevity make sense. Dr. Beauchamp cites a Mary & Albert Lasker Foundation study, authored by William D. Nordhaus, an economics pro- fessor at Yale. This study claimed that about 50% of the growth in the U.S. economy throughout the 20th century was attributable to improvements in health and health care. As a result of this “Nordhaus calculation,” Dr. Beauchamp believes that he has a basis for a new strategy that recognizes health care as the most power ful engine for economic growth. He extrapolates this argument and builds his thesis that “as long as we allow health care based on trust to grow and prosper, economic growth will follow.” He believes we can do away with insurance companies and all types of thirdparty payers. He supports the creation of a “federal reserve–like structure” or a “health care bank” to help sort all of this out and keep the market humming along. Ultimately, health would be the only tangible good. I believe that George Beauchamp’s work will be widely cited, because it will empower physicians and other caregivers to tackle the seemingly runaway market economy that characterizes health care today. I suppose that many of us bristle at the role of health care as a mere commodity. Finally, I am confident that other health care providers agree, as Dr. Beauchamp says, that “power and money, viewed and sought as ends, are corrupting and enslaving.” Although many of the messages in Slaves are compelling, I think the author runs the risk of losing his audience when he likens health care of the future to a “family business model” that sees all citizens as part of the health care family, where some provide ser vices, others require them, and each is responsible for maximizing their contributions. The family is constructed of individuals and is not some shadowy structure created to respond to goals tangentially related to health. The view is long-term, and the benefits accrue to each and all. I think this concept is dangerously simple-minded and, based on my own practice experience, unworkable. The author envisions a world where we would go to the doctor and take our medications and no charges would exist. The productive outcomes would somehow magically fuel the resource needs of the system. In the concluding section of the book, the author suggests that there are only two jobs for people employed in health care: taking care of patients and taking care of those who care for patients; any other role in the system is of no added value. I consider this a very narrow interpretation of what our industry is about— and a sophomoric view of health policy, pharmacoeconomics, pharmacoepidemiology, and all of the applied social sciences that help us understand the health care system. Can I reconcile the notion that values, and not power, should be the drivers of health care? Can I agree that only two outcomes really matter—quality of life and longevity—with the silliness of a federal reser ve-like structure, magically ensuring that all patients will take their meds and that we don’t really need a fee structure? In the end, I cannot support these arguments, but I can appreciate the courage it has taken to disseminate these ideas in a cogent way so that they can be widely discussed. I also acknowledge that a little book like Slaves to Medicine can help balance some of the political rhetoric that bombards us daily as the presidential candidates crisscross the nation and as snippets about health policy appear regularly in the mass media. Sometimes it takes courage to stake out a position far from the mainstream to help direct the flow of the conversation in an effective manner—thereby enabling us to conduct a meaningful dialogue instead of hearing only disconnected tidbits and sound bytes relating to health policy on the nightly news from reporters who don’t have enough time to discuss the important issues. So we can forget about health care as continued on page 247 Vol. 33 No. 4 • April 2008 • P&T® 193
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