PBM: Unmask the Villains of Healthcare’s High Costs

Marion Mass, M.D. and Christina Dewey, M.D.

Would you like to lower healthcare costs, restore quality and improve choice? Yes? Then you MUST learn about Pharmacy Benefit Managers (PBMs).

If you look on the Fortune 500 top 12 companies, you will find three companies who own PBM. Dig deeper, and you’ll discover these companies are CVS  health, who owns the PBM CVS Caremark, United Healthcare who owns the PBM Optum Rx, and Cigna, who owns the PBM Express Scripts. These three PBM control 85% of the prescription drug market, and are the biggest revenue generators for their parent companies. 

For example, when the insurance company Cigna, purchased Express Scripts in 2019, their revenues tripled. Take a peek under the hood of CVS Health, and you will discover that CVS’s  PBM CVS Caremark is, to put it frankly, its prize cash cow, its biggest source of revenue.  Moo.  

Until recently, many Americans had no idea what a PBM was, and blamed insurance and pharma and physicians for the high cost of care. The truth is much more complicated, and those making the money don’t want you to pull the mask off the villain of high healthcare costs.  They aim to prevent  the Scooby Doo denouement and keep Americans from discovering the biggest, richest, most devious villains in the healthcare space are the PBM.

Some really important clues to why we should suspect that the PBM are villainous profiteers:

–    The PBM and insurance companies now own one another, and some, like the CVS Health empire, also own pharmacy chains

–    The PBM controls the pharmaceutical companies, by creating the formularies, aka the list of medications that the insurance companies will “cover”. Physicians play no part, nor have any say in  this choice.

–    The PBM can collect legalized kickbacks, called ‘rebates’ from pharmaceutical companies because the PBM were granted an exemption from the anti-kickback statute in 2003 by GW Bush’s HHS secretary. This anti-kickback exemption allows pharmaceutical companies to simply pay for placement on the formulary.  Americans are not necessarily getting the best medication, but the best med a legal bribe can buy.

–    There is no transparency for these kickbacks (aka rebates) but sources have revealed that in 2020, the total amount of kickbacks approached $200 BILLION (yes with a B).

–    PBM like CVS Caremark are now facing charges of preventing elderly Medicare patients, including those with End Stage Kidney Failure from access to affordable life sparing medications.

–    In multiple states, PBM have been found to be helping themselves to Medicaid money… not a small helping, either: In Ohio alone, the PBM subsidiary of Centene as well as CVS and Optum were pocketing $244million per year.


–    The big PBM that own pharmacies, like CVS are utilizing shady practices to put trusted Mom and Pop pharmacies out of business.    


–    In an NBC News exclusive with Cynthia McFadden, the PBM mail order pharmacies were found to be delivering ineffective medications.  One young pediatric patient with cystic fibrosis was hospitalized after wasting away because of medications delivered by PBM giant Express Scripts, whose agent pooh poohed the concerns of the patient’s mother.

Do you need to hear more? 

Yes, you need to understand who is granting more favors to the behemoth companies responsible for the maleficent behavior noted above.

Let’s look at several recent congressional bills in chronological order of passage. 

The Affordable Insulin Now Act was passed by the House and Lingers in the senate

Although those who support the bill  claim to have lowered the cost of insulin, Lloyd Dogget, a Texas Democrat correctly stated that the bill does not lower the cost of insulin by even a penny.  He’s correct.  It lowers the co-pay, but the uninsured, and those who pay insurance ( whether they be employer or independent purchaser)  will continue to pay the full bloated cost of insulin, 80% of which is flowing to the PBM via kickbacks and fees.  In other words, this bill simply ensures that the taxpayers keep paying the PBM in the form of kickbacks.

Worse yet, the bill grants a delay of the rebate rule for PBM.  The rebate rule was an Executive Order introduced in 2020 and demanded that the kickbacks (aka rebates) would flow to the patient at the point of sale and not the PBM and the insurers.  PBMs are continually telling Americans that they pass on the rebates, yet when the rebate rule was suggested, they have threatened to increase Medicare premiums as soon as the rule is enacted. 

