Institutional betrayal in corporate medicine is a topic that has gained increasing attention in recent years. It refers to instances in which physicians or other healthcare professionals feel that their employers have acted against their best interests, or violated their trust. This can occur in a number of different ways, from unfair treatment of staff to unethical business practices, and can have wide-ranging effects on both staff and patients.
A recent example from Medscape (which also blew up on Twitter) was where a physician employed by an insurer declined to fund a specific oncology treatment. The requesting physician had already had the claim denied once, then at appeal, and finally got to speak with the corporate MD – a retired oncologist themselves, but not a specialist in that particular area of breast oncology.
The oncologist still refused the drug, citing their own ‘misinterpretation’ of study data and ‘mansplaining breast oncology’ to the specialist. The patient lost out and both doctor and patient experienced the betrayal where profits were put before patient care in this scenario. The insurer, contacted by Medscape replied that these processes were needed to evaluate the medical necessity and safety of care, given that “15-30% of care is unnecessary”.
Betrayal in corporate medicine is a problem that affects healthcare organizations of all sizes. In some cases, it may be the result of a few bad actors within an otherwise well-intentioned company. In others, it may be the result of systemic issues that are deeply ingrained in the organization’s culture or business model.
Regardless of the cause, betrayal in corporate medicine is an issue that affects both large and small healthcare providers.
Betrayal between medical professionals is common once indoctrinated into the culture of medicine and can be fueled by jealousy, power-seeking, and fear that can push student doctors, resident physicians, attendings, even close friends and family to act against each other for their own personal gain" - Dr Pamela Wible MD
The prevalence of institutional betrayal in corporate medicine is difficult to measure precisely, as it often goes unreported or unrecognized. However, a growing number of healthcare professionals and patients have spoken out about instances of betrayal within the healthcare industry.
Studies have found that healthcare professionals who report feeling unsupported or retaliated against by their employers are more likely to experience burnout and leave their jobs.
Similarly, patients who experience instances of medical harm or neglect are more likely to experience negative health outcomes and reduced trust in the healthcare system.
As Pam Wible, physician and advocate wrote about her book, ‘Physician Betrayal: How our Heroes become Villains’: “Betrayal between medical professionals is common once indoctrinated into the culture of medicine and can be fueled by jealousy, power-seeking, and fear that can push student doctors, resident physicians, attendings, even close friends and family to act against each other for their own personal gain.”
Dr Wible describes a number of types of institutional betrayal where physicians are involved:
Teachers who offer apprenticeship to trainees build relationships of trust and connection that may end in manipulation, exploitation, and abuse of naïve students who then experience peer betrayal—an act of emotional infidelity to medical peers who then become active participants in the betrayal cycle.”
There are a number of different factors that can contribute to betrayal in corporate medicine. One of the most common is a misalignment of values between the organization and its staff. For example, if a healthcare provider prioritizes profits over patient care, this can create tension between staff members who are more focused on providing high-quality care to patients.
Another factor that can contribute to betrayal in corporate medicine is a lack of transparency. When healthcare organizations are not transparent about their business practices or decision-making processes, staff members may feel as though they are being kept in the dark. This can erode trust and lead to feelings of betrayal.
Underlying all of this is greed. There is no better word. An article, “Salve lucrum” (Hail, profit) in JAMA by Donald Berwick sums it up:
“The grip of financial self-interest in US health care is becoming a stranglehold, with dangerous and pervasive consequences. No sector of US health care is immune from the immoderate pursuit of profit, neither drug companies, nor insurers, nor hospitals, nor investors, nor physician practices.”
Competition beyond a point does not work in healthcare. It works for lots of other industries, but people are not Model T Fords, hospitals are not factories, and staff are not robots.
Finally, excessive competition can also be a contributing factor to betrayal in corporate medicine. When healthcare providers are in direct competition with one another, there may be a temptation to cut corners or engage in unethical practices in order to gain an edge.
We say “excessive” competition, but in reality, we see that competition beyond a point does not work in healthcare. It works for lots of other industries, but people are not Model T Fords, hospitals are not factories, and staff are not robots. Moreover, as technology and lifespans increase, and chronic disease prevalences grow, costs will inevitably rise. Throw in the free market for pharmaceutical drugs and you get a system primed to become more expensive over time.
