That “healthcare” is a new word, and probably a new notion is indisputable. Fifty years ago, the word was not spoken or written. The word was not in the dictionary. And there were no “healthcare specialists” in law, accounting, consulting, government, or administration. This troubling word (it combines an end with means) flows so easily off tongues it wants exploration. Here is a graphical representation from the Google Ngram search tool. Note there was no use of the word in millions of books prior to the 1960’s, and it only began to be discernible in the 1970’s. (See Figure “Follow the Words”)
In contrast, the words “medical care” have been present, though now decreasingly, across the recorded time span (arguably for millennia). If current trends continue, “healthcare” may consume medical care, turning the tables on Regina Herzlinger’s book title (“Who Killed Healthcare?”). Maybe “healthcare” itself is the predator. Ask yourself who is doing this, and why?
Words have power and meaning, and they rarely pop up by accident. Was there something about medical care that was insufficient, requiring a new notion? Were patients, physicians, nurses, and others caring for patients demanding something? It might seem so, but let’s use the first rule of forensic accounting—“Follow the Money”—to see what’s really happening. (See Figure “Follow the Money”)
Note the percentage of out of pocket expenses paid by patients (they are now called consumers by “healthcare” specialists) is flat to declining (at just over 2% of “healthcare” expenditures) over sixty years. And the percentage paid to physicians (after a small blip following passage of Medicare in 1965) is also essentially flat and gradually declining (at around 20% of expenditures). On the other hand, the really big number is the percentage of GDP allocated to “healthcare.” Who is getting all this money?
Structurally enabled by the Medicare Act (1965) and the HMO Act (1973), it appears that financial, industrial, and political (FIP) intermediaries discerned an opportunity to intermediate the “processes,” recasting them as “healthcare transactions.” Systemizing patient care required fundamental restructuring the practice of medicine: monetizing its value and consolidating the myriad new transactions. Portrayed as an attempt to bring order to the presumed chaos of a “cottage industry,” the non-accidental capture of the value created by clinical medicine increasingly inures to the to the benefit of FIPs in currencies meaningful to them—power and money. For this to occur required some radical changes, since they were not actually providing medically useful services as competent medical professionals. Why not create a new big tent, or umbrella, subsuming the medical professions as a subordinate component of the new construct, of course under their control?
First step: change the terms of engagement, literally. Make patients “consumers” (or “beneficiaries” if we are trying to sell them something); make physicians and nurses “healthcare providers”; and portray the new, improved “healthcare system” as a just, efficient, omniscient apparatus administered by intelligent agents who wisely and fairly allocate resources. We’ve come to call this “healthcare”—a financial sector, a group of industries (e.g., pharmaceutical, insurance, hospital, technology, etc.), and reformed political entitlement.
As with all such complicated mechanical constructions, there are always consequences. We are now learning about how this “healthcare” thing is working out for us.
There is more to it than meets the eye…
Google Ngram search
Regina Herzlinger, “Who Killed Healthcare?”
National Health Data