Congress has discovered they can pull the entirely disingenuous accounting sleight of hand of delaying the rebate rule (in other words, allowing the PBM to keep collecting their kickbacks and not forcing them to pass on to patients) and thereby claiming that they are saving money by preventing Medicare premium increases. To put another way, the PBM’s and Insurers are playing Chicken with the rebate rule by threatening Medicare premium increases, and the Congress-people that delay the rebate rule are taking the bait.  I suppose that makes them lower than chickens in the game.  Perhaps they are simply chicken….. oh, never mind. Maybe they simply don’t understand.

The insulin Bill was not the first time Congress  delayed the rebate rule.  Apparently they did it in the infrastructure bill, too.  Howard Dean, a physician and former presidential candidate called them on it in Newsweek, even pointing out that the rebate rule was solid, and potentially the best thing to come from the Trump Presidency. 

Based on the above, we ought to let that insulin bill die and come up with a real way to lower insulin costs.

The recent Gun Bill Passed by the Senate and House and signed into law sneaked in a gift to PBMs.

Why on earth would a bill on guns contain another delay in the rebate rule, yet another gift to the PBM industry?  The same faulty accounting gimmick of using the rebate rule delay as a pay for.  Unbelievable.  Senators Chris Murphy, D-CT and John Cornyn, R-Tx are mum about who put the PBM poison pork into the gun bill.  Interestingly, Murphy’s top donor is the law firm that helps CVS negotiate mergers.  And Cornyn is a top taker from Vizient, a hospital Middleman Group Purchasing Organization.

Good news at last!  PBM reform in the Mental Health Package

Thankfully, some good news exists. .  Some colossally INCREDIBLE news:

HR 7666, the bipartisan mental health bill introduced by Frank Pallone, D-NJ, and Cathy McMorris Rogers –R, Wa passed the house this week with 400 yay votes.

Some of us were really yelling ‘Yay’ when we discovered splendid section 602, quietly added by Rep Michael Burgess (R-Tx), mandating   big time TRANSPARENCY for big PBM/Insurers with shocking penalties of $10K per day for non-compliance.

Requiring  PBM transparency will save $2BILLION/10 years, paying for the bill.  Billion with a ‘B’.  As Mental health and substance abuse medications are largely overpriced due to PBM kickbacks, this provision absolutely belongs in the bill.

Americans will receive  some wonderful services  with this bill for Mental Health and Substance Use Disorders. Full detail can be found in the bill,  but here is a screenshot of some of the high points

WE CANNOT STOP… we must make sure the mental health bill passes in the senate WITH PBM reform Intact

Please CALL and EMAIL  both of your US Senators ASAP, (find their numbers and email contact links  here ) and tell them to PASS  the Senate version of HR 7666 with the Burgess amendment to bring PBM transparency and accountability intact.  Ask  your friends to call.  Ask your neighbors to call. Ask everyone in your circle and beyond. Tell YOUR Senators you now know the PBMs are behind the ever increasing healthcare costs and it’s time for Congress  to listen to we the people and not the profiteering villainous Pharmacy Benefit Managers! 

Drs. Mass and Dewey are proud to be pediatricians for over 20 years each and fierce advocates for patients and physicians!

Dr. Mass, graduated from Duke Medical School and trained at Northwestern. She has practiced in the Philadelphia area. She’s a cofounder of Practicing Physicians of America And leadership in Free To Care .

Dr. Dewey attended Loyola University Stritch School of Medicine . She did a year of surgery internship then two years of pediatric surgery research before training in Pediatrics at University of Minnesota. She is founder and CEO of Peds Mama Doc and has published in multiple outlets

Practicing Physicians of America: Our Comments to the FTC in Regards to PBM Business Practices

Full transparency and De-consolidation of PBM Monsters are the Remedy to Drive Pharmaceutical Prices Down, and Remedy Medical Supply Shortages

Over half of Americans have skipped filling a prescription because of costs. 

Large pharmaceutical companies and the inflated prices and portion of the market that some hold for a particular drug beyond a reasonable patent period is a scenario familiar to most Americans and must be addressed. Lesser known but at the root of the problem of monopoly power and high prices in the pharmaceutical world are companies that don’t innovate and don’t manufacture, namely pharmacy benefit managers or PBMs. 

The public’s awareness of these drug intermediaries or middlemen and their effect on prescription drug pricing has grown exponentially over the past decade. This awareness has increased the will of state and federal lawmakers to do something about the lack of transparency and competition enjoyed by PBMs. 

