Healthcare Diagnosis
Sick and getting sicker; Treatment: A Catholic Prescription
Amidst this very broken healthcare system, I count myself among the most fortunate of all physicians in the United States. Twenty-one years ago now, my anesthesia partner, Keith Smith, and I co-founded the Surgery Center of Oklahoma (SCO). The national notoriety that SCO enjoys stems from our pricing model that is often 6-10 times less than what a typical hospital would charge. Once the claim is made, that our prices are multiples less than the big box hospitals, the incredulity, as well as the how and whys of what we are doing, starts flooding in. I will address this toward the end of the article. One other great personal satisfaction for me though, is that because SCO is owned by doctors and run by doctors, rather than faceless corporations, no immoral procedures have ever darkened our door.
As we approach the 50th anniversary of the encyclical Humanae Vitae, issued July 25, 1968, I have been asked to evaluate healthcare today in the U.S., and to keep the myriad surrounding events and implications of Humanae Vitae in our minds as we do so. I will limit this evaluation of healthcare to two general areas of concern, namely the moral and the social aspects. The moral issues will tend to be more global or universal and the social concerns, such as economics will be slightly more particular to our system in the U.S. So in a rough order then, let us begin with a perusal of historical influences and the development of immoral problems, followed by more particular social problems and lastly, conclude with a few attempts at solutions, including the Surgery Center of Oklahoma.
In All the King’s Men, Robert Penn Warren writes, “reality is not a function of event as event, but of the relationship of that event to past, and future events.” He is speaking of the importance of ‘context’. We need go no further to understand the danger of not interpreting things in context, than to look at Catholic and Protestant biblical disagreements. The two examples that come readily to mind are: 1) (Mt. 23:9) “Call no man your father on earth, for you have one Father, who is in heaven” and 2) (Mk. 6:3) “Is not this the carpenter, the son of Mary, the brother of James and Joseph and Jude and Simon?” Taking these two passages out of context, Protestants argue, that it is blasphemy to call our Priests father and that Jesus had siblings. If only they could see the bigger picture. To examine our topic in context then, let us proceed with relevant and related history beginning approximately 200 years before Humanae Vitae was published. Please keep in mind, that even though, all of these examples are nefarious, the purported purpose of all of them was for the health and welfare of the population (healthcare).
Moral History: Immoral Progression
We will begin with Thomas Robert Malthus, a cleric and economist. In 1798, he writes “An Essay on the Principle of Population.” It is Malthus who firmly plants the deadly seed of population control. He is most well known for his “Malthusian Principle,” that populations increase geometrically, while food production increases arithmetically. He noted that there were two varieties of controls governing population, those that were positive (hunger, disease, war), and those that were negative (abortion, birth control, prostitution, marriage postponement, celibacy). In a nutshell, fast-forward 200 years to the present, and all of these, except celibacy, are thought of as normal parts of society.
Charles Darwin is chronicled next on our illustrious list. Darwin was a descendant of the wealthy Wedgewood (Wedgewood China) family and was a partial inheritor of that grand estate. His On the Origin of Species appears 1859. Darwin credits Thomas Malthus for being the source of the concept of “natural selection.” So, Darwin adds the idea of improving the species through controlled breeding, to Malthus’s idea of the necessity of population control. From this point forward, the ideas of population control and anything concerning manipulating or controlling the gene pool, are tightly woven together and almost never separately considered.
The Birth of Eugenics
Next, Francis Galton, Charles Darwin’s half cousin, coins the term “eugenics” in 1883. His definition was, “it is the study of the agencies under social control that improve or impair the racial qualities of future generations, either physically or racially.” So, although the definition of eugenics varies widely today, it is generally agreed upon, that the aim is to improve the genetic quality of the human population. Malthus and Darwin claimed what they promoted was for the good of mankind, but at this stage of the game, it is Galton that gives this dark movement the name, eugenics, a word that by it’s construction denotes goodness. The root of “eugenics” is derived from good or well, “good genes.”
These ideas are exported to the United States. In 1904, the Cold Springs Harbor Institute was founded on Long Island, with money from the Carnegie Institution of Washington. Under Charles Davenport, It became the Eugenics Record Office from 1910-1939.
The Kaiser Wilhelm Society for the Advancement of Science was founded in Germany in 1911. In 1927, the Kaiser Wilhelm Institute of Anthropology, Human Heredity and Eugenics began, with funding from the Rockefeller Foundation. Josef Mengele “the Angel of Death,” served his mentor, Otmar von Vershuer, at this institution for some of 1942 and 1943.
Indiana becomes the first state in 1907, to pass forced sterilization laws in the US.
