I'm the only physician in the emergency room. There are still several patients to see. The waiting room is overflowing, and the mountain of paperwork grows.
I know there are consequences if I don't document what I've done, what I've seen, thought, heard, and who I've talked to.
But then a patient's family member knocks on the door and says "Doc, can we talk about my mom? I'm worried."
I want to talk with this person. I want to talk about her mom's prognosis and how her family should prepare. But I have other patients, and that mountain of paperwork keeps nagging at my subconscious. I speak with her, but I'm in a rush. She senses that.
She is upset. But so am I. This family doesn't feel like I've listened to them. And it's that I do -- for the sake of their mother's health, but also for my mental well being as a caregiver.
The simple act of taking time and listening is one of the most important components of patient care. But as physicians we feel we do not have time to listen, much less harness and demonstrate compassion. According to a University of Chicago study from last year, it would take a primary care physician 26.7 hours per day to provide complete, guideline-based care for their average number of patients.
These facts have consequences. According to a survey by the National Partnership for Healthcare and Hospice Innovation, of Americans believe the U.S. healthcare system puts profits over patients.
Healthcare workers enter the field to help patients. And patients expect us to help them. They want to be heard. They want us to listen. They want to be treated equitably, with compassion, and ultimately, to feel better. Compassionate care involves acknowledging the emotional distress and suffering of others, along with acting to improve their situation through motivation and relational efforts.
That is not happening in the U.S. today. And it won't happen until regulatory controls are used as a check on our capitalist system to better balance profits with the needs of our patients.
High Costs, Low Quality
According to CMS, healthcare spending in the U.S. to $4.3 trillion in 2021. That number represents $12,914 per individual or 18.3% of the nation's total economy. Yet, despite the highest cost per person for healthcare, care is not administered evenly, and Americans experience than their peers around the world. U.S. life expectancy at birth was 77 years in 2020, 3 years lower than the average for other industrialized countries.
Many and nurses attribute burnout to the increasing corporatization of medicine, where companies prioritize "profits over patients." are considering leaving the profession. Activists have , both for-profit and not-for-profit, for shutting down their services in underserved communities. Patients and doctors are unhappy with the exorbitant prices of medications and prior authorizations. Meanwhile, insurance companies earn massive profits. In 2022, UnitedHealth's revenues or 13% from 2021, while hospitals and physicians face decreasing reimbursements.
Blame for the ills of the U.S. healthcare system flings far and wide. Maybe it is the influence of private equity. Or perhaps it is too many hospital mergers. Or maybe fault lies with physician staffing firms, insurance companies, or pharmaceutical giants.
There is a lot of anger. Still, nothing changes.
Why are we here? Because profits, not compassion, drive our healthcare system.
Are Capitalism And Compassion At Odds?
The truth is, the U.S. system is doing exactly what it is supposed to do: generate profits.
Capitalism is founded on the ownership of private property, self interest, competition, freedom to choose, and limited government. Adam Smith famously said, "It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest." Now, replace butcher, brewer, and baker with investment firms, insurers, and pharmaceutical companies. Is it not the same?
Of course it is -- which is why there are winners and losers. Those with greater scale and influence ultimately win and those with less, over time, lose.
Right now, based upon the levels of burnout and healthcare outcomes, it is providers and patients who are losing.
Let's look at private equity. Private equity has become in healthcare due to a straightforward strategy: buy a struggling practice or hospital, improve its performance and offerings, and sell it for a profit typically in 4 to 10 years. But what does it mean to "improve performance" in healthcare? Does that mean quality performance, physician satisfaction, or financial and operating performance? For private equity firms, it is the latter. In healthcare, this means optimizing operating efficiencies, reducing workforce needs, providing capital investments for innovations, and even reducing salaries to pad the bottom line. Quality improvement is important and can happen -- only if there are financial reimbursement mechanisms attached.
Is that bad? No, that is just capitalism.
The same is true with private payers, hospital corporations, and pharmaceutical companies. Mega-health insurers and pharmaceutical companies are all stock traded. Even some hospital corporations are stock traded. And their financial goals are simple: generate returns that outperform the initial purchase price (i.e., make profit).
To be clear, many of the people who work at these companies do so because they want to improve care. That is their mission, but despite their good wishes, the company's reason for being is to make a profit.
Should we, as physicians, nurses, and patients, be angered or blame the players in the capitalism game for following the laws and regulations? Should we expect benevolence to be their primary motivator when benevolence is not traded on the stock floor?
The answer is no, but that does not mean we cannot change the system or make it more compassionate.
Policymakers can change regulatory policy, enhance financial support for the underserved, and rework laws so that financial incentives, market dynamics, and outcomes change. We need a balanced approach where:
- Providers understand the financial system
- There is alignment on what we believe are fundamental patient and healthcare workers' rights
- Lawmakers support healthcare as an infrastructure investment
- Federal and state governments apply reasonable regulations that level the playing field, preventing monopolies while promoting innovation
- We shift financial incentives away from quantity of care to quality of care
- We support payment models that incentivize cost-containment while improving outcomes
Capitalism clearly has significant benefits for healthcare. But capitalism without appropriate levels of regulatory control results in unequal treatment, hospital closures, clinician burnout, ignored patients and families, and an erosion of the social contract.
is a practicing emergency medicine physician, founder of , and a professor of practice at the University of North Carolina's Kenan-Flagler Business School. Previously he served as president of emergency medicine and chief impact officer for one of the nation's largest national medical groups.