Healthcare is a service, not a product and we serve a population, not a market.
I have never claimed to be an expert in economics. If anything, I’ve avoided the subject. But even I know the economic arguments around the changes in the structure and funding of primary care are questionable.
No matter how I spin it, I just can’t see that the new landscape will be cheaper, better or more accessible.
The shift to a more regulated, more commodified healthcare “market” doesn’t seem to have improved access, or quality, or cost. However, healthcare HAS been commodified, so I thought it was about time I worked out whether economic theory has the answers.
Is general practice a capitalist project?
I’m indebted to a Greek economist, Yanis Varoufakis, who wrote a wonderfully accessible book — Talking to my daughter: a brief history of capitalism.
What struck me most is the way he describes the commodification of labour. Like Karl Marx, he talks about labour having two parts: the actual product, and the part that theoretically can’t be commodified, the human bit – the enthusiasm, or expertise, or even flair.
Mr Varoufakis says this is where companies get their profits, by monetising the human bit and extracting it as profit. It’s hard to do, and it leads to stupid business practice, like yelling at entry level retail workers that they need to HAPPY, or, in fact, trying to regulate healthcare workers by demanding compassion.
They want the icing on the healthcare cake thrown in for no extra cost. Ideally, the government pays for the product, and relies on regulation and good old-fashioned guilt, shame and fear to provide the rest. That way, they don’t have to pay for the expertise, they legislate for it.
Unfortunately, if you really want the human bit, you have to treat people like humans, not like commodified products. It is not particularly effective to demand things like kindness, but that is not an economic problem.
What this strategy does do is whittle down the bit you buy to its bare essence, the “product” delivered to the “consumer”.
Shifting to a pharmacy model of ‘healthcare delivery’
Pharmacy, of course, is the natural home for this sort of thinking because it has always been the part of the health system where delivery of a product is the centre of its business.
For the business of pharmacy, a market approach makes sense. However, it does shift our understanding of a consultation.
If we see healthcare as a market, and patients as consumers, a consultation is the provision of an obvious diagnosis, the use of an evidence-based protocol and the delivery of a monetised solution.
Pharmacy is keen to extend its engagement with this model. Its businesses are already designed as retail entities, which is why its journals contain articles about how to increase its market share through careful retail design and lighting, intelligent branding and competition.
The Australian Journal of Pharmacy, hidden behind its paywall, has plenty of articles that focus on marketing the business of pharmacy. Some articles focus on competitive advantage, often comparing their service with that of GPs.
“Migraine is a common condition affecting a disproportionate number of women,” writes one author. “However, many women with migraine feel brushed aside by the medical community.”
Other articles emphasise the importance of marketing services to enhance profit:
“Pursuing a patient health experience approach opens up a myriad of opportunities encompassing competing on non-price grounds, pharmacist productivity, enhanced relevance (to payers including governments and patients) and financial benefits!”
Doctors of other primary care disciplines have always had an uncomfortable relationship with discussing profits. I can’t imagine an article in a GP or physio or nursing journal discussing optimising floor plans to increase profit, but a better retail layout “allows pharmacists to generate much higher incomes—boosting retail health sale/patient and services income”.
It is hard to find fault with profit maximisation while seeing illness though a capitalist lens, using the language of consumers, marketing, retail and profit. This fits very well with the government narrative of “bang for buck”.
Pharmacy business models (not the pharmacists themselves) are committed to a capitalist view of health care, and this means focusing on selling products. They may be worthwhile products, with clinical benefits, but the model doesn’t work unless it relies on a simple formula where healthcare products are the solution to consumer’s health issue.
An example is the dysuria = UTI = antibiotic flowchart underlying the UTI pharmacy trial.
It is really no different to an expert mechanic diagnosing worn brake pads and solving the problem by replacing them. It’s a worthwhile service, but it doesn’t work with the breadth of healthcare needed in contemporary primary care.
Related
Who doesn’t fit the capitalist model?
The multimorbid, socially disadvantaged patient with fatigue doesn’t easily lend themselves to being understood as an opportunity to dispense a product. Or the measurement of an outcome. Or the standardisation of service delivery.
There will always be outliers. Outliers will not respond to the standardised solution and may never achieve a measurable outcome. Unfortunately, they are often outliers of more than one system, leading to cumulative disadvantage. These people need bespoke, individualised, relationship-based services.
The economic argument I often hear about general practice is that time-based item numbers are inappropriate because there is no incentive to provide good care. The doctor of medicine is paid whether they provide an exceptionally good service, or a poor one.
I have never understood this argument.
Hospital specialists, economists, politicians, policy makers and managers are generally paid on salaries, which theoretically pay per hour, and are not paid for outcomes either. If economists truly believed in outcomes-based funding, they would use it in the provision of care that fits the most easily commodified parts of the system, like cataract surgery, or hip replacements.
But instead, they target GPs, the lowest of the hanging fruit.
What does this mean for policy reform?
I worry that the new inquiry into GP time-based item numbers is yet another attempt to reduce general practice to commodity production.
The reality is that when other healthcare professionals “free up general practice” by taking the straightforward patients, they also remove the patients whose interactions can be easily commodified.
Our diversity, as we duck and weave around the regulations, gaps in other services, rapidly changing guidelines and need of diverse patients means we will always be the service that is most difficult to commodify.
If government policy on healthcare continues to see health as something you can define, commodify, and purchase, general practice as we know it and teach it will not be possible.
Commodifying general practice means less flexibility, less autonomy, and less capacity to see a person as a whole, rather than a sum of their individual parts.
At the moment, we are losing the GP workforce through threats to wellbeing. GPs are donating increasing resources to maintain their professional commitment to quality care while funders insist on only financing the delivery of healthcare products.
Unfortunately, this means GPs are unable to care for the most needy Australians with the least capacity to use any of the new services available to others.
That, in my view, is a result of profiting from the unpaid labour of doctors, and expecting they will continue to donate it, in the name of economic growth for the nation. It is unethical, unsustainable, and privileges healthcare workers who are prepared to deliver poorer quality care within six minutes.
The capitalist model of healthcare is not cheaper, better or more accessible. Nobody wants to be treated like a consumer seeking a standardised product. Thinly disguised vending machines are not what people need.
Healthcare is a service, not a product and we serve a population, not a market.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.