By 1912, London hosts the first International Eugenics Conference.
Margaret Sanger enters the scene in 1916 by opening the first birth control clinic in the U.S. In 1922, she founds the American Birth Control League, which later became the Planned Parenthood Federation of America in 1942. So enamored was Adolf Hitler with these English and American eugenicists, that when he wrote Mein Kampf in 1924, he showered them with praise.
The list of notables that were involved in this movement was breathtaking. For instance, Aldous Huxley author of Brave New World and H.G. Wells, author of The Invisible Man and War of the Worlds, believed eugenics would help improve humanity. This is the world in which Pope Paul VI’s encyclical was written.
Humanae Vitae is given to the world by Pope Paul VI, July 25, 1968. It is given at a time when the world is drunk with the need for population control. England, the United States, and Germany are leading the way with brutal and immoral, human experimentation. It is at this time in history, that the world, especially the West, demands that the Catholic Church, change its teachings on the matter of birth control.
After the Encyclical
Whether Humanae Vitae was effective of not, or whether it was too little too late, is not the purpose of this brief essay, but let us continue to explore, if in these areas, there is improvement or continued degradation.
There are many books that chronicle the continued zeal for the depopulation of the world. Here are just a couple examples of some notable world figures and their opinions.
In a 1974 National Security Study Memorandum (NSSM 200), Henry Kissinger maintained that depopulation should be the highest priority of U.S. foreign policy towards the Third World. And in 1988, Prince Phillip stated that in the event that he is reincarnated, he would like to return as a deadly virus, in order to contribute something to solve overpopulation.
So, this brings us to present day observations.
Birth Rate: In 1910, the birth rate in the U.S. was 30.1 (number of births per 1,000 population). By 1968, the year of Humanae Vitae, the birth rate was down to 17.5 and by 2009, the birthrate was 13.8. In 2017 in the U.S., we are at record lows.
Abortion: According the Guttmacher Institute, between the years of 2010-2014 there were approximately 1.2 million abortions/year. Most sources are claiming a slight reduction in these numbers over the last few years. While we want to find solace in the fact that abortions may be decreasing, the number of permanent sterilizations (as chronicled below) is on the rise. Fewer overall pregnancies, is most likely the reason that there are fewer overall abortions. The number that is remaining constant however, is that roughly 1 in 4 women in the US will have an abortion before the age of 45.
Contraception: Again, according to Guttmacher, 99% of sexually active American women, age 15-44, have used a contraceptive method other than NFP. Although this number is stable, the more alarming portion of this statistic, is that there is an increase in both permanent and long acting reversible contraceptives (LARC). LARCs are subcutaneous implants and intrauterine devices (IUD).
Euthanasia: Hard and fast statistics on euthanasia are very hard to come by, partially explained by the fact that, legalization varies by state. What is easy to find though, are statistics showing that the vast majority of Americans are for euthanasia and the numbers are growing. A related topic, is that the growth of hospice programs since 1974 is staggering. The Washington Post in an article entitled, “Dying and Profits: ‘End of life care’” states that end of life care was once dominated by community and religious organizations; but now it has become a $17 billion industry. Virtually every priest one speaks to today, has witnessed deplorable end of life events such as fatal narcotic over medication. The motto of this movement seems to be “all for comfort.”
Organ Transplantation: Similar to our hospice example above, much of the organ transplant phenomenon is driven by economics. It is big business. In 2017, organs were removed from 10,281 deceased patients. This was greater than a 3% increase from 2016, and a 27% increase over the last 10 years. For those of you who are unsure about the morality of organ harvesting, let me offer my anecdotal experience. I have personally visited with two patients, both of whom, after severe motor vehicle accidents were determined to be brain dead. Both of these patients were only unconscious, not dead at all, and if their families had allowed, both would have been killed for their organs. In 1967, the “Harvard Brain Death Criteria,” were presented to a naive audience as science. Clearly, our experiences prove, that these criteria are not scientific at all.
Let us conclude this section on the immoral progression into healthcare, by noting, 1) immorality is progressing, 2) it is worldwide (east and West), 3) it is commonplace, and 4) the toleration is increasing and the disgust decreasing.
Healthcare in the United States
Let us now move on and focus on issues, more or less specific to the U.S.
