Lessons from The American Experience: What Not to Emulate

By Dr David Quek

At a recent American Medical Association (AMA) meeting, several members and trustees of the AMA leadership were castigated by an outraged membership who slammed the blatant commercialization of the AMA and its loss of professional ethical standards. Five top AMA officials resigned.

The story behind this was the signing of a "cobranding" or endorsement contract with Sunbeam, in which the AMA logo and name would have been put on to consumer medical products. However, the AMA was not party to the testing or the production of these products and therefore not in a position to influence their quality or actual value or usefulness. The AMA was accused of selling the organization's name, and member after member lambasted the AMA board and executive staff.

Dr Arnold Relman (former NEJM editor-in-chief) was the first to articulate his strongly-worded condemnation: "In my opinion, it is essential that this association purge itself of all commercial deals that involve endorsement of or joint marketing ventures with particular health-related products and services sold to the public... The recent trend toward commercialization of the US health care system and the growing threat of corporatized managed care to the autonomy of doctors have made it increasingly difficult for physicians to follow this fundamental precept" that their financial interests should not influence their professional obligations to patients.

Dr Relman continued: "...If they (doctors) do not, they will be swallowed up by the healthcare corporations, and the process is already happening... Without an ethical compass, physicians will end up as part of the labor force employed by or under contract with these corporations or they will become profit-driven entrepreneurs themselves, competing futilely with the corporations. In any case, the relationship between physicians and patients will have been fundamentally damaged. Equally important, a medical profession lacking ethical standards that set it apart from business will inevitably lose the public trust and the ability to influence public policy."

He exhorted the AMA to uphold ethical principles–standards it has urged its members to follow. "The AMA's behaviour itself and not simply its rhetoric must reflect the values that it espouses for physicians... In short, the AMA is an association of physicians, not a trade association, and its actions should reflect that crucial distinction...I conclude by reminding you that the professional standing of medicine is in greater jeopardy than at any time in the past century.... We are being judged now more than ever. More than ever, physicians need to be represented by associations that promote professional values over commercial interests. If the AMA wants to lead in this effort, it must take forthright action against commercialization in its own house."

Dr George Lundberg (editor of JAMA) extended his misgivings: ...This is an extraordinary time... Patients must trust their physicians. Can they trust insurance companies, the managed care companies? No. Not really. The public needs to trust us and our professionalism."

Needless to say, the AMA had to hastily cancel their contract with Sunbeam, the result of which–a $20 million lawsuit.

The above scenario exposes the very sad state of affairs in the United States, where the extremes of unbridled freedom, crass commercialization, and the escalating idolization of the Money God reigns supreme.

Many professionals are now quite sicken that the country is fast losing its moral and ethical edge, and that moral relativism and money-grabbing ethos has supplanted the previously much-vaunted American way.

Everything these days, is painted in shades of gray and the greenback, with no clear-cut right or wrong. Nothing cannot be challenged. Everything is fair game in a pervasive climate of legal one-upmanship and commercial enterprise.

Slowly but surely we in Malaysia, are encountering a piecemeal dismantling of our own values and professionalism. We are steadily replacing our values with hard currency. Money and power looms large and determines almost everything we do or how we live. Because of powerful business considerations and connections, many corporations are now scrambling and muscling in onto the health turf, seeking to carve out lucrative pieces of a finite pie for themselves, fast. Our medical profession has been nudged aside and told to accept a new era of managed care, seemingly transplanted wholesale from the US of A, even when there have been loud protestations to be cautious.

In recent months, the MCOs and PPOs in America have begun facing an onslaught of problems which are now only manifesting themselves. This is because their inherent profit-orientated policy at the expense of genuine health care provisions, has resulted in shocking failures in providing reasonable but necessary health care to deserving patients. Many MCOs are now facing charges for negligence and fraud. Clearly patients as well as physicians are quite unhappy with the entire system.

But not surprisingly, this brand of managed care industry was resoundingly applauded and endorsed by The Economist (Mar 7-13, 1998) which is currently, at its peak pro-capitalist and pro-market stance. In a rather lopsided leader and main article entitled "Health Care in America" the HMO revolution was touted as a great success, and urged that its programs be further developed and extended, notwithstanding the public "opprobrium'" which The Economist says, is misplaced.

Significantly though, The Economist alludes that "Most HMO foes argue that managed care, by allowing managers to second-guess or overrule the verdicts of medical professionals, puts lives at risk," and even gave some examples of "terrible mistakes" that were made. However, it then goes on to exonerate this by stating that mistakes take place "under any system of medical care" (sic)! Without giving any credible evidence whatsoever, it goes on to extol its own suggestion that the HMO revolution has "saved a fortune" as well as doing so "while maintaining and sometimes improving upon previous medical standards."

It seems to be quite happy with the ridiculously short post-procedural hospitalization policy, and the substantial reduction in "unnecessary surgeries", but particularly because, this saves the employers billions of dollars, and to a lesser extent, taxpayers who might benefit from higher wages as a result (but, this was not clearly substantiated at all!). It also claims that "fee-for-service" practitioners do not participate in primary prevention care, and gave the quirky example that Americans were under-vaccinated under the former program, and that "managed care should, in theory, correct it."

In theory, everyone should be doing good. However, it is curious how The Economist can come to the conclusion that left with fewer (not more) regulations, the HMOs will police itself and in the best of traditions, would assiduously track down and nag negligent parents and patients for inoculation or cervical screening or whatever. In a cost-saving enterprise, it is absurd to expect that these HMOs will do anything beyond their prescribed role. In practice, they have more often than not, denied tests, investigations, and even certain therapeutic measures which they deem not cost-effective enough, just to save a dollar or two.

The prevailing disgruntlement could still break the entire healthcare management system in the near future. And, we have probably not yet seen the light at the end of the tunnel. As physicians, most of us feel very strongly that, HMOs or MCOs may yet prove to be another gamble with a grossly flawed system.

Health should not be equated with dollars and cents, because some degree of social responsibility is required by and of everyone concerned. It is becoming increasingly clear that not all "Americana" is good for everyone. Neither should we blindly accept whatever dictates or prescriptions which may arise from the West, especially without due critical analysis.

Perhaps, this is the time to reconsider our own direction, to go our own way, in creating a health care system which is truly Malaysian, with incorporation of our highly successful public service-oriented health care facilities, and not dabble with the debacle of adopting a potentially stillborn system.

Much as the MMA should not unduly commercialize itself beyond its accepted professionalism and ethical concerns, can we not also expect our policy makers to dissociate themselves from the hugely unpopular and anti-social aspects of managed care systems? We will all have to re-think, and evolve a more workable, more equitable, and just system soon.

/March 98

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