Money-Driven Medicine: The Real Reason Health Care Costs So MuchBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7566.504 (Published 31 August 2006) Cite this as: BMJ 2006;333:504
All rapid responses
To the editors:
I would like to thank Jeanne Lenzer for her kind review of my book,
Money-Driven Medicine: The Real Reason Health Care Costs So Much. It is
clear that she read it closely and insightfully.
There is just one point that I would like to clear up. Early on in
the book, I suggest that power in the U.S. health care system has
shifted, from the physician to the corporation, and suggest that “before
patients can reclaim their rightful place at the center—and indeed as the
raison d’etre of our health care system—we must empower doctors to
practice patient-centered medicine, based, not on corporate imperatives,
doctors’ druthers, or even patients’ demands” but on the best scientific
evidence available.” In other words, power must shift from the corporation
back to the physician.
Today, too many decisions about how to allocate our health care
dollars have become corporate marketing decisions. Drug-makers, device-
makers and insurers decide which products to develop based, not on what
patients need, but on what their marketers tell them will sell—and produce
the highest profit. There is a saying in the drug industry: “A pill that
you take once is good; a pill that you take every day is better.”
In a fiercely competitive marketplace where not-for-profit hospitals
compete with for-profit hospital chains, even the not-for-profits keep an
eye on the bottom line when deciding whether to invest health care dollars
in a new heart pavilion, valet parking, or palliative care for the dying.
“Is there a business case for palliative care?” hospital administrators
ask. So, when it comes to palliative care, the U.S. lags far behind the
To be fair, it is only natural that corporations put profits first.
Indeed, under U.S. law, a corporation's first obligation is to its
shareholders, not to its customers. A physician, by contrast, is a
professional, who pledges to put his patients’ interests ahead of his own
financial interests. And that is a major reason why I would like to see
physicians taking back some of the power that they have lost.
Having said that, I recognize that not all physicians live up to
their oath. Lenzer suggests that I “idealize” physicians and that I think
the AMA was acting “heroically” when it adopted a code of ethics making it
"'unprofessional' for a physician to permit `direct profit' to be made
from his labour.” At that point, I’m afraid she misreads my tone. I tried
to make it clear that the AMA was protecting its own turf. There was
nothing heroic about its action. Just two pages later, I talk about how
“the AMA’s most self-serving pronouncements displayed a surprisingly frank
combination of cupidity and self-righteousness . . ..”
At the same time, I think a great many U.S. doctors still think of
themselves as professionals, and believe that they should be (and are)
putting their patients' interests ahead of their own. Of course, some of
the time, some of them are kidding themselves, which is why I believe that
doctors must avoid all financial conflicts of interest.
In many chapters, I tell stories of doctors who have been corrupted
by corporations that offer enticements ranging from fat consulting fees to
outings to topless bars in order to win a physicians’ endorsement for
their products. I also describe cases where for-profit hospitals have
paid doctors to “put heads on beds”—bribing them to steer their patients
to a particular hospital so that the corporation can meet Wall Street’s
So when I express my hope that physicians will re-claim their power,
I envision completely disinterested physicians sitting on panels that
decide how we spend our health care dollars. I don’t think that
acknowledging a possible conflict is enough; I believe that physicians
must disentangle themselves from financial incentives that create even the
appearance of a conflict.
Today, corporate lobbyists have a great influence on what drugs and
devices our Food & Drug Administration (FDA) approves, which products
the Centers for Medicare and Medicaid (CMS) agree to pay for, and how much
Medicare agrees to pay private insurers when they enroll Medicare
Meanwhile, the doctors that advise both the FDA and Medicare often
have ties to industry. If are going to cut some of the profit-driven waste
in our health care system, we must make sure that the doctors who oversee
clinical trails and advise government agencies on what to cover and what
to approve have no financial interest in the outcome.
Finally, when I suggest that we need to empower physicians to
practice patient-centered medicine “based, not on corporate imperatives or
doctors’ druthers” I am saying that the days of the Lone Ranger solo
practitioner, who practiced fee-for-service medicine as he saw
fit(“without anyone looking over his shoulder”) are over.
First of all, these days, there is just too much knowledge for any
one physician to absorb—even in a single specialty. Secondly, we can no
longer afford a fee-for service system that creates perverse incentives
for doctors to overtreat. And finally, the cost of running a small or
even a medium-sized group practice has become prohibitively expensive.
The physicians’ groups that I hold up as models in the book are very
large groups like our Veterans’ Health Administration, Kaiser Permanente,
and the Mayo Clinic. In each case salaried doctors work collaboratively in
a setting where they make use of electronic medical records to practice
evidence-based medicine. Physicians, not corporations, set up practice
"guidelines" (not rules)for treating patients, and science, not money,
drives those decisions.
Competing interests: No competing interests