TSTAM, The Corporatization of Health Care and What to Do About That Petition

A physician I respect, Dr. Arvind Cavale, sent me a link to a petition decrying the corporatization of health care in America, “Claim the patient-physician relationship back!” I had a couple of misgivings about it. One was that I didn’t see what authority would receive the petition after a requisite number of signatures (1000? 10,000?) were collected. The other was that I was not sure I knew what “corporatization of health care” meant.

I’m a geezer psychiatrist and when I went to medical school, they didn’t teach us about health care policy. I learned practical things like the Krebs Cycle.

Anyway, I did a PubMed search on corporatization in health care. I didn’t find much of anything recent, but I did manage to find an entire issue of the Journal of Health Politics, Policy and Law in 2004 devoted to a rock star named Paul Starr who wrote a very important book on the subject “The Social Transformation of American Medicine.”

It’s known as TSTAM for short and it was published in 1983 originally.

One thing I know; anything that gets an acronym is something a medical student was expected to learn cold. Yet somehow this book was not on the shelf at the Health Science Book Store.

I haven’t bought the book and I found only a scrap of it online. It’s from Book One, the part Joel D. Howell said most doctors preferred not to read [1]. I can see why. Much of it is not complimentary to doctors as you can tell in the short excerpt I found online. Likewise, what little I read of the 2004 issue of the Journal of Health Politics, Policy and Law. Havighurst clearly sees doctors as the heavies:

My own diagnosis of why the health care “revolution” failed to topple medicine as a “sovereign” profession–and did not finally make physicians subject to appropriate corporate control in the ultimate interest of consumers–entirely vindicates Starr’s instinct that the American political system is far too committed to compromise and half-measures ever to allow competition and consumer choice to operate in the health sector in any but a half-baked, politically watered-down way…[2]

Moreover, TSTAM is real reading, not like the stuff you see in blogs like mine. If you’re used to reading text online, you get a shock when you open up a real book. Howell noted that it sold a lot of copies, many of them to physicians. Howell says most doctors at the time liked Book Two, which told them what they wanted to hear:

Part of TSTAM’s appeal is that it delivered exactly what the doctor might have ordered for a highly stressed profession. TSTAM could be read as affirming the centrality of physicians, as well as revealing physicians to be selfless heroes opposing a villainous threat. Both of these readings might be challenged, even contradicted, by a careful reading, but both readings could be (and were) found within TSTAM.

The reason doctors were stressed was “the growth of corporate medicine.” Physicians seemed to especially like the last few sections of the final chapter of Book Two of TSTAM, which was about the “coming of the corporation.” This was about the villain, which at the time were the health maintenance organizations (HMOs), preferred provider organizations (PPOs), and the diagnostic-related groups (DRGs), and then for god’s sake, relative value units (RVUs) which now our department is inflicting on us.

TSTAM painted a very ugly picture of the future with doctors becoming providers and patients becoming customers and health care being turned into a commodity. The prediction was that the bigger the corporate world got, the more patient care would suffer.

At this point in TSTAM, even though most of the book described doctors in fairly derisive tones (just like the 2004 issue of the Journal of Health Politics, Policy and the Law by the way) the last chapter shifts the focus to the greedy health-care corporations stalking America, which throws the greedy doctors into the shadow.

It sort of gets you all excited to fight corporatization. Doctors wanted to see themselves as something nobler than just businesspeople.

We prefer to see ourselves as paladins–or maybe, scientific paladins.

So TSTAM justified the power of the medical establishment and I caught myself wondering if the petition writer had read the book. Paul Starr even supported former President Bill Clinton’s attempt at health care reform. Fast forward to the Affordable Care Act and Maintenance of Certification (MOC) by the corporate boards? No, maybe nobody feels like doing that right now.

