American College of Physicians on For-Profit Medicine; Mortality from For-Profit Dialysis

September 13, 2021

Summary: Investor-owned care, with a focus on profit, has permeated U.S. health care. The American College of Physicians critiques this trend, but avoids a clear opposing position. Meantime, evidence accumulates of its deleterious effects on health. 

Financial Profit in Medicine: Position Paper from American College of Physicians
Annals of Internal Medicine
Sep 7, 2021
By R Crowley et al

From the Abstract:

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics.

From the Recommendations:

ACP affirms support for . . . providing all Americans with access to comprehensive health care coverage, either through a public choice model or single payer model.

Mortality at For-Profit Versus Not-For-Profit Hemodialysis Centers: A Systematic Review and Meta-analysis
International Journal of Health Services
Dec 15, 2020
By S Dickman et al.

From the Abstract:

We conducted a systematic review and meta-analysis to assess differences in risk-adjusted mortality rates between for-profit (FP) and not-for-profit (NFP) hemodialysis facilities.. . . We included nine observational studies of hemodialysis facilities representing 1,163,144 patient-years. In pooled random-effects meta-analysis, the odds ratio of mortality in FP relative to NFP facilities was 1.07 (95% CI 1.04–1.11). … Approximately 3,800 excess deaths might be averted annually if U.S. FP hemodialysis operators matched NFP mortality rates.

Comment by: David Himmelstein and Steffie Woolhandler

For a generation or more doctors mostly remained silent as care was commercialized; the frogs sat still as the water heated up. The ACP’s statement continues the “let’s wait and see approach”, even as it cites the mounting evidence that allowing investor-owned (a clearer term than “for-profit”) health care delivery distorts care and raises costs. The confusion arising from the term “for-profit” is evident in the ACP’s position paper, which conflates investors’ gains from ownership of facilities (and the labor of others) with income derived from the work you do yourself, i.e. physicians’ incomes for the care of patients.

While the ACP studiously avoids taking a position on investor-owned care, many of the position paper’s 193 references attest to the harmful effects of such ownership, and the two principal profit-boosting strategies employed by investor-owned providers: (1) raising costs; and (2) skimping on care. Where payments can be inflated by raising prices (e.g. by taking ED docs out-of-network), or financial gaming (e.g. upcoding) they do that.  When payments are mostly fixed (e.g. for nursing home care or dialysis) they skimp on care, sometimes with fatal consequences (as the Dickman/Mirza study demonstrates).

While the position paper happily reaffirms the ACP’s support for single payer reform, it otherwise remains silent on the market-oriented health policies that have opened the door for investor ownership and also force non-profits to prioritize generating surpluses or risk a downward spiral toward closure.

Doctors and other health care workers should receive reasonable incomes. Health care institutions should devote all of their revenues to patient care, not to rewarding investors or accumulating funds for expansion or investment. Instead, funding for new or upgraded facilities should be allocated based on objective assessment of communities’ needs.