Another middleman contributes to inefficiencies and increased costs, and you’ve probably never heard of them. As we built awareness of the issues related to PBMs, we must now do the same for Group Purchasing Organizations (GPOs). GPOs are lesser-known corporate middlemen who control the healthcare supply chain in hospitals and other medical institutions, driving up overall health care costs. This section will discuss the respective roles of PBMs, GPOs, and pharmaceutical companies in increasing costs and decreasing access in the healthcare space. Much like the last section, Free2Care will focus on increasing transparency, unwinding perverse incentives, and creating changes that lead to more competition.   

PBMs were created to help insurers contain drug spending for prescription medicines. They control formularies, utilization tools, and administer drug claims. They do this for Medicaid-managed care, Medicare part D, commercial payers, and large employers. Historically, they achieved this purpose and provided the value that was intended. However, since the PBM’s received the benefit of safe harbor from the Anti-Kickback statute in 2003, drug costs have soared year over year. 

The PBM market has consolidated with the six largest PBM controlling 95% of prescriptions.

Consolidation, coupled with complexity and opacity, has allowed large PBMs to pocket substantial revenue. Using questionable practices, they have driven companies that own (typically insurers) PBM’s to the top of the Fortune 500 top 20. This growth comes at the expense of all Americans, especially those who most need affordable medications: Those with chronic diseases. 

Significant and questionable revenue streams and business practices of PBM include the following.

Spread pricing is how PBM retains a portion of the money paid to them by the third-party payer meant for the pharmacy. In Ohio’s Medicaid program alone, the state found two of the nation’s largest PBMs to have helped themselves to $224 million per year. These PBM were charging the state six times the going rate for their services. 

Multiple other states have followed Ohio’s lead in uncovering this practice in the Medicaid space. The spread phenomena are not limited to the Medicaid space but spills into government-led entities such as counties, schools, and employers. 

Direct and Indirect Remuneration (DIR) fees result from a loophole in Medicare regulations. DIR fees are charged to pharmacies as a clawback based on the PBM’s unpredictable and inconsistent quality metrics. Clawbacks can happen months after a patient receives their medication, leaving pharmacies at the mercy of PBM. 

Some PBMs have close ties to or even own a large pharmacy chain. There is no transparency in what these PBMs pay their big-box pharmacies vs. independent pharmacies for meds, what they retain via the spread, or how much they charge for DIR fees. It is a perverse incentive to overpay their associated pharmacy chain entities and underpay independent pharmacies. Some are doing this. 

This practice can destroy the over 20,000 small businesses and independent pharmacies that are highly trusted by the patients who use them because of the PBM practices above. 

Specialty and Mail Order Pharmacies In addition to the other vertical integration mentioned, PBMs’ have their own specialty and mail-order pharmacies. Specialty pharmacies are created to deliver drugs to patients that must remain in certain environmental conditions.  “lock up” huge chunks of market share by contractual arrangements with the government’s Medicare and Medicaid programs, or their contractual arrangements with, ownership of, or ownership by insurers, and even with the 340-B program participating hospitals, as detailed in section A. With exclusive access to such large shares of the market, price manipulation and other shenanigans become not only irresistible, but essential to conceal. Hence the resistance to investigation.

Worse yet, the 3 big PBM Express Scripts, CVS Caremark, and OptumRx took in over 70 percent of mail order  prescription revenue in 2019, to the tune of $113 billion and yet often sent medications that were unviable, resulting in declining health conditions.  Sometimes, meds were sent late or damaged to cancer or insulin dependent patients. 

Look at those conflicts of interest!

The vertical integration harms patients directly while increasing the monopoly power of those PBMs associated with large pharmacies and, in turn, compounds the conflicts of interest that potentially harm patients.

We echo Senator Wyden’s call for the FTC to investigate how DIR fees are an anti-competitive tool. We also support the CMS proposed rule to allow DIR fees to pass through to medicare beneficiaries in the Part D space.

Utilization tools such as prior authorization, step therapy, and non-medical switching are administered by PBM and prevent patients from medications that have stabilized their disease. These tools often create health problems for patients and time-consuming tasks for physicians.  These tools form a revenue stream as delays in needed care equate to PBM retaining capital. 

Kickbacks An astounding portion of the money flow going to PBM has no transparency, as demonstrated below. This is especially true of “rebates,” also known as kickbacks.

