Tim Flannery’s latest book, Here on Earth: An Argument for Hope, was one of Croakey’s holiday reading pleasures, but it did not leave me feeling particularly hopeful for the planet’s future.
It also left me wondering about the contribution of the health industry to planetary ill-health, and why we don’t hear far more about the environment and sustainability in discussions about health reform and the future of health care.
Perhaps health policies and health care interventions need to be explicity evaluated for their broader environmental impacts, as well as their effects upon human health and budgetary bottom lines (particularly as much activity, whether at a policy, public health or clinical level, is probably of marginal health benefit).
Meanwhile, Professor Peter Brooks, Director of the Australian Health Workforce Institute, at the University of Melbourne, suggests that we should be scrutinising the “medical industrial complex” far more closely, and argues that financial incentives (such as fee-for-service healthcare) are undermining the sustainability and fairness of our health system.
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Is the medical industrial complex holding us captive?
Peter Brooks writes:
I recently spent a weekend in New York, my favourite city. I was returning (the long way round) from the Annual Meeting of the American College of Rheumatology, held in Atlanta, Georgia, the city that hosts one of the greatest threats to public health on the planet – Coca Cola.
The meeting was the usual synthesis of excellent musculoskeletal research from around the world – how modified stem cells may solve the problems of autoimmunity and transplantation, new biologics to reduce the number of swollen joints at great cost (but not cure rheumatoid arthritis) and new ways of assessing joint diseases with technology.
At this meeting there were also an increasing number of debates about the ‘health system’ – its costs and complexity, and how the Obama health reforms will affect clinical practice.
At one session, a practitioner explained how he had recently hired a ‘scribe’ – like a court reporter – so that he could talk TO/ WITH his patient, rather than jot down unreadable notes or type directly to the computer. Bring on the voice recognition software.
I was struck once again by the influence that technology has on modern medicine – acknowledging that it has been enormously successful in curing/palliating many diseases but one has to ask the question as to whether we have become a little too captive to what I might refer to as the ‘Medical/Industrial Complex’ – in much the same vein that President Eisenhower voiced his concerns about the rising ‘militarism’ in America and its association with the military industrial complex in the 1960’s.
November in New York is always spectacular – those brilliant sunny days with the temperature hovering around 5-10 degrees centigrade and catching the golden tops of the older skyscrapers and the red and yellow of the late autumn leaves. The streets are full of folk of every colour and creed – the quintessential international community and increasingly from every class in society and more obviously so. They look older now, the homeless begging for money for food and health care on the subway, pushing their shopping trolleys with all their worldly goods and rubbing shoulders with the ‘young/old – and beautiful’ emerging from Saks and Tiffany with their early Christmas fare!
Now this is the issue: inequity. And health in the US is a great example of this – the very best medicine can offer, but still a very significant population who cannot access even basic health care, and a nation that does not rate on the score board in terms of the usual measures of good and equitable health system.
This issue of inequality has been highlighted recently by an excellent book, The Spirit Level: Why More Equal Societies Almost Always Do Better, by Richard Wilkinson and Kate Pickett (Penguin), and a companion by the late Tony Judt – Ill Fares the Land (Penguin). Tony Judt has also has also provided an excellent essay published in the New York Review of Books, in which he develops the philosophical basis to this dilemma.
Spirit Level provides numerous data showing that if you take almost any societal parameter you like to think of – be it the number of criminals in prison, the level of nonviolent or violent crime in a community, literacy, obesity, life expectancy, infant death, social mobility – there is a correlation with income disparity. The higher the inequality, the greater the problem.
Why do we need to understand this? Because we (Australia) are up there with the US in the inequality stakes, along with New Zealand, United Kingdom, Portugal and Singapore. The percentage of the Australian population that controls 80 % of the finances has decreased significantly over the last few years, while the number on incomes below the poverty line has increased significantly, and in 2010 some 1 million Australians had to access food support.
Disparities in the health system are growing – at a number of levels – both within patients and in the community and across health professionals. The “gap” that patients have to find between what a doctor (or other health professional) charges and what they are reimbursed by Medicare or private insurance is growing, and there is some evidence to suggest that this is impacting on willingness of patients to access treatment.
On the other hand, the variation in remuneration between different specialties is also of growing concern and is likely to be a factor in influencing career choices. For example, a recent paper from the MABEL Study (Medicine in Australia: Balancing Employment and Life) has suggested that increasing GP earnings by $50,000 per annum as well as increasing opportunities for procedural or academic work might result in increases to the numbers of junior doctors choosing general practice by between 8 and 15 percentage points, equating to between 212 and 376 junior doctors per year (PDF download).
On the other hand, this same cohort has shown that doctors are pretty satisfied with their work situation, with specialists slightly more satisfied than general practitioners. Again, this might be related to earning capacity.
The uncapped fee for service system that currently operates in Australia, with its significant bias towards procedures, is driving these inequalities and is unlikely to be sustainable in the long term.
Some review of the financial incentives driving the Australian health system – albeit politically hard to achieve – will have to be part of the health reform required to put sustainability back into the equation.
PostScript from Croakey: It would be good to hear far more about the intersection of population and environmental health (please get in touch if this is an area of interest for you, and you have ideas for Croakey articles over 2011).