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Phil B.FontanarosaMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Fishbein FellowIndividualAuthor
To the Editor: Leaving aside the admitted "serious
shortcomings" of the HEDIS quality indicators used in the study by Dr Himmelstein
and colleagues,1 some of the reported differences
between investor-owned and so-called not-for-profit HMOs appear modest—while
statistically significant these differences may not be meaningful or useful
for setting policy. The author's example of mammography rates to buttress
their argument is particularly unfortunate: the clinical usefulness of mammography
has been widely questioned.1 Similar doubts
have also been long expressed concerning Pap tests. We question the estimate
of lives likely to be saved given the known unreliability of these tests and
controversy concerning their predictive value.
Rather than focus on the magnitude and meaningfulness of differences
between quality of care in these 2 types of HMOs, we wonder if there is, in
fact, a tenable distinction between for-profit and not-for-profit facilities.
Like others,2 we suggest that the
debate between the advocates of for-profit and not-for-profit medical care
represents an outdated dichotomy. Advocates of not-for-profit care embrace
a simple world view—they possess superior values (community service),
blame current health care crises on the emerging market-based system, and
romantically dream of the good old days (precorporatized health care) or some
other idealized health care system. Those favoring for-profit arrangements
naively believe the market's invisible hand will eventually fix everything—their
values appear crass (wealth accumulation), and they would discontinue or shift
responsibility for unprofitable activities (eg, care of the disadvantaged).
In a drive for efficiency, profit-driven management encroaches on professional
autonomy and undermines the patient-physician relationship. Both sides appear
to suffer from hardening of the categories.
While there are some differences between these 2 organizational approaches—in
tax status, ownership, and (possibly) community orientation—there may
be no analytically useful distinction. Both "produce" the same commodity (health
care) in pretty much the same way (managerial and accounting procedures) but
simply give a different term to the revenue yield—one calls it "profit,"
the other "surplus." Apart from superficial differences, the means by which
profit or surplus is obtained appear the same. The categories, for profit
and not for profit, are too crude to be operationally useful. Some not-for-profit
organizations control and are dependent on for-profit subsidiaries. Not-for-profit
surpluses might not be invested for the benefit of the surrounding community,
whose local taxes subsidize the not-for-profit organization. If most "profits"
go to stockholders and infrastructure expansion, while "surpluses" go to already
well-rewarded administrators, new buildings, and equipment, this makes for
an analytically questionable distinction. Some for-profits (like family-owned
businesses) evidence a humanistic concern for the welfare of workers.
Vulgar Marxist dichotomies (like profit vs not for profit) have limited
explanatory use for market encroachments on US health care. There are few
real not-for-profit organizations in existence in the United States. Rather
than blindly accepting a questionable dichotomy and building an analysis on
it, perhaps the reasons for the dichotomy itself and its continuing existence
would be a profitable area for future study.
McKinlay JB, Marceau LD. Quality of Health Care and the HMO Marketplace. JAMA. 2000;283(5):602–605. doi:10.1001/jama.283.5.601
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