Who Controls Quality Control?

Corporate Expropriation and Professional Abandonment

Of The Healing Arts  

Bernard McDowell

Introduction

Over two thirds of all people insured by HMO’s in the US are enrolled in organizations subscribing to standards set by the National Committee for Quality Assurance [NCQA].  This paper begins with a description and critique of the NCQA and ends with a commentary and one specific proposal addressing that critique. The NCQA postures itself as a super licensing board at the national level for the protection of consumers.  Contrary to its mission as a “private, non-profit”  dedicated to improving the quality of health care”, the NCQA serves the intense private, profit motives of its major corporate sponsors and associates.  It exists in order to expropriate the very definition of healthcare necessary for corporate credibility in potential legal battles that circumscribe orthodox practice.  

Though highlighted here, the NCQA is only the most recent example of corporate strategies isomorphic to the main vectors in the development of  medicine as a commodity.  To that end, philosophical and organizational links are traced here between the NCQA and the World Trade Organization’s explicit agenda to institutionalize economic gain as the guiding criteria for healthcare policy.  The NCQA’s intimate association with major finance capital entities and their role in the medical and pharmaceutical industry are detailed along with the latter’s virtual ownership of the information infrastructure of the medical industry.  That all spells conflict of interest between industrial profit motives and the NCQA’s claim to guard the “nation’s healthcare.”   

 From a narrow perspective, the NCQA stands for nothing less than corporate theft of cultural and archetypal heritage, healing as a vital, essential human activity, as natural as singing, building, making art, or walking.  However, to empower any significant change, a broader analysis must include the role of professional groups and the deep alienation of the whole society.  In this view, corporations may be owned by a few people but they reflect a common denominator of consciousness.  Therefore, it is a myopic misreading of this paper as blame upon corporate control; rather it is a call to every interested person to greater awareness and responsibility.  To reclaim the joy, art, and science of their craft and restore honest, authentic relationships with clients, professionals will do well to inquire into the shadow of the professional persona.  Historically, working within a concept of professionals as separate from patients and with exclusive rights to healing practices, racist and sexist exclusions were justified and alternative methods suppressed in the name of protecting consumers.  The  mechanisms used to effect that expropriation over the last century parallel those of the NCQA’s funding, formation, and function:  major finance capital concerns set up privately held non-profit organizations to define educational and licensure standards for their benefit.  Vested interests or the naive may attempt to dismiss this as a “conspiracy theory”, but the following account simply describes business as usual!   

 Who Controls “Quality Control”

The healthcare sector of the world’s economy is enormous with countries spending from 7% to 14% of their GNP on medicine.  With such high stakes up for grabs, major finance capital entities have a keen interest in controlling healthcare to suit their investments in insurance and pharmaceutical companies as well as hospitals and HMO’s.

 A great deal of press frames typical problems with healthcare in the US as a national concern about rising costs versus fears of HMO’s skimping on services.  The debate plays out between doctors and families at hospital bedsides as well as in courtrooms and boardrooms.  At the heart of these conflicts lay a struggle over the definition of health, itself, though clouded in a welter of terminology like ”standards of practice,” “overutilization,” “protocol,” and “medical necessity.”  The prevailing assumption is that modern medical interventions derive from scientific research.  In practice, they come into operational focus by other mechanisms like case law, cost/profit potential,  and “quality control standards”.  In decades past in the US, physicians were the acknowledged keepers of the collective wisdom about healing.  Medical information and diagnostic algorithms are increasingly computerized, but medical authority now issues from corporations legally vested to make medical decisions which doctors simply execute.  Therefore, concentrated corporate ownership interests in the healthcare sector seek to control “quality control” which, when pervasively implemented, become the “orthodox standards of practice” that, in turn, are encoded into case law, taught as protocols in grand rounds, disseminated in continuing education courses, adopted in agency policies, etc.

 Not What, But Who...Is The National Committee On Quality Assurance [NCQA]

The NCQA bills itself as a “private, non-profit...dedicated to improving the quality of health care” by efforts “organized around two activities, accreditation and performance measurement”^[1].  As of February 13, 2000, their website proclaims that over one half of all HMO’s, enrolling over two thirds of the total lives covered by HMO’s, endorse NCQA standards.  Not restricted to HMO’s, the NCQA advertises “new” guidelines for government agencies and ”preferred provider” quality standards.  Therefore, this essay concerns the commodification of medicine not just the narrow corporate HMO structures currently in vogue.  It purports to advocate for consumer choice and to “lay the foundation for America’s health care industry.”