The PBMs were granted an exemption from anti-kickback statutes by HHS in 2003. PBMs were allowed to accept monetary remuneration from pharmaceutical companies from that point. Their role as formulary makers poses an enormous conflict of interest. This erodes trust in our medical system. The making of the formularies is shrouded in secrecy. PBM euphemistically calls these kickbacks rebates. 

The legalized kickback system creates “rebate walls.” Pharmaceutical companies outbid one to become sole or near sole suppliers of many medications. Note that BIG pharmaceutical companies would be more likely to afford kickbacks that have been increasing. This effectively makes competition for smaller manufacturers more difficult. 

My my… hard to see the money and where it’s going. Show us the money!

Insulin and List vs Net Price

Choosing just one high-profile essential medication, insulin, The Senate Finance Committee, working in a bipartisan manner in 2021, uncovered a portion of the tangle for the unprecedented rise in the cost of insulin. 

The tangle could be summarized in a simplified chart for a particular essential medication: Insulin. 

All 3 major insulin manufactures have graphs just like this.

Net price is what the pharmaceutical company collects. List price, what the patient and or third party pays, is the net price plus all the opaque kickbacks and fees collected by the mediators in the market. The lion’s share of insulin cost tripling comes from the PBM middlemen and insurers themselves. However, we must point out that manufacturers are willing to play in this broken marketplace and, as a result, they profit from the kickbacks that drive monopolies in production. As seen in the senate finance report, it seems as though the three companies that make the bulk of insulin set their prices based on one another. And it is not necessarily the price that companies need to make profits. It should be evident that the drugs are chosen to be ‘covered’ by insurance (i.e., those on the formulary, maybe (and likely are) covered because a sizable pharmaceutical company paid the kickback to get them there. It should also be evident that this can occur for every drug for which there could be competition. The growth in the list price is feeding corporations that do no research or manufacturing. 

The horizontal and vertical integration that has occurred between large pharmaceutical chains, insurance companies, PBM, and specialty pharmacies, allow these companies to have the revenue streams mentioned above to consolidate further, knock competition from smaller PBMs, smaller manufacturers, independent pharmacies, and others out of the market, and allow increased monopolization by large pharmaceutical firms themselves. 

It is not just PBM that can collect kickbacks in the healthcare space, but also Group Purchasing Organizations (GPO). GPOs write the contracts that facilitate the movement of all supplies—masks, medical devices, sterile solutions, and medications —into hospitals, hospital-owned clinics, and nursing homes. This represents a staggering source of revenue, given that supplies can account for up to 40% of a hospital’s overhead, second only to payroll. Estimates are 300 billion per year. In 1972, Congress had passed anti-kickback legislation in the healthcare arena to protect patients. In 1987, the GPO was given a “safe harbor” exemption from the anti-kickback statute. In 2003, the HHS extended this to PBMs. Rules placed oversight on the kickbacks: They were to have been limited to 3% or less of the purchase price of the products. The HHS OIG has never exercised its responsibility for ensuring the kickbacks remained at or below 3%. 

Even if rules enforced the 3%, they still perversely incentivize PBM and GPO. They select a more expensive product for their contracts and formularies. GPOs, like PBMs, have become consolidated: A GAO report found that in 2012, six companies (now consolidated into four) controlled 90% of this segment of the supply chain.

The cost burden of kickbacks has tended to reduce the number of manufacturers for supplies and medicines. The wealthiest manufacturers can afford the kickbacks. Smaller competitors have tended to disappear or never enter the market in the first place. The effect of single or few suppliers for many products is a brittle supply chain that has led to over 700 products in shortage. Hundreds of drugs and solutions —chemotherapies, antibiotics, and anesthetics—have been on the list of known deficiencies for years, decades, in some cases. Most are familiar; with generic medications, which should be plentiful and inexpensive due to great competition.  The fact that shortages for generics exist is a red flag that the root cause is a distortive factor, like kickbacks. 

In a recent Zoom meeting with legislators from the state of Maryland the representative for the PBMs said that if a particular law regulating PBMs was passed, they would only pass the expense back on to the employer. They will do whatever they can to not lose revenue, even as patients are harmed.

 Telling that with pressure on for PBM and more aware of the kickbacks, PBM have started to diversify again horizontally into the GPO space.  

CVS launched a GPO called zinc, and both Express Scripps and the internal PBM of BC/BS, prime theraputics are both working with the Switzerland based GPO Ascent 

This gives the FTC even more justification to fully investigate the mergers and acquisitions in the PBM space. 

