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Clarifying different roles in health care provision

Introduction -- Some Issues to Consider

Criticism Number 9

Roles, Competition and Cooperation

Samuel's model is structured around a set of defined economic roles. This is in order to introduce market principles and economic competition.

I suggest that in an integrated cooperative system there would be no need for these starkly defined separate roles - all at arms length from one another. It is better to promote a sense of common purpose, mutual regard and trust. It works better. Roles cannot work for a common purpose if they are at arms length. In a cooperative system roles are facets of a whole and are defined in terms of the services provided rather than abstract economic theory. People identify with their roles and this is what motivates them to provide the maximum benefit from available resources.

The contrivance of arms length roles only becomes a necessity when competition is introduced into a system whose effective operation requires cooperation. The problem is that cooperation is anticompetitive. When we compete the selfinterest of one group conlicts with that of another. In the marketplace selfinterest is legitimate and is encouraged. Health care is about cooperating for a common purpose and not about competition. Self interest is frowned upon. The market disrupts this sense of common purpose and fosters divisions. When roles are required to facilitate care they should be cooperative. They cannot be if they are at arms length.

Our society is a community of people living together. It is not a marketplace. The marketplace is where we go to sell and buy goods, to make the money needed to support ourselves so that we can participate in our community. It should serve that community. Increasingly the market's activities serve the interests of those who have no interest in the particular community. Clearly this is an even greater problem when the goods being sold are the health and well being of citizens. In this new health system the community and particularly its most vulnerable members increasingly come to serve the marketplace.

As I understand his speech Samuel is suggesting a proliferation of multiple structures to address each of the roles. We have a very good example in the USA where problems in health care have been solved by fragmenting the health system into multiple competitive fragments. Delineation of roles has followed market requirements rather than patient care considerations. What has resulted is an inefficient and costly mess with which the majority of US citizen are disenchanted.

The Marketplace

In reviewing Samuel's model there are a number of aspects about the way the corporate marketplace has operated in the USA which should be considered. They have relevance to Australia because of similarities in our societies, and to Samuel's model because it depends on the same competitive processes. If we look at these aspects now then the insights from the US system can be related to Samuels model. Some comments can also be made as to how desirable objectives might be attained with a more suitable system.

1. Collecting Information:- The first of these is the availability of data from the corporate market system and about the corporate market system. Readily available data is essential if unanticipated adverse outcomes and creative manipulation of the system are to be detected.

Corporate interests control much of the data in the system and it is commercially sensitive. It is collected for private commercial purposes. Information which impacts adversely on corporate interest is released only under duress. Serious problems not previously identified and where legislative disclosure is not required can go undetected.

There are therefore a number of ways in which data can be collected. In the US corporate system various agencies do require the release of some data. This is tedious and the information obtained is incomplete. The marketplace does not and cannot be forced to collect the information needed to effectively monitor care and evaluate the effects of change.

CLICK HERE -- for more information about data collection.

2. Monitoring and oversight procedures in the market:- Samuel's does not conceal the fact that his model will create pressures towards some dysfunction. Samuel's model lays considerable stress on these processes and it is clear that he believes that they will contain any adverse impact from the competitive pressures which his model introduces.

Regulation by government using contracts is therefore an important component of his model. These contracts will be monitored and their provisions enforced. Whether these oversight procedures will be contracted out to for profit groups as has happened in the USA is not clear. Our aged care minister has placed great emphasis on accreditation as a means of protecting vulnerable people from those intent on exploiting their weakness for profit.

In practice government regulation and accreditation have both failed to protect the aged and health care systems from fraud and the patients fom misuse.

CLICK HERE -- for more information about the failure of government oversight.

CLICK HERE -- for more information about the failure of accreditation

3. Power structures:- The relationships between corporations on the one hand and the political process and politicians on the other have become a core issue in the health care marketplace. Government controls funding and also oversight and penalties. The vast sums spent on political donations, lobbying and on marketing by health care interests now exceed even the smoking lobby. Many consider the political support given to health care corporations by the political recipients of this largesse to be the major impediment to addressing the problems in the US marketplace.

The close relationships between politicians and health care organisations has also become a problem in Australia.

CLICK HERE -- for more information about politicians and health care in the USA and Australia.

Brief Review

I have deliberately digressed in order to supply some background from the health care marketplace before examining the actual proposals. A few points deserve emphasis before looking at the model.

Structure:- I challenge arguments for structuring health care along the requirements of competition theory rather than the services themselves and the communities they serve. A health system provides services to the community and to a simple mind it should be organised on the basis of these services so that each can be brought to the community as efficiently and effectively as possible. The participants are motivated and focused by their roles in doing so. Samuel must explain why his system organised around competitive "roles" will do that better. Systems organised in this way focus attention on money rather than care. They have failed elsewhere.

Logic Challenged- I also challenge the idea that we can provide human care to one another better by competing about it than by cooperating to provide it. I am particularly concerned that the competition Samuel proposes is largely for profit and not for care. Profit competes directly with care for the available money. The less care provided the greater the profit. The greater the competition and the less money available the greater will be the pressure to compromise care in order to maintain profits. To my simple mind there are several major problems of logic in this which Samuel has not addressed.

The system he has proposed sets in place powerful internal stresses which set the stage for severely dysfunctional practices. To address this he plans an array of regulatory and oversight "roles". We need to ask whether they also depend on competition? From Samuel's other arguments it might be assumed that oversight will not work unless it is competitive. Why we need all this when we can simply cooperate to provide the care needed with the resources available escapes me.

There is a Comparable System:- There is already a health system which has most if not all of the features suggested by Samuel although the components may be slightly rearranged and the roles less rigidly defined. In the USA they have even turned oversight into a competitive for profit activity! It is the most expensive system in the world and among the most inefficient. There is a nation wide outcry both because vast numbers of citizens are denied care, and because other groups who are unable to look after themselves are misused and neglected. By any sensible analysis the failure of the system can be seen to be due to a marketplace system driven by competition for profit.

In this system the participants prime interest is to make more money for shareholders. Their only interest in the health system is getting more money from it. The people who work in this system, who provide the care, the doctors and the nurses are alienated, angry and in revolt. Complex regulatory, oversight and accreditation procedures have failed to protect patients and the state, not once but over and over again. Repeated attempts to reform and make it work have failed.

Samuel's proposals:- In the face of overwhelming evidence Samuel advocates an expensive competitive market system of health care for developing countries. It is bizarre. He is advocating it for developing countries which are unlikely to have the structure and resources for oversight. This is surreal!

CLICK HERE -- to proceed to the next criticism - Number 10

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

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