It is true, that there are two predominant healthcare systems in the U.S. What is more false than true, however, is that one is public and one is private. This is a grave misconception and believing so might be a great hindrance to finding a solution to our healthcare problems. My opinion is that both systems are much more similar than they are disparate. What unites the two systems is centralization of control. Public, governmental or socialized medicine (call it what you may) in the United States is most characteristic of Medicare, Medicaid and the VA Hospital systems. Examples of the private system would be, insurance companies, pharmaceutical companies and hospitals. The private system happens to not be very private at all and I believe is better described as having attributes of “crony capitalism” (an economic system in which family members and friends of government officials and business leaders are given unfair advantages in the form of jobs, loans, etc.). A typical example of the way this works in medicine, is that the head of the CDC or FDA, becomes a lobbyist or CEO of a major pharmaceutical company. They then, use their governmental connections to get drugs fast-tracked through. Just one vaccine approved by the CDC, can make that pharmaceutical company billions of dollars a year.
Both predominant systems in the U.S. have inherent flaws. For instance, in the Medicare system, trouble gaining access to healthcare could be primarily due to the bureaucracy in the system, whereas in the world of insurance, the affordability of a $6,000 deduct able, could be the main obstacle. The lack of timely, affordable, and ethical care seems to abound in each model, albeit to differing degrees. With Medicare for instance, the triple whammy of incredible bureaucracy, heavy-handed government penalties and decreased reimbursements, contribute to physicians not wanting to treat Medicare patients.
Is There Really a Problem?
The American Journal of Medicine reported, from a Harvard Study that in 2007, 62.1% of all bankruptcies in the U.S., had a medical cause, and that 75% of these folks had health insurance. The share of bankruptcies attributable to medical problems rose by 50% between 2001 and 2007. From this study, we conclude that for many in the US, healthcare is unaffordable.
Healthcare, compared to wage and GDP, is becoming more expensive at an alarming rate. Most concerning is that this rate is unsustainable. It would appear that without some drastic change, a collapse of some sort is inevitable in this sector.
What to Do?
The best answer in any situation such as this is attributed to St. Augustine, “pray as if everything depended on God, and work as if everything depended on you.” So prayer is always our first defense, but what does Holy Mother Church tell us about the second part of this formula, the work part? We are talking about “action,” more particularly, Catholic action. St. Thomas Aquinas says, “the highest form of contemplation, is that which superabounds in ‘action.’” Pope St. Pius X on this topic says, “the subtle raising of multiple questions and the most eloquent dissertations on rights and duties matter little, if all this does not end in ‘action.’” So we need to act, but how? What’s appropriate and what is not?
Subsidiarity in Action
“Subsidiarity,” as defined by Pope Leo XIII, in Rerum Novarum (1891), is “the principle that a matter should be handled by the smallest, lowest or least centralized authority.” Forty years later, in 1931, Quadragesimo Anno, Pope Pius XI writes and reaffirms what Leo XIII said about subsidiarity: “just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community, so also it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher association what lesser and subordinate organizations can do.” Subsidiarity then, is a wake up call that many problems (not all), would be better served with more “local” solutions. It is noteworthy that these popes are issuing these warnings during the same, “immoral progression,” time period I have chronicled above. Concurrently these governments are becoming more centralized, tyrannical and immoral.
Let us present three examples of subsidiarity in healthcare.
The first example is Sarto Village. This is the retirement facility that the SSPX is starting in Veneta, Oregon. Corporate entities that run similar enterprises, for the most part, are giving marginal care at very high prices. John Senior in The Restoration of Christian Culture has chapter two entitled “The Air-Conditioned Holocaust” to describe this malady. A whole cottage industry has arisen in the legal profession, chasing monies for lack of care and abuse in these settings. What a fresh breath of air the SSPX is bringing to this space. The model is beautiful in its simplicity. Folks that are still in relatively good shape, physically and mentally, will live there and while able, will participate in care-giving, and for this participation, if the monies work out right, may receive a discount so to speak, on their rent. As these folks become unable to give help and need help themselves, it will be a natural progression. These facilities will be located near schools, to receive the benefits of the young being nearby (caring, sharing, entertainment, etc.), but also for the elderly to share their gifts. The priory and the access to priests and the sacraments will also be integral to this model. This is subsidiarity at its finest.
The second example is that of Christian Healthshare Ministries. These operate like insurance companies, in helping people acquire care, but much of the similarity ends there. For the most part, these organizations are Faith based. Every member has to acknowledge his belief in Christ and promise to take some responsibility in avoiding certain behaviors that would put the patient and the plan at risk. These plans are also generally much cheaper. More of the monies go to patient care, rather than administration, advertising, investors, investments etc. This also is an example of subsidiarity, because the group is of a size that makes sense, small enough to share the belief in Christian charity, but large enough to have “buying power” and efficiency of administration.