Marion Mass, M.D.

Co founder Practicing Physicians of America

Philadelphia area pediatrician

How to Save America’s Broken Medical Landscape

a Seussian inspired rhyme by Dr Marion Mass, M.D.

Medicine is and will forever be in evolution.
Corporates and the government tell us they have a solution.

 Remember when: In the past, larger than life were physicians?
 7 to 15 years of training put us in charge of patients life and death decisions.

Once upon a time there were groups that spoke for the docs. 
Sadly, many are polluted and speak for money, the corporates and MOC.

In 1962 on the eve of Medicare launch,  
Dr. Edward Annis tried to staunch.

He stood bravely in  Madison Square Garden in front of empty seats.  (1)
The press covered the politicians… docs and patients got tricked… The government and corporations got the treats. 

Dr. Annis told us: Medicare real insurance it ain’t. 
He was correct, Medicare became a path for greedy corporate middlemen to taint.

What happened to the quality medical picture? In came slick middlemen saying "coverage is care"
Over time… patients were sent packing to… Who knows where?

And the physicians who thought with our training would always have a say. 
Many stopped speaking or caring, just took the check: We too went away. 

The patients remain and tell us they are in pain and  distress.
United, Optum PBMs, big hospital systems, private equity have made medicine a mess.

Not just physicians but PTs OTs, RTs, and those who bedside nurse, 
have fallen and suffered at the hands of the corporate power of the purse.  

The relentless corporates don’t give a fig.
All they care to do is become ever more big. 

Does your Congressman or Senator care about all this pain? 
Or is it easier to listen to those with BIG money for a campaign?

You and loved ones will suffer and some will die.
While CVS, Centene, Blue Cross and Practice Fusion gobble more of the juicy healthcare pie.

What happens when the last doc, the last good nurse Falls? 
Are corporate middlemen going to care for you all? 
There will be blood on their hands and splattered on the wall.

It’s been over 50 years of our government sanctioning medicines poison: The corporate pill. 
When will you stand up against this vile swill? 

You took the Hippocratic oath,  you can’t take it back. 
We gotta do more or risk being called a quack. 

Stand speak and deliver to make healthcare attainable,
with choice, transparency and competition to make it sustainable. 

Patients, help us become free to care for you once more. 
Help be a part of the new healthcare ecosystem to even the score.

Patients, tell the government to earn your trust.
Make the FTC get in there and bust bust bust!
Tell your lawmakers stop listening to corporate drivel; that’s a must! 
Put patient’s needs first; leave PBM, GPO, insurers and big hospital systems in the dust!

Stop listening to wealthy rent seeking corporate parasites for the wrong solution. 
Unwind these parasites perverse incentives for real evolution: 
Direct pay, innovation, small companies are the new revolution.

Thanks to Dr. Seuss, a non-medical doctor for inspiration. His quote from The Lorax could lead to a new medical landscape for our nation."Unless someone like you cares a whole awful lot, nothing is going to get better. It's not."

  1. Dr Edward Annis is the former president of the AMA, and was a Florida surgeon.

After President Kennedy had a full house at Madison Square Garden to explain the pitfalls of the King Anderson Bill which later passed under President Johsnson and became Medicare, Dr Annis was refused equal time to counter the President’s arguments. The President explained “we do not affect the freedom of choice, you can go to any doctor you want.”[2]

Dr Annis told America that the intended Medicare would cover “millions who do not need it, heartlessly ignores millions who do need coverage. It is not true insurance. It will create an enormous and unpredictable burden on every working taxpayer. It offers sharply limited benefits. It will lower the quality and availability of hospital services throughout our country.” ” IT WILL STAND BETWEEN THE PATIENT AND HIS DOCTOR.”

He warned that cost-plus financing of Medicare would doom it to bankruptcy and trigger destruction of the doctor-patient relationship. “This bill would put the government smack into your hospital, defining services, setting standards, establishing committees, calling for reports, deciding who gets in and who gets out, what they get and what they do not get, even getting into the teaching of medicine.”

I am not advocating the destruction of Medicare. It’s been here since the 1960’s. We have to start where we are. I am pointing out that having a middleman, a third party paying for care in ALL cases, even when that middleman is the government… this model… the model of COVERAGE will lead to unnecessary costs and profiteering at the great expense of all Americans.

