Salve Lucrum

I think it was probably 2007, and I was a recently minted market Medical Director for United Healthcare (UNH) in Central Texas. Because I had a solid background in systems programming and automation, I decided to build a business intelligence (BI) system based on Microsoft’s Visual Basic toolkit at home and in my office downtime. Using Excel, Access and Visual Basic for Applications, I built a nuts-and-bolts BI system that told us more about our health plan’s income stream(s) and expenses than even the national UNH system told us. We began to explore the data.

It wasn’t long before we discovered that we were hemorrhaging money paying for things that were not the responsibility of our health plan. We plugged those holes in our payment system. Then I found that we were pouring enormous sums into some very expensive medications. One of them was pegfilgastrim – an agent given to stimulate the production of white blood cells in folks recovering from a course of chemotherapy. Filgastrim, an older version of the same medication, cost only 7% as much as its more recent alternative. Why were doctors ordering it? WTF was going on?

As a non-oncologist, I was hopelessly naïve about these medications. After some study, I realized that the newer medicine was a long-acting biological whose effects lasted for 14 days. Its predecessor had to be administered by daily injection for fourteen days. The new medicine had been priced at exactly 14 times that of its short-acting counterpart. Salve Lucrum!

This was my first lesson in practical, medical profit making. It came as a surprise since my almost ten-year career in private practice had been a shoestring affair from which I earned about twice as much as my employees who were earning just over minimum wage. I later abandoned my practice and went to work for the Veterans Administration at 2.5x my solo-practice salary working only 8-hour weekdays without hospital duties instead of the 24×7 schedule to which I had become inured. Salve Lucrum!

I saw the phrase Salve Lucrum today, and it struck a chord. It means “Praise Profit!” It might as well mean “Praise Price Gouging” or “Praise Fraud!” It made me think that healthcare enterprises are now in the hands of Star Trek’s Ferengi. Let me explain.

I read earlier today that Moderna is poised to price its m-RNA vaccine at $130 a dose plus or minus. I don’t know the economics of its production, but I expect that with the expected worldwide need and demand for safe and effective COVID vaccines, it would draw a respectable profit at a tenth the price. But that would be a poor business decision for Moderna. Pfizer is charging the US government about the same price, and it is better to not undercut the competition. Besides, having hundreds of millions of folks unvaccinated is what is best for business. Unvaccinated people sustain the epidemic and are the incubation system for new COVID strains and hence demand for new vaccines. Salve Lucrum!

I’ve been thinking about the corruption of healthcare by profit for at least a week – albeit for very different reasons. Just as profit-seeking can dominate pricing, it can also dominate clinical decision-making. Imagine that you are insured, and you visit a healthcare professional who has a strong financial incentive to avoid ordering expensive tests. If the insurer views healthcare expenses as a proxy for healthcare waste, there is substantial incentive to avoid costs – even if they are medically prudent and necessary for the health of the individual. I never worried about such things when I was a physician in training. I became aware of them later as a private doc and more so as a VA physician, but they were never the first consideration in my evaluation or therapeutic decisions.

When I had a stroke about a year and a half ago, I had no inkling of such things entering into my care decisions. I received state-of-the-art evaluation and treatment. Yet, having been recently ill, I have to wonder whether salve lucrum has not played a role in my care.

This evening, I read a Medscape article about the influence of profit on American Healthcare writ large. I don’t know whether this link will work for you since I am a Medscape subscriber and you may not be, but I recommend the article for its objectivity addressing the issue of how profit can and does (too often) corrupt the practice of the healing arts.

If the link above doesn’t work for you, try this one, where you can get the gist of Donald Berwick, MD’s JAMA article on the corruptive influence of profit on healthcare. Don’t get me wrong, I think that healthcare professionals, pharma companies, and the creators of effective medical technologies should be able to earn an honest dollar – just as do teachers and firemen. But when the primary goal of organized healthcare becomes profit for shareholders rather than health for those in need, I think that the pooch has been seriously screwed.