The third example is the Surgery Center of Oklahoma (SCO). The Surgery Center of Oklahoma opened in 1997, so we are enjoying our 21st year of existence. Ten years ago however, we had to drastically change how we were doing business. The insurance companies were literally penalizing people for having surgery at SCO, even though our prices were a fraction of the hospitals. If a patient wanted to have surgery at SCO, the insurance company would “stack” their deductible. This means, if they went to a more expensive Hospital X, they would have a $1,000 deductible and be responsible for the remaining 20% of the bill. If, however, they had their surgery at SCO for a fraction of the price, they now had a $3,000 deductible and were responsible for the next 50% of their bill. Based on a knee arthroscopy of $4,000 at SCO and $25,000 at Hospital X, the respective out-of-pocket, would still favor SCO ($3,500 vs. $5,800). Our attempts to educate patients to the reality of the situation however, would often evoke a strong visceral response to the term “out of network.” So rather than the reasoned response, which would be, better care for less money, the patient most often, chose Hospital X. Obviously, the whole process was to mislead the patient and harm our practice.
Our initial efforts to deal with this were mostly defensive, but we had no idea just how offensive and disruptive our ideas would become. Our method was as simple as simple can be. We did what every business does, calculated our overhead for every surgery, added a small profit, and put it online for any willing buyer. To begin the process, we asked every one of our surgeons what they thought fair compensation was to do any of the hundreds of surgeries listed on our website. After obtaining those numbers, we factored in labor, variable and fixed costs to come up with cost of operating an OR per unit of time. We knew on average, how much time each surgery required and the average cost for disposables and other things consumed during any given surgery. Our anesthesia fees were also based on the average length of time we would be in the OR. To all of these component parts, a 10-15% profit margin was added and the resultant prices put on the internet for the world to see.
The Problem Persists
So, here is the $64,000 question: Why aren’t more healthcare related entities charging reasonable fees? The answer: Because there is too much money to be made doing it the other way.
Let me illustrate this with a very real example of a typical interaction between that of a patient, a hospital and an insurance company. I most often use the case of a cochlear implant surgery, because this is based on an actual surgery for which we saw the explanation of benefits (EOB). At Surgery Center of Oklahoma, the total facility charge is about $30,000. This represents $27,000 (our cost for the implanted device), plus approximately $3,000 for the Center’s overhead. The hospital charge is roughly, $110,000. Their price is determined by tripling the implant cost and then adding $25,000 for overhead.
Here is the sequence of events as succinct as possible: 1) Hospital X (HX) generates $110,000 bill, 2) Insurance Company Y (ICY) receives bill, 3) ICY negotiates with HX to get bill down to $60,000 (this is known as “re-pricing”) 4) HX claims $50,000 loss and puts this loss in a pot, so that at the end of the year, they get some compensation from the federal government (our tax dollars) 5) ICY, as an incentive and inducement to get the best price for their client, gets a bonus of usually 25% from the client, for saving them, in this case $50,000. So the client pays ICY an additional $12,500 in this scenario.
Points to be made, 1) Except for SCOs prices, none of the other figures have any basis in reality. The hospital bill is fictional, therefore the savings are fictional as well. 2) The bigger the bill, regardless of what is paid, both hospital and insurance company profit more, and 3) the insurance company and the hospital are both obstacles to the patient having a fair exchange with his doctor 4) the essence of our model is just the opposite, only those adding value to the exchange are being compensated.
Conclusion
Our healthcare system is broken and sick. There are solutions to solving the unethical, immoral and unjust problems, but fixing it will require strong medicine. Holy Mother Church gives us the principle of subsidiarity as the proper ordering principle for our existence. Over the last two centuries though, this order has been inverted, and is not just the cause of problems in healthcare, but in every other area imaginable. If we are to invoke subsidiarity then, as one of our solutions to these many crises, let us make a couple of general observations.
Act primarily in those areas in which you have the most responsibility and influence. This roughly corresponds to our duty of state. For instance, fathers and mothers will want to provide safe, effective and moral care to their children. If there are practical ways to withdraw support, with monies or otherwise, from elements causing the dysfunction, then do so. Businessmen, I believe have very much clout in this arena. Providing healthcare benefits for even 10 or 20 employees, represents a substantial yearly spend. It’s difficult for the sellers of these healthcare products to overlook or ignore someone spending $200,000 a year on healthcare for their employees. So, choose the good for your employees. There are more and more alternatives for you to choose from. Doctors may want to avoid as much as possible working for or receiving monies from many of the institutions that are perpetuating these problems. This is not practical for every doctor, but the more one can separate themselves from hospitals, government and corporate medicine, the better. Avoid as much as possible funding or participating, in any system which centralization of control has resulted in evil. This may not be an easy task, but it is a necessary one.
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