Meanwhile, the model of COVERAGE will cause the continued destruction of the quality of CARE, and the destruction of the practice of medicine

This poem was first read at the 2021 Mitigate Partners “Demystifying Healthcare Costs” Conference

You can register online or in person for this years conference here: https://mitigatepartners.com/event/demystifying-healthcare-costs-2022/

Champions of Excellent Medical Care

Marion Mass, M.D., Practicing Physicians of America, co-founder

Female mature doctor examining little girl – closeup

Over twenty years ago, I was a fresh new attending, barely out of residency when called to the ER at three am to admit a patient with gastro and dehydration. I found a two -year old little girl, whose family spoke almost no English. She looked uncomfortable, her abdomen was distended, her platelets were slightly low and her potassium was slightly high. Her eyes had no sparkle. On her x ray, she had a paucity of gas in the right lower quadrant. These are all the signs of an intussusception, and needed an emergent enema to try to reduce the telescoping of bowel. The patient had been there for over four hours.

The ER doc, an old seasoned veteran was at the nursing station yukking it up with the nurses. I’m sure he had had a rough night. After I read him the riot act, for not calling sooner, I called the radiologist, who told me he’d handle it at six am when he came in. I politely told him I had no problem calling the hospital CEO and legal right away to let them know of the risk to patient and hospital. He came in immediately. (I offer mercy, as I don’t know what else in their lives these two physicians may have had that distracted them, and God knows, I have had my own mis-steps over 23 years)

All of us should call anyone who stands in the way of excellent patient care: “Disruptor of Patient Care”.

There are a subset of docs that will always speak for the patient, that would put their jobs on the line before they would allow shoddy or inappropriate care. A subset of administrators and government officials call us “disruptive doctors”. Nope. We are Champions of Excellent Medical Care. We are the ones America should trust for the solution.

Some physicians cannot be as vocal as the Champions of Excellent Medical Care. Many have gargantuan loans, many care for their parents, or have a houseful of children. We all must offer mercy to those physicians, who cannot be as vocal. Many of those physicians are spreading the word and supporting the Champions of Excellent Medical Care. The percentage of both of these groups are growing. We are ready to jump the chasm in the chart below.

Some physicians are tired, or scared, or disenchanted. Some are at the end of their career, and don’t want to become “champions” because they will have to call out friends in doing so. Friends that may have become administrators, politicians, industry players.

Some think we must move slowly, take measured steps. True patient champions have been woke for years, or now, newly woke, run to the long-existent code occurring in American medicine. We don’t aspire to place a band aid on a hemorrhage. COVID-19 has opened all of America to knowledge of how bad things have been.

Some physicians have not yet dissected the whole system to see and understand all the players who are the Disruptors of Patient Care. Please do so! Hint: FOLLOW THE MONEY!!! Here are two resources:

1.A primer on corporate care

2.Solutions and rationale for reducing cost and waste that will increase access.            The Free2Care white paper was presented April 2019.  The ideas are supported by the Free2Care Coalition: 8 million American patients and over 70,000 US physicians!  As a coalition of groups, each group does there thing and we come together surrounding ideas.  There is no one group in charge. Go team!

Some physicians know exactly how the system works and sold out, now working as leadership in organizations that take vast monies from the corporates. Some of these organizations have wonderful physicians who are foot soldiers, and are trying to change these organizations from within.  

I’ve had a tiny fear of being fired my entire professional life, for being a Champion of Excellent Medical Care, but deep down, I reasoned that if I put the needs of the patient first, how could I be doing the wrong thing?  Bottom line for all of us who want to be champions: allow us to give our patients, every patient, the best care possible If you choose to disrupt us, we will first ask you nicely to get out of the way, but then will breathe fire at you until you do.

That two-year old little girl… she got her enema, her intussusception was reduced, and the dull eyes I had looked into at three am were lit with a sparkle. I smile still thinking of that sparkle.

Jump the chasm, physicians of America. Sparkle. Do not be some physician: be the physician America’s patients need right now. Be the solution!

Be a stellar doc

Be a Champion of Excellent Medical Care!

With thanks to an old friend and a new physician friend for their inspiration. We all have many muses. I believe they are both champions.

Scrubs vs. Suits — the Battle Inside the Nations’ Hospitals (Part 1)

Marion Mass, M.D.,  PPA co-founder

The headline to a news article dated March 25 on a recent Gallup poll was “Coronavirus Response: Hospitals Rated Best,  News Media Worst.”


