Health for Sale: Business or Public Service?
With all current and future healthcare reforms, there is one fundamental question that underlies them all: is our healthcare just a business or is it a guaranteed service to protect citizens’ lives and well-being? Which way leads to Dr. Jekyll and which one to Mr. Hide?
Citizens’ right to life is one of the basic principles of the European Welfare states. Governments are protecting their citizens with armies, social services and, last but not least, their healthcare systems. This protection costs money. With 17% of US GDP and 7-11% of the GDP in developed EU countries spent on Healthcare [1], more and more voices are questioning whether healthcare should be a commercial endeavor rather than a guaranteed service the citizens are to receive. After all, pharmaceutical industries as well as many others (e.g. medical equipment production) have been making their profits on Healthcare for a longtime with the unanimous social acceptance.
It is this “last mile” – this point of care such as primary or hospital care that we are still struggling with. On the one hand, all healthcare services including salaries of health providers, nurses, laboratory tests, etc. cost money. On the other hand, our humanistic consciousness cannot tolerate the vision of people dying just because they cannot afford adequate medical services. So how relevant to healthcare are fundamental principles underlying any commercial business models?
- Drive for revenue is a core priority for business: Is the ultimate goal of the national healthcare system to derive more revenue? Or is it still to make their citizens healthier and to improve their mortality and morbidity rate? On top of that, not all private healthcare enterprises are straightforward revenue-driven. For example, more than 90% of Dutch hospitals are owned and managed on a private, but not-for-profit basis.
- Market share: The more products you sell the higher is your revenue, the more stable is your business. While for some private hospitals it may be crucial to increase the number of their patients, one can hardly consider the rise of patient cohorts as the ultimate goal of the national healthcare systems.
- Customer satisfaction: Here we hope to find some similarities with Healthcare. For commercial enterprises, customer satisfaction is, in ideal case, taken for granted since they do not want to lose business to competition. But is patient satisfaction is always the key performance indicator (KPI) for every hospital overshadowing financial indicators, length of stay, bed occupancy and so on? Can patients always easily change a hospital or a health insurance company?
- Return on Investments (RoI): Business investors are usually risking their own money. In the case of healthcare, let us not forget amidst all the commercial vs. “health for free” discussions that it is the citizens that are paying for the healthcare services. Either they have already paid with their taxes to refill the budgets of their governments or regularly transfer money to their health insurances. Are they entitled to get a part of the revenue like a normal investor?
Healthcare as a system cannot meet the classical requirements of a commercial enterprise just because of its strong social significance. Talking about public, private, “cost free” or commercial healthcare we are rather referring to the ratio of private vs. public contributions within the national healthcare systems. But those contributions ultimately have one source of funding, namely the taxpayer. In this sense the difference between public and private is fairly obscure.
Is private healthcare better than public?
Private insurance companies will assure you that of course it is. You can set up an appointment faster, get a professor that will presumably operate you better; you will be put in a separate room and get a special three-course menu with meals at your bed side. Of course you should pay for these benefits, hence the price for private insurances vs. public ones is usually significantly higher. But does it really worth the money?
The big issue with some of the private health insurances, at least in Germany, is restricted flexibility. One is always welcome to step in, provided one has a sufficient income level (currently earning more than 54.900 € annually), but has no way to step out i.e. to switch back to public insurance. On top of that, in private insurance plans you cannot accumulate your contributions to compensate for the services you would most probably need in your later years, at least if you change the insurer. You have to pay over and over again. The deficiency of such a system can be shocking for some patients, e.g., for a 42 year old privately insured German patient who suddenly got cancer. Prior to that he lost his job. His private health insurance to which he had been diligently paying premiums all his life refused to cover treatments. The man was sent to suffer – quietly or painfully – at home.
An increasing number of people in Germany are seeking to switch to public health insurance plans, but the German law imposes stringent constraints on private patients desiring to migrate to public insurance companies. Moreover, the German insurers are vehemently lobbying the ban or at least significant limitations on the operations of the foreign insurers – so far quite successfully despite the EU unified market requirements.
Is public better than private?
One of the advantages of public care is its social accessibility. Yes, you can wait for months, but at least you will receive some level of services guaranteed by the Government. There are of course some problems: general rules such as the Governmental health regulations appear arbitrary and can hardly be influenced by the patients. Furthermore, it is often hard to decide what exactly patients are paying for. If the citizens are stripped of the ability to decide which doctor or hospital, or service they can choose, some bureaucrats will decide for them, and the competition between health organizations will be distorted.
Sometimes it can lead to the decisions our minds find hard to accept. Such as the decision of the National Health Services (NHS) UK to pay general practitioners in England £50 bonuses for placing patients on controversial ‘death lists’ in order to reduce the number of occupied hospital beds and thus healthcare costs. The doctors received payment for every care home patient they successfully signed up to an end of life plan.
Only 6 doctors raised their voices in UK against Liverpool Care Pathway Liverpool Care pathway , which allows medical staff to withhold fluid and drugs in a patient’s final days, claiming that it is the kindest way of letting them slip away. But this “kindest way” could turn simply into murdering patients.
90-year-old Kathleen Vine was staying for months in the South-East of England with dislocated shoulder after doctors at a hospital told her relatives that she had only 48 hours to live. Fortunately relatives did not believe the prognoses, since from their perspective the lady looked not bad. “Nanny was sitting up in bed and she was saying, ‘I’m really hungry, I’m really thirsty.’” Kathleen was immediately taken home where she lives happily now with her relatives. “I was being left to die. If it hadn’t have been for my family I would be dead now. I would just have been another statistic on the books,” she told later.
The Hippocratic Oath “I will not give poison to anyone though asked to do so, nor will I suggest such a plan” has become hopelessly obsolete, as this event testifies.
In a letter to The Daily Telegraph doctors claimed that tens of thousands of patients with terminal illnesses were placed annually on a “death pathway” to help end their lives. Informed consent was not always being sought either from the relatives or from those patients who were still in control of their faculties. The prevailing assumption apparently was that patients do not understand all the complexities of healthcare business.
Conclusion.
What controls business is the market and the market are consumers. If the healthcare system wants to be successful for a long time, be it privately or publicly funded, it has to follow the same rules: be accountable to the consumers, in other words to citizens. The crucial point seems not the ratio of public or private spending in healthcare, but who actually controls the distribution and the quality of care: consumers or the bureaucracy, be it government or the private corporate bureaucrats.
Looking at the successful European Healthcare systems at the top of 2014 Euro Health Consumer Index one can notice a distinct commonality: the ability of citizens to impact costs and efficiency of care services they receive either through direct financial contributions of individuals or due to control and easy intervention of local authorities. 
If people are putting their skin in the game, they should be able to measure the level and quality of the services they receive either with their money, their voices or with their feet. After all, we are all actual or potential patients no matter what our profession is, and we want to see our healthcare system as a “point of care” and not the point of no return.
References.
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