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The role of competition in health care

Criticism Number 16

Answering some common criticisms

1. Introduction

The real criticisms - starting points: - The first step in answering criticisms is to identify the criticisms correctly. In attempting to answer criticisms Samuel falls at the first step by not understanding what the criticisms are. The criticisms are about the market, about the profit motive and about competition. It is about the "starting points" of what Samuel proposes. In the first three paragraphs of this section he accepts them as unchallenged "goods" - self evident truths. This is pure "NMEspeak". He carefully keeps clear of the core criticisms and instead turns to government control, efficiency and equity. In criticising I have responded by questioning these but this is peripheral to the core criticisms.

Government and corporations: - I have no particular confidence in government, particularly their involvement in health care. Their performance is very variable. I have an intense distrust of the share market as a place for making medical decisions. It has a truly dreadful track record in health care. It has demonstrated a willingness to buy control of government and has been remarkably successful in doing so. This is the primary criticism.

The community: - I have great confidence in the community - the ordinary people - the people who have exposed what has been happening often at great cost to themselves. They have an excellent track record. I want them to watch over me when I am old and unable to do so myself. Bodies like the Health Issues Centre in Victoria are taking an ever greater interest in healthcare. It is a good start.

The share market: - The point is that the for profit sector and particularly those listed on the stock market are subject to outside pressures which render them unsuitable groups to be involved in health care. The market creates a context which generates discordant paradigms. In this context the least suitable people to provide health care succeed. That this is so is confirmed by corporate conduct in the health care marketplace.

Samuel does not specify exactly what private groups he is talking about. It is clear that he sees large market listed companies as the prime purchasers and providers - a giant corporate health care marketplace.

Contracts: - Experience in the USA and my personal experience outside the USA is that medicine under contract is abused and misused in the marketplace. Enforcement is extremely difficult. Government has neither the ability, the capacity or the willingness to do this in an ongoing manner. Thirty years of trying in the USA has failed.

Common sense: - Health care is about the community. a community is a group of cooperating people. As soon as cooperation and community values are accepted as the preferred starting points for a humanitarian service is accepted then Samuel's model dissolves away. This is particularly because the ability of many to compete is impaired. Corporate healthcare predators have ruthlessly exploited this vulnerability.

The criticisms and concerns which Samuel refers to are because common sense and common experience indicate that the paradigms which are being used are likely to compromise care and waste resources in unproductive activities. They are not as he likes to think because of an unwillingness to change.

The criticisms are based on the ability of others to view the proposals using different paradigms which give different insights. Experience of health care over the centuries is that the sort of pressures which Samuel's model introduces threaten care. That this is so is well illustrated by what has clearly happened in a very similar market based system in the USA. It is not the differences but the similar "starting points" which Samuel must confront.

Head in the sand: - This is the sort of head in the sand approach adopted by Mayne Nickless in 1994 and by Tenet/NME in 1995. They believed that what they were doing was legitimate. They had not done anything wrong and were victims. A senior member of Tenet/NME's staff stood up at a national meeting of lawyers and claimed the company had been victimised. He claimed that it was unfair that the company had been prohibited from employing people with a criminal record. There was a stony silence.

The information about market based health care systems is in. It now remains for the NCC and its staff to remove the blinkers, devote sufficient time to study it and draw obvious conclusions.

Moving ahead: - I also agree with Samuel that the current structure of health care is not ideal and that the competition between different sectors of health care funded by government or by other means is unproductive.

The organisation of health care is not as Samuel claims designed for the convenience of the professions. It is structured for the economic convenience of the funders. This is not in the interests of patients, doctors or the services which are provided. Samuel compounds the problem we have already experienced by introducing more competition and an even more fragmented system structured to meet the economic ideology of the marketplace.

I first attempted to motivate for a more integrated and cooperative system of care in about 1970 - 30 years ago. I helped to set up an integrated cancer service which brought care to patients whose care was previously fragmented by race, hospital and payment system across a vast geographic area. My arguments at the time for organising health care along similar lines rather than methods of payment fell on deaf ears. Not much has changed!

Reforming the organisation of health care around funding by introducing competitive financial roles is like addressing the market failures in health care by making it more market like.

CLICK HERE -- to proceed to the next criticism - Number 17

CLICK HERE -- to go to the next section of Samuel's speech

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This page created October 2000 by Michael Wynne