TSTAM gave doctors a villain to fight–corporatization of health care. It dignified the battle against all of the administrative hassles that get between doctors and patients including but not limited to the insane insurance company reimbursement refusals, still a huge topic today and bitterly cursed even in the January 2015 issue of Psychiatric Times by Allan Tasman, MD:

So what do we tell the parents of those children whose disabling psychiatric problems cannot be treated because the treatments prescribed just aren’t “medically necessary”? I don’t know, but maybe some corporate or government leaders have a good answer. Yes, we have limited financial resources to care for an entire population, but I don’t hear too many stories about denials of care for diabetes or cancer or heart disease like we hear for psychiatric illness (Tasman, A., MD (2015). In With the Old, Out with the New. Psychiatric Times).

Historians have decided what role physicians have in the evolution of health care policy in America. It’s a very small one, like a small cogwheel driven by lots of other much larger political wheels. But without this cog, that machine won’t go.

Doctors aren’t great at politics. We’d rather be paladins than politicians…heroes who act in the context of our own time, leaving the historians to judge us later. Even our petitions reflect that. Is there no longer any room for that ideal?

On the other hand, when I think about what’s happening in Iowa when it comes to mental health, I can see that paladins must find a way to confront political and corporate realities. Can we reclaim the patient-physician relationship? Can we take it back? What should I do about the forces which influence our mental health system in Iowa?

What can a paladin say that would help move us beyond the politicized skirmish which makes this look like the closing of a couple of mental hospitals is the big issue when what is really important is what we as a people are willing to do on behalf of those who are unable to defend themselves–our patients.

I did not renew my membership in the American Psychiatric Association (APA) this year. Would it have helped? I don’t know. It looks like the biggest story lately is whether the APA will move its headquarters back to the most politically inflamed place in the country–Washington, D.C., on the premise that advocacy efforts would be more effective there.

What would Paul Starr say?

And so, I’m still trying to decide what I want to do about this petition, “Claim the patient-physician relationship back!” Part of me wants to know whether it will ever go anywhere outside of a small circle of dedicated physicians. And did we ever at any time in history ever truly control this relationship, this faith we held only in trust? Can we take something back we never had?

References:

1. Howell, J. D. (2004). “What the Doctors Read.” Journal of Health Politics, Policy and Law 29(4-5): 781-798.

2. Havighurst, C. C. (2004). “Starr on the corporatization and commodification of health care: the sequel.” J Health Polit Policy Law 29(4-5): 947-967; discussion 1005-1019.

 

 

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Comments

  1. Julie Schulman, MD says:

    A whole blog entry on whether or not to sign a petition, while off-handedly mentioning that you’re giving up your APA membership? I guarantee that the petition will not influence policy in any meaningful way. The only thing that influences policy is an organization with the power of numbers — both membership numbers (as in, the number of voters the APA brings to the table) and financial resources (for campaign donations, lobbying, and so on.) There are other organizations that fight for doctors, or that fight for patients. But the APA is the ONLY organization fighting for psychiatrists, and as you know, the issues that are most important to psychiatrists aren’t necessarily high priority for those other types of organizations.

    Please don’t mistake the hoopla over moving the headquarters for the real work of the APA — what gets people’s attention isn’t the same as the bulk of what the APA does. “The APA” is not just the national APA; it’s also your state and local district branches with support of the national APA. At the state and local level we are fighting to stop the closure of mental health beds, fighting to make sure mental health care is paid for — including lawsuits against insurance companies, when needed — and fighting against state and local laws that increase stigma related to mental illness. You’d be surprised how much of that money comes from membership dues. And how important it is, when we speak to local politicians, to say that we represent 1800 psychiatrists (as we do in the NY County Psychiatric Society) and their patients, rather than a smaller number.

    The membership dues to APA are a tiny percentage of what any psychiatrist makes — less than 1%. I guarantee that the work of the APA has more than covered that in terms of fighting for mental health parity in health insurance payments. This is your voice. Please don’t neglect it.

    Julie Schulman, MD
    Immediate Past President, New York County Psychiatric Society

    Liked by 1 person

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