Placing utmost importance on “accreditation” standards, the NCQA determines guidelines for institutions to earn the NCQA’s seal of approval.  One basic requirement, for example, is that institutions should only hire medical professionals who are properly academically accredited, licensed, and insured.  On first examination that seems benign, but monitoring quality performance implicitly assumes the ability and/or authority to define good health.  The NCQA now functions as the cutting edge instrument for defining medicine legally according to the major finance capital entities--insurance, pharmaceutical, and banking institutions--that pay for it and are represented on the NCQA board.  

The Board of Directors of the NCQA represent corporate interests weighted heavily in favor of insurers and HMO’s while 9 of the 13 sponsors of its current initiatives are large pharmaceutical companies^[2].  Companies represented on the Board Of Directors include the largest insurance company in the U.S., Aetna, along with General Motors and General Electric; all three maintain large finance capital subsidiaries while GE owns a medical equipment subsidiary.  Others include IBM, Pacificare, and Kaiser.   A superficial investigation immediately reveals inherent conflicts of interest between the financial motives of the NCQA board and sponsors and their self appointed task of setting scientific standards for the “nation’s” healthcare.

A 1968 landmark study by the House Banking Committee on the Trust Activities of Commercial Banks^[3] identified two critical factors for determining the underlying controlling entities behind major corporate enterprises:  1) institutional ownership^[4] and 2) interlocking directorships.  Other researchers across the political spectrum^[5] hold to the same criterion.  A cursory review of the pharmaceutical companies sponsoring the NCQA reveals a tightly knit institutional ownership pattern among those companies and between those companies and other financial interests represented on the NCQA board.  

Pfizer, Eli Lilly, Merck, Bristol-Myers, Proctor & Gamble, Upjohn, etc. all “sponsor” the NCQA.    A highly concentrated overlap of institutional ownership exists between these companies.  Look at the chart below:  NCQA sponsors are listed across the top row.  Inside the boxes are their  institutional owners, ordinally ranked by how much they own, of the NCQA sponsors: 

Pfizer                               Merck                              Eli Lilly                          Proctor & Gamble

Now, consider the NCQA Board of Directors.  Companies with representatives on the board are listed across the top row with the institutional owners inside the boxes: 

General Electric                   IBM                                     General Motors                   Boston Scientific

Interlocking directorships are commonplace among companies represented here:  the Chair of IBM holds a directorship at Bristol-Myers; another director of IBM sits on the board of Aetna, whose sixth largest institutional owner, Barclay’s, is also IBM’s largest institutional owner.  Aetna is also owned in part by Morgan, which, in turn, has two directors on the board of Merck, whose second largest institutional owner, Barclay’s, has a major ownership position in Boston Scientific,  also represented on the NCQA’s board.  The chair of the Executive Committee of Proctor & Gamble serves on the board of Boston Scientific. The list goes on.  At one time, two thirds of all the directors of major insurance companies acted as directors of major banks and vice versa, while two thirds of all directors of hospitals were either a director of a major bank or major insurer.  Only one of the 13 sponsors is a government agency:  The Agency For Healthcare Policy and Research was renamed the Agency For Healthcare Research and Quality in December 1999^[6].  The  change “corrects the misperception that the Agency determines policies.”  Its task force on quality was set up by an advisory commission consisting of 32 members from the private sector. 

Connections To The World Trade Organization  Barclays “is one of the leading providers of coordinated global services to multinational corporations and financial institutions in the world’s main financial centers” ^[7].  The former chairperson of Barclays also chaired the “Financial Leaders Group” of the US Coalition of Service Industries [UCSI]^[8].  This same UCSI attended the Uruguay round talks that concocted the World Trade Organization.  According to an article in Lancet^[9], the British Medical Association’s journal,  the UCSI explicitly promotes dismantling national healthcare in England, Canada, and elsewhere as an “opportunity for US businesses to expand“,  while the US trade delegation considers all social services worldwide as potential gold mines--the entire “spectrum of health and social care facilities, including hospitals, outpatient facilities, clinics, nursing homes, assisted living arrangements, and services provided in the home”!  Others in the US Coalition “leaders group” run companies among the top ten institutional holders of the sponsoring companies for the NCQA as well as other multi-national insurance conglomerates.   Four of the NCQA sponsors along with NCQA Board representatives, GM, GE, and IBM,  are on the WTO’s Intellectual Property Committee which attempts to forge international agreements about genes, herbs, patents, and more.  An employee of Monsanto, wholly owned by NCQA sponsor Pharmacia until the Fall of 2000, wrote the GATT Intellectual Property Codes in 1990^[10].  Lancet identifies the heart of the strategy behind these activities: “health-maintenance organizations target the public funding behind foreign health-care systems.  Multibillion-dollar social-security or tax pools are effectively...redirected through private-sector organizations”.  Of course, many citizens of other countries oppose privatization^[11]. That’s contrary to the NCQA’s  stated mission of advocating for choice for US consumers--46%^[12] of whom support national health care along with numerous professional groups and even 24% of corporate employers^[13].

