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Medicine and the Market: Equity v. Choice, Daniel Callahan and Angela A. Wasunna, 2006, The Johns Hopkins University Press, 334 pp., $35 |
The dictionary definition of market is that it is “an exchange mechanism that brings together sellers and buyers of a product.” Market mechanisms include patient choice, competition, negotiated contracts and open bidding. In healthcare the market is seen in contrast to government as a control mechanism. Market proponents place liberty as the highest value. The authors of this book evaluate the appropriate role of the market in healthcare and present a historical review of market theory and look at healthcare systems around the globe. The Canadian and United States healthcare systems are contrasted, European systems are described in detail and then healthcare in developing countries is examined.
| Physicians in America struggle with the distinction between medical practice and commerce. |
They present a very convincing case that the U.S. system of healthcare does not stack up well against other countries according to the Organization for Economic Cooperation and Development, an organization of 30 industrialized, market-economy countries. OECD rates the United States poorly in quality indicators of survival rates for various diseases and in life expectancy. It was shocking to discover how poorly the United States compares to other countries in statistics of patient satisfaction. Other nations in the OECD have citizens who are much more satisfied with their system of healthcare than U.S. citizens are with theirs.
Every American and every person from a developing country should envy the Europeans for their commitment to solidarity, a value that grasps the need for human interdependence and mutual support in the struggle against disease, illness and death. It was Adam Smith’s genius to acknowledge that the market lacked a moral core. Somehow society has to compensate. That 47 percent of the uninsured in the United States postpone medical care because of cost, 37 percent fail to fill a prescription for the same reason, and 35 percent skip recommended treatment, gives evidence of America’s lack of commitment to solidarity and provides an example of how the market has failed healthcare in the United States.
Pharmaceuticals are another example of market failure. The pharmaceutical industry has been the most lucrative of all industries. Annual profits are 15 percent to 20 percent and the cost of drugs is the most rapidly increasing factor in escalating healthcare costs. The United States basically pays for research and development of new drugs for the whole world because the Europeans will not and the developing countries cannot. In addition, the National Institutes of Health accounts for most of the basic research of importance to the industry.
Physicians in America struggle with the distinction between medical practice and commerce. Doctors increasingly are using advertising, marketing and public relations techniques to attract patients. Professional societies have viewed competition among physicians as a necessary feature of the new medical marketplace. The influence of market on medicine seems to have produced a new culture of affluence and prosperity among a significant percentage of practitioners.
The weakest chapter in this book is on the market in developing countries. The authors conclude that “increasing disparities in healthcare access and utilization can be attributed almost directly to the introduction of market practices in healthcare systems.” Poor countries will have to decide how much inequality in the healthcare system can be tolerated by the population for the sake of economic growth.
In the United States most of our energy, money, publicity, and political clout is focused on providing goods, technology and services for sickness care and cure. Yet improvement in health comes not from sickness care but from social and economic conditions under which people live.
In summary, Callahan and Wasunna do not see the market as the answer to our healthcare problems even if it works well in other sectors of society. The principal danger of market practices is that they will increase healthcare inequities, giving those with economic resources an advantage over those without.
This is an interesting book that the conservatives among us may not enjoy but which will give all readers food for thought.
Gary Vander Ark, MD, is clinical professor of neurosurgery at the University of Colorado Health Sciences Center. He is the 2001 recipient of the AANS Humanitarian Award.