The public’s low opinion of much of the news media is no surprise.  In polls, journalists have managed to work their way into a special zone of disdain occupied by some salespeople, lawyers and members of Congress. 


But there is a reality underlying what this poll says that probably would surprise the public. The physicians and nurses who work in the hospitals of which the public thinks highly do not always share that opinion.


That’s putting it mildly.


If the public understood what physicians and nurses really think these days about many hospitals and the way they are managed, the likely result of polling would look very different. The treatment by some in hospital management of nurses, physicians and many other healthcare workers in the direct line of fire during the COVID-19 pandemic would probably make the public think long and hard about putting the words “hospitals” and “best” in the same sentence.


Cynics could even be excused for wondering whether a hospital corporation bought that headline about the Gallup poll. 


On one hand, in the modern, corporate hospital, which may be a hub in a regional healthcare system, we have the “suits,” the executives in the C-suites, with the administrative, bureaucratic structure in which they function. They run the hospitals.


On the other hand, we have the “scrubs”—doctors, nurses, and others who change into the uniforms for dealing directly with the sick, uniforms that must be changed frequently and cleaned. 


For many weeks, the scrubs, the people “on the front lines” of the fight against COVID-19, have been receiving well-deserved acclaim as HEROES and SHEROES, as the ones risking their health, perhaps even their lives, to take care of others.


Remember: the scrubs don’t run the hospitals. The suits run the hospitals.


The quiet conflict between these two classes has been building for decades as hospitals have become increasingly corporatized, and more and more doctors have abandoned private practice to become employees. The bitterness of the conflict is generally kept from public view as people bite their tongues and get on with the job, trying to make the best of increasingly difficult circumstances. In any case, it’s not a story that the public, which is most concerned with access to medical care and cost, finds especially interesting.


If your antennae have been up during the pandemic, you would have picked up on disturbing and noisy eruptions of the underlying conflict from reports (we may not like them, but the news media have their place) such as these:


·   Nurses having to remove their personal protective equipment (PPE) because they were ordered to ration it.

·   Physicians and nurses being threatened with termination if they brought their own PPE to the job.

·   Threats of firing against and actual firings of employees (physicians) who spoke about the actual conditions of their work during the pandemic. 


A prominent spokesperson for the suits in hospital administration, Dr. Laura L. Forese, executive vice president and chief operating officer of New York-Presbyterian Hospital, has offered a perspective on the recent problems as someone who left her scrubs behind some years ago for a $3.4 million position in the C-Suite. In a video, she spoke of how “dispiriting” it is for her and other hospital administrators to receive e-mails of protest from weary physicians, nurses, and others describing what they are actually up against, e-mails alleging a lack of respect on the part of management.


We note here that Dr. Forese has been adept for years at making high-minded statements about hospital culture. She is a skilled spokesperson for those who decided to lock up the PPE and then retreated to their homes to work in their PJs.


In assessing the words of Dr. Forese, there’s something important to remember. The modern hospital corporation has a public face–the people who speak on behalf of the suits in the C-suites. Those spokespersons are masters of serving up a product marked by what the British euphemistically call “an economy of truth.”


It would not be politic, for example, for such a spokesperson to mention that at least some of the inhabitants of the C-suite have an entirely too cozy relationship with the Group Purchasing Organizations (GPOs), the huge business entities that control the supply chain for PPE and other hospital equipment—a dysfunctional supply chain that now stands fully exposed by the pandemic.  The Wall Street Journal and others have reported on the dubious nature of the relationship between hospital C-suites and GPOs, about whom we will soon have more to say in another blog entry. 


These relationships between suits in hospital C-suites and GPOs make those suits complicit with the GPOs in creating both the specific dangerous shortages that have been exposed by this pandemic and other shortages in recent years that have received almost no coverage. And this is to say nothing of the decline in the quality of what the GPOs supply to hospitals and other institutions involved in caring for patients.


But this is only one corner of a healthcare economy that has been emitting a stronger and stronger stench with the passing years.


In our next blog entry, soon to follow, we’ll discuss how this fetid complex has developed out of lobbying aimed at a receptive political class and at bending government agencies toward the service of very private interests. Fallen by the wayside in this process? The greater public interest in finding medical care at an affordable cost.


Until then, be safe. Protect each other and yourselves. Keep on being scrubs. It’s the honorable thing to do.