For the vested interests aligned with the NCQA this is simply big business as usual.  Many even applaud the ability of a few to concentrate so much power and postulate that “the invisible hand” of capital works for the good of the whole.  Taking an opposite tack, others argue there is a “power vacuum”:  just because Barclays “owns” a good part of this crazy world, it can not influence scientific health care standards more than any passive investor.  After all, there are representatives on the NCQA board from organizations other than major corporations, board members are professionals, often doctors, who vote their conscience with a primary orientation to ethical service, etc..  But there is no law of nature in evidence for any such vague notions while a specific conclusion can not be avoided.  That concentration of ownership forms a vector of financial interests: that is, NCQA players share the same force and direction of intense, private profit goals in the health care arena.  Elements intimately entwined with the NCQA openly seek to destroy national healthcare in other countries while the NCQA doesn’t even consider national health care as one of the consumer choices it supposedly lives to defend in the US.  Irrespective of the reader’s position concerning national health care, the case is clear that those elements act contrary to the NCQA’s stated  mission.  Secondly, despite its official non-profit status, the NCQA is paid for, directed by, and acts on behalf of companies motivated for profit.  So, is it a non-profit?

Though professionals complain among themselves about “managed care,” whether out of ignorance or fear, they have not collectively taken a stand against it.  Tens of thousands of professionals endorse the NCQA by default by contracting with insurers/HMO’s.  Therefore, as tedious as it may seem to some,  several arguments outlined here tap diverse epistemological currents: 1) specific historical records illustrating inflation and folly in the development of accrediting standards, 2) inquiry into how contractual restrictions on research, lawsuits, and cognitive dissonance distort what passes as the scientific basis for “quality,” 3) highlights of logical contradictions in the stated position of the NCQA versus its actions, and 4) commentary by several noted social critics on the collective influence of prevailing worldviews on the “professional knowledge base.”  Of course, in such a short paper, there is no possibility of making a complete case, but, then, this paper isn’t intervening on an aggressive, massive scale like the NCQA.

Pollution in the Information Infrastructure:

 Beyond Cognitive Dissonance & the NCQA

Every scientific field relies on an information infrastructure that may include journals, dedicated newspapers, continuing education courses, newsletters, lists of “requests for proposals” that are out for bid, businesses acting as information providers, etc..  Professional researchers plug into that infrastructure for orientation to the current trends in their field.  In medicine and psychotherapy, the quality or scientific validity of that information flow is seriously polluted by dominance of large capital concerns including those sponsoring the NCQA.  As briefly outlined below, pharmaceutical companies play the major role in funding what gets researched, what gets published, what parts of research conclusions get deleted, the position of research articles in journals and what editorial slants appear.  The same companies control a substantial part of the industry for providing continuing education that promulgates their preferred agenda.  Meanwhile, HMOs send flurries of newsletters to providers insisting on the appropriateness of certain treatments and so on.  When all is said and done, pharmaceutical and insurance companies filter and pre-treat the great preponderance of medical information flow before it ever reaches providers or consumers.

