nurses protest

In recent years, I, like many of my colleagues, have faced challenging decisions in my professional life as a result of the corporatization of health care. I have no problem with providing documentation for the work I do and the services I provide in order to get paid by insurance companies for doing it. However, I felt queasy when I saw the “bean counters” — the non-clinician auditors — enter the clinic where I worked to review client files to look for every possible reason to take Medicaid dollars back. What clinical expertise did these people have? Most likely, none whatsoever. It was all about money. The clinic got paid for what was documented. If the documentation was somehow imperfect or inadequate, the clinic risked losing reimbursement for services that were provided.

Perhaps because I tend to be somewhat OCD about doing documentation for my work, I wasn’t as concerned about the clinic losing money as I was that the clinic’s clients’ privacy inevitably had to be somewhat compromised by the auditing process. I was so concerned about the potential harm to clients that I chose to resign and file a civil rights complaint to the US Department of Health & Human Services based on what I believed to be a violation of HIPAA. At that time, the “minimum necessary” standard was defined much more broadly than it is now. The Federal regulations have since changed to make that definition more narrow, providing greater protections for patients’ privacy.

As a licensed clinical social worker who provides psychotherapy, I am bound to a professional code of ethics. The details of the requirements of that audit — which I purposely am declining to disclose here — presented me and my colleagues with an ethical dilemma. It put our obligation to protect client confidentiality into conflict with our obligation to provide services to clients. I later learned through an ethics professional development event that this dilemma apparently was experienced by many in my profession nationwide.

My thinking was that my clients’ trust could not be compromised. As professionals, we are required to adhere to our professional code of ethics and standards for practice. Yet, the corporate influences of the settings in which we practice often challenge us as professionals to do things that could erode patients’ trust and confidence. Sadly, many patients understand this and accept it because they believe they have no other choice. Maybe, they’re right.

Perhaps, by participating in an insurance-driven health care system, health care professionals inevitably end up providing insurance-driven rather than patient-centered care. For example, insurance won’t pay for two mental health visits in the same day. So, rather than providing a psychotherapy appointment with a therapist and a med check appointment with a psychiatrist or other prescriber on the same same day, we have to require the patient schedule those appointments on different days. If the patient has limited time or money for gas or public transportation to access that care, that’s his/her problem. If that situation limits the patient’s access to care in such a way that make it impossible for us to provide the quality or level of care the patient needs, then we as professionals have to choose between our obligation to the patient and our need to be compensated for our work. That’s a choice patients and health care professionals should not have to make.

The corporatization of health care, including some provisions of the Affordable Care Act, is requiring and enabling us to create impressive electronic health records. But, is it helping us provide more accessible and better health care?

Much like the concerns we now see getting media attention about the corporatization of public education — particularly the overemphasis on testing — there are valid concerns among patients and health care providers about an over-reliance on the metrics in patients’ charts. Metrics-driven care should not prevail over the use of good clinical judgment.

Here’s a personal example. I’m sure the care managers at Excellus mean well when they call to offer to help me manage my care for a diagnosis that’s documented in my medical record. However, that doesn’t change the fact that I don’t experience any day to day symptoms or difficulties functioning as a result of that condition. I’ve explained this each time a care manager has called me. I’ve even asked for help navigating the insurance company’s requirements so that I can better utilize my benefits for a different health problem that’s not so common that, in fact, does have symptoms that I need to manage daily and does impact my capacity to function. That condition, however, does not have the power of the “metrics” behind it. With no metrics-driven “red flag” in the computerized medical records system to prompt attention to it, I am left on my own to navigate and advocate for the care I need.

Recently, parents, educators and education leaders have seriously begun to respond to the corporatization of public education — e.g., No Child Left Behind, Common Core and Race to the Top — because they see serious challenges to local governance of public education and, ultimately, are concerned that the emphasis on standardized tests is taking too much time, energy and resources away from teaching and learning that promote problem solving, critical thinking skills, creativity — educational outcomes that many economists and others believe to be what our future workforce will need to make our democracy and our economy healthy and strong. Teachers and others in public education have experienced a considerable loss of professional autonomy as a result of corporate-driven public education reform. The same is true for health care professionals as a result of corporate-driven health care reform. Corporate driven public education reform has not been good for all students and teachers. Similarly, corporate-driven health care reform has not been good for all patients and health care professionals.

Health care professionals cannot lose the trust and confidence of the people who rely on us to be healers. Perhaps, the grassroots movement in public education against corporatization will pave the way for a similar movement in health care. For the health, safety and privacy of our patients and for the integrity of our health care professions, let’s hope so.