Competition may indeed spur on innovation in healthcare, but the US healthcare market is a prime example of where corporatized competitive medicine does not improve outcomes for serve patients or staff.
The US spends close to 18% of GDP on health care, almost double what the average OECD country spends. Yet our outcomes are “mediocre” – something about the competitive US system costs (us) more and delivers (us) less.
One major factor is billing and insurance-related (BIR) costs, which are duplicated in each competing organization. Each year, health care payers and providers in the United States spend about $496 billion on BIR costs, according to the Center for American Progress. A 2010 report by the National Academy of Medicine (NAM) estimated that the United States spends about twice as much as necessary on BIR costs.
A single payer system has been suggested to save $600 Bn a year – not a trivial amount – which could reduce insurance fees and copays, as well as administrative burden for everyone; and any excess could be reinvested in the healthcare system as occurs in many European countries.
Betrayal in corporate medicine can have a number of different effects on staff members, especially physicians. One of the most common is burnout. When physicians feel as though they are being forced to prioritize profits over patient care, or when they are not given the resources they need to provide high-quality care, this can lead to feelings of frustration and burnout.
In addition to burnout, betrayal in corporate medicine can also lead to job dissatisfaction and high turnover rates. When physicians feel as though their employers are not acting in their best interests, they may be more likely to look for employment elsewhere. This can lead to a high turnover rate, which can be expensive and disruptive for healthcare organizations.
More concerning is the effects on culture and individual staff. As Berwick explains, “Greed harms the cultures of compassion and professionalism that are bedrock to healing care. Health care executives and board members who know better nonetheless feel compelled to play the games of pricing, acquisition, and revenue maximization that others do. Professionals find themselves trapped in record keeping, coding behaviors, and productivity imperatives that belie the reasons many went into health care in the first place. “Moral injury” is the harvest, with demoralization and disengagement to follow.”
At the same time, insurers are reporting record profits. Another commentator has suggested that, “Only a sociopath could work for a large health system and not be burned out. Anyone who cares about patients is doomed to burnout.”
Another oncology story posted on Medscape involved a patient being refused funding for ondansetron on a Friday evening. This patient had severe oral mucositis and 2 previous admissions for dehydration as they were unable to take fluids orally.
The prescribing physician was advised by the insurer to fill out a pre-authorization form, which could only be submitted on Monday morning. The patient had to wait 5 days for treatment in suffering and unable to swallow.
Where is the humanity in this scenario?
When healthcare organizations prioritize profits over patient care, this can lead to a number of negative outcomes for patients, such as longer wait times, lower quality care, and higher costs.
Patients who experience institutional betrayal – especially those with high care conditions – were significantly more likely to self-report anger and irritability symptoms, a lack of trust in their HCPs, and more negative expectations for future healthcare than those not reporting institutional betrayal. This in turn can rupture the physician-patient relationship and trust in the healthcare system as a whole.
Betrayal in corporate medicine can also have a number of negative effects healthcare providers’ finances.
Unethical business practices can result in fines, lawsuits, and other financial penalties for healthcare providers.
Healthcare staff will just “quiet quit” or “rage quit”, and patients will suffer.
There are a number of different solutions that healthcare organizations can implement in order to reduce the likelihood of betrayal in corporate medicine. One of the most important is to prioritize transparency. By being open and honest with staff members about business practices and decision-making processes, healthcare providers can build trust and reduce the likelihood of betrayal.
Another important solution is to prioritize patient care. When healthcare providers prioritize patient care over profits, this can help to reduce tension between staff members and create a more collaborative and supportive work environment.
Finally, healthcare providers can work to reduce competition between different organizations. By collaborating with one another and focusing on shared goals, healthcare providers can create a more cohesive and supportive industry that is better equipped to meet the needs of patients.
In conclusion, betrayal in corporate medicine is a complex issue that can have wide-ranging effects on both staff and patients.
By prioritizing transparency, patient care, and collaboration, healthcare providers can work to reduce the likelihood of betrayal and create a more supportive and collaborative work environment.
Further, reducing beaurocracy and administrative costs will improve cost-effectiveness and reduce the competetive drives which can lead to so much betrayal in medicine.