Cognitive dissonance refers to the notion that individuals tend to form beliefs according to what fills their pocket books--without realizing how their beliefs crystallized.  On a collective level, there is enormous literature demonstrating the influence of the political worldview currently in power on science in general.  The whole field, matured over the last 40 years, now known as the History of Science is replete with accounts of political orthodoxy masquerading as scientific truth.  A few examples relevant to this discussion:  The New England Journal of Medicine published a 1998 review of 70 different studies of calcium channel antagonist drugs.  It showed that researchers rated drugs favorably 96% of the time when they had financial relationships with the drug manufacturers but only 37% of the time when they do not have a financial relationship.^[14]  There is no implication that the scientists consciously manipulated their findings.  Rather, the default assumption is that they were unconsciously biased (cognitive dissonance) in favor of who paid them.  Bear in mind that those scientists are in the business of research and, typically, depend on the repeat business of a handful of drug companies.  The drugs in question ring up $4 billion in annual sales^[15].  There’s some “controversy” over how drug companies routinely buy dinners or river cruises for whole hospital departments in exchange for pitching their products (which are then prescribed at greatly increased rate by the doctors in attendance).  But what a trivial issue relative to lawsuits that drug companies threaten against individual researchers and their employers when research conclusions don’t support the drug companies’ motives.  Such legal attacks even compromise the decisions at national health departments.

Why Leave Cognitive Dissonance To Chance?

Medical journals serve as the main artery for disseminating new scientific research.  Yet even the most respected journals, e.g., Lancet or JAMA, receive direct demands to withdraw planned publication of research under threats of lawsuits by drug companies.  After pressure from drug companies, journals^[16] may ask authors to tone down their conclusions, deter uncooperative authors with negative editorial slants, and/or delay publication on research for which there had previously been nothing but praise.  Valenstein^[17] details the case of Fenoterol a drug given by inhalers to asthmatics in the 1980’s.  Epidemiologists in the New Zealand Health Department noted a rise in deaths related to the drug.  Wary of a challenge by the manufacturer, the health department employed a review panel before conclusions were drawn. Following its normal review procedure, Lancet accepted the research for publication.  However, after pressure from the manufacturer, writing to the authors of the study, Lancet cited its “anxiety” and suggested withdrawal of the publication or reduced exposure accompanied by a “highly critical editorial.”  Later, the drug company threatened “legal consequences” to the health department which temporarily delayed disseminating the research.  When they finally did, the death rate dropped dramatically and more studies confirmed the role of Fenoterol in the deaths.  Individual scientists may also encounter “harassment and intimidation” from their employers, who fear drug companies will turn off funding and turn loose legal attacks.^[18]  Obviously, these latter examples go beyond cognitive dissonance because participants know fully well they alter the presentation of research to avoid threatened consequences.  However, drug companies don’t leave much to chance:  before funding, contracts with researchers institutionalize pharmaceutical company rights to delete information from the researchers work (35%), delay publication (50%), or both (30%).^[19] 

The cognitive dissonant effects of such contracts as well as threats of legal actions further confound the atmosphere for other researchers.  Noam Chomsky^[20] concludes that most professionals are so confiscated that they are not even likely to know how they came to their own professional beliefs: “the professional guild structure in the social sciences, I think, has often served as a marvelous device for protecting them from insight and understanding, for filtering out people who raise unacceptable questions, for limiting research--not by force, but by all sorts of more subtle means--to questions that are not threatening.”  It is therefore a daunting task to jolt professionals out of their political presuppositions in anything less than a major tome.  Foucault^[21] devoted a book to the obvious by arguing that all “knowledge” is embedded in power relations, while Guattari^[22] specifically attacks the standardization policies of “power groups” as a scientific, “conceptual superego” importing external constraints onto local systems.

A tenet of any basic history class calls for analyzing the financial motives of researchers.  So how is it possible that the NCQA’s background goes unexamined while tens of thousands of professionals fill out voluminous paperwork to meet NCQA standards?^[23]  Pharmaceutical companies do more than insert themselves into the medicine’s information infrastructure. Increasingly, the drug industry dominates 1) 85% of the research industry^[24] as well as 2) the continuing education industry.  In addition, pharmaceutical companies provide much of the revenue for many journals, the symposia of professional associations, and grand rounds at hospitals.  One company, PCS Health Systems, postures itself in the marketplace as an information provider to doctors though wholly owned by NCQA sponsor, Eli Lilly, whose products it recommends without divulging affiliations.  But just in case your trusted doctor or therapist hasn’t properly internalized their role as provider, frequent bulletins from HMO’s give helpful hints to providers on how to fill out forms while instructing them on the standards of practice as interpreted by those HMO’s.  One recent newsletter cited NCQA guidelines to advise that clients’ “anxiety” about giving up confidentiality rights is “resistance” to “responsible care.”  It suggests that providers with different opinions “need more education” ^[25]; that’s a proven tactic of the Peer Review Organizations that preceded the NCQA in the 1980’s.^[26]  

