Sunday, November 15, 2009

Inconvenient Truths about Health Care as Industry

As I continue to argue that one of the most significant impediments to serious health care reform has been the efforts of a "consciousness industry" to induce a general acceptance of the phrase "health care industry" and thus accept, by implication, industry-based thinking in all sectors of health care, including providing care, providing insurance to cover the care, and providing supporting agencies (to use the terminology of Kenneth Burke), such as pharmaceuticals and new technologies. However, such industry-based thinking has its own implications; and I found myself thinking about them while reading Arthur Loesser's account of the transition of piano-making from craft work to manufacturing. The most important element of that transition is the migration of a craftsman's personal shop, which tends to involve only a few people, to a factory that supports mass production. Loesser raises the interesting point that, while the craftsman may only have to worry about supervising and coordinating a few assistants and apprentices, the move to the factory necessitates a change in worldview:

Inevitably, the head of a factory tends to regard sales as more important than production. Unfilled orders give him less of a stomach-ache than excess inventory. A piano maker who expands into a factory ceases to be a craftsman; he becomes a businessman.

Where health care is concerned, this is the inconvenient truth that dare not speak its name. We may be comfortable enough thinking of the production of pharmaceuticals and advanced medical technologies in a factory setting; but, in accepting the concept of health care as an industry, we accept the implication that, from the businessman's perspective, the view of hospitals and clinics as factories is more important than the view of them as care centers. The same can be said about insurance providers; but, as our relationship with our insurance providers becomes more and more depersonalized, it is easier for us to think of them as some form of cubicle-based factory. My point is that, when it comes to patient care itself, those who provide it must now contend with business processes that have more to do with extrapolations of the concepts of "sales" and "inventory" than with either what is taught in medical school or the broader issue of, as Jerome Groopman put it, "how doctors think." Indeed, Groopman's latest critique of medical practice aligns nicely with Loesser's observations: Doctors now think more like the sort of businessmen that Loesser had in mind than they do about patient care.

Of course all that attention to sales and inventory escalates to broader questions of supply and demand, which, in turn, leads to demand creation in the interest of increasing sales. This brings us back to the primary domain of the consciousness industry and the recognition that it has been warping our view of medical care for several decades. The primary agency of demand creation is advertising, and advertising has now corrupted just about every aspect of health care. Doctors are besieged with advertising, primary for those pharmaceuticals and new technologies; and there should be no question that such advertising warps their diagnostic judgment as much as advertisements from the food industry warp our perspective of good nutrition. The pharmaceutical sector has now become even more devious, taking their advertising to the general public but always concluding with that ask-your-doctor punch line.

It should be no surprise that none of these issues have surfaced in Congressional debate over health care reform. Calvin Coolidge may have been the one who said it, but it is hard to imagine anyone of either political party currently working in Washington who does not accept the precept that the business of America is business. The ultimate goal of the consciousness industry is the reinforcement of that precept, even if it implies that the health of the individual citizen may be an insignificant inconvenience to the smooth operation of business.

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