In effect, exactly the same entities sponsoring the NCQA, invest enormous efforts to define, by ownership and market domination, diagnostic and treatment protocols--not simply to suit product lines, but rather to fulfill corporate objectives.  Given the disjointed blame on “special interest groups”, bear in mind that pharmaceutical companies are not independent agents but are better described as one face of the finance capital/medical complex.  In fact, the term, “agriceutical”, now more often replaces “pharmaceutical,” which inadequately reflects the facts.  NCQA sponsor, Novartis, manufacturers a full complement of herbicides and pesticides as well as Ritalin.  Pfizer, Merck, and Eli Lilly own large animal “health” divisions.  Smithkline, Merck, and others run healthcare service companies.  Several NCQA sponsors run prescription management companies.  Others produce crop and pest “protection.”  By one estimate, these agriceuticals will soon account for over one half of the world’s economy and employment.^[27]  Pharmacia & Upjohn produces genetically modified foods [gmo’s], operates in over 100 countries, owns over 8.5 billion animals, and held Monsanto as its wholly owned subsidiary until very recently.^[28]

Over such vast economic dimensions, it appears that in the waning of the imperialist era, corporate strategies now focus less on real property and more on the collective inheritance:  what many people consider the property of the commons--genes and seeds in agriculture, diagnostic and treatment protocols or rights to practice a healing art.  Monsanto is currently the target of international protests against the dangers to human and animal health of genetically engineered soybeans which Monsanto collects royalties on.  From the perspective that genetic modifications are, at best, an inflexion on life forms that belong to no one or everyone, agriceuticals steal seed varieties^[29] through patenting.^[30]  Without the soybeans, which originated in China, there would be no genetically engineered versions.  From a similar perspective, diagnostic and healing protocols belong to an archetypal, collective realm: at best, modern medicine stands on the shoulders of millenniums of experience and primarily catalyzes natural regenerative processes in the body.  True, we don’t have to pay royalties on the body yet (though 1,250 gene sequences have been patented and one company holds the patent for all umbilical cord cells from fetuses and newborns).  It’s instructive to note parallels in corporate tactics employed across industries at this historical juncture.  Similar to tactics used to coopt the field of medicine, agriceuticals stand against food labeling laws and for “food disparaging” laws^[31] to outlaw dialogue and sue those who speak out (Oprah)^[32] or plant seeds in defiance of patents^[33].  Aside from the deaths of millions attributed by some to the disastrous failure of genetically altered seeds to date, products such as Monsanto’s new herbicide dependent Terminator seeds (which can’t be replanted) discourage farmers’ self reliance and interfere with their care of and responsiveness to the land.  Obviously, the complexity of the full argument goes far beyond this paper.  This divergence is offered here to introduce deeper issues, elaborated later, that beg for thorough inquiry before evaluating corporate influence over medicine.  

Many doctors signed much publicized “gag clauses” forbidding them from revealing their financial incentives in HMO contracts to patients.   Medical professionals spend years of their lives and up to hundreds of thousands of dollars leading to certifications making them eligible for insurance reimbursement.  From that vantage point, it’s not so astounding that gag clauses proliferated.  But much more disturbing, some docs contracted not to tell their patients about standard medical alternatives to those approved by the HMO.^[34] That bears restating.  Even when the cheaper, HMO treatments had significantly higher life threatening consequences, docs not only contracted not to recommend standard, safer treatments, they agreed not to share knowledge that alternatives existed.  That is simply wrong and contrary to the most basic codes of medical ethics though remindful of corporate strategies in other areas.^[35]  Yet, how many licensing boards at any professional level protested? Did the NCQA intervene?

The CEO of Pacificare ($10 billion in revenues in 1999) sits on the board of the NCQA and an industry lobbing group, the American Association of Health Plans.  Does he take off his CEO hat for maximizing the profit of his company and then go to an afternoon NCQA meeting to defend health for everyone in this country?  His job description dictates constructing health as it puts money into the company’s coffers.  Irrespective of our opinions about the value of profit motive, we can conclude that there is no scientific evidence whatsoever that doctors, psychologists, or board members of the NCQA are immune to cognitive dissonance.  We may also conclude that the big money and legal power of NCQA associated companies do more than merely bias what passes as the science behind “quality” medical decisions.  Does it take a PhD to see the NCQA’s problems with conflicts of interest?  Perhaps, we need continuing dis-education courses.  My uncle who flunked the second grade four times, always told me that paper does not refuse ink.  One unavoidable conclusion here is that although the NCQA is listed on paper by the IRS as a non-profit, it is a “for profit” enterprise by virtue of functioning for the benefit of the companies that run it and pay for it--but that’s nothing new.

 Historical Precursors: For Defining Who and What Gets Accredited

Around 1900, major capital players established commissions to define proper education and proper medical credentials--in favor of those who paid for the commissioning.  Those interests initially vested M.D.’s with the last word about medicine.  Betty Leyerle,³ an historian and critic of the medical industry, makes the case that as costs and the profit potential of industrial strength medicine escalated in the ‘60’s and ‘70’s, corporate forces repossessed the authority which, in fact, they had first bestowed on doctors; while docs were busy resisting socialized medicine, they were “blindsided by capitalism.”  During the 1970’s, a series of corporate backed laws and regulatory organizations reset the parameters for medicine in terms of utilization rates, “peer review” controls, etc.  In the 1980’s and ‘90’s, measures of quality medical care were radically confounded by inextricably linking clinical outcomes research with cost/benefit analysis.  Ironically, from the beginning quality control attempts have been a comedy of errors.

In the mid 1800’s, the largest single grant to any college was about $50,000 given to Harvard.  With the advent of industrialization, major industrialists bought most big universities and not just for altruistic purposes.^[36]  For example, Carnegie Mellon University, funded by Andrew Carnegie, still has its sloping hallways originally designed for the easy movement of big machinery used by engineers trained there to work in Carnegie’s steel mills.  Near the turn of the century, Carnegie offered a substantial monthly pension to all college professors in the country--a grand philanthropic gesture except for...a catch-22!  There was no definition of what a college was.  Thus it was for the Carnegie Foundation for the Advancement of Teaching^[37] to define what proper credentials were for colleges and professors.  Some instructors who objected were rejected by their peers.  At Vanderbilt, the entire faculty supposedly “resigned” as a condition for a $4 million endowment distributed by a man named Abraham Flexner for the Carnegie Foundation^[38].  Wesleyan, Drake, Brown, and others gave up their religious affiliations to comply with the foundation’s conditions.

In addition to determining who got to play in the education game, the foundations forged what got to be studied by awarding the major portion of grants to less than 25 universities where 75% of all PhD’s were awarded.  Those PhD grants served as templates for acceptable areas of study, outside of which awards were scarce.  The University of Chicago dominated the grant winning landscape of the social sciences by adopting a united behavioral approach across political science, economics, psychology, and anthropology.  Supposedly value free and focused on external behavior, behaviorism allows little room for concerns about sexism, cultural values, ecological loss, or depth of feeling; perfect for big business then as it is for the WTO now.  That’s relevant to contemporary psychotherapists working with HMO’s.  They sign contracts to be on “Behavioral Health” panels; the name itself an artifact of the match between behaviorism and big business.  But behavioralist schools will never acknowledge that:  up to 1970, there were only 12 articles in 50^[39] years on the relationship of business to politics in The American Political Science Review!  In other words, there’s no influence by big money on politics according to political behavioralists!  and by extension, psychology and medicine!  If you believe that, my uncle is selling some land I’d like to show you.

 Quality Control Follies

The nexus of control formed by licensure, accreditation, and so called quality standards share at least one premise: for individual licensing, before a professional in any field is permitted to intervene with individuals, they must demonstrate a mastery of vast amounts of knowledge and skill encompassing years of study, exams, and individual supervision.  Curiously, though licensure laws intervene on entire professions and the society as a whole, historically there have been virtually no requirements for accreditation, licensing, and quality control “experts”  to demonstrate knowledge about such macro interventions.  It would be a shock to find a dozen licensing board members anywhere in this country who could competently discuss, for example, the views of some of the major intellectuals of the last hundred years on themes explored here along with other critical questions.  Can they discuss the effects of licensing across professional lines (teaching, medicine, plumbing, law, etc.) at a rigorous academic level? across capitalist/socialist boundaries in consideration of developed/undeveloped economic parameters?  with regard to gender or race, the role of corporate influence, contemporary and historical alternatives in other countries, research on the effects of licensing and quality control, etc.?  These questions are relevant to the macro economic interventions involved:  Obviously, NCQA related entities aren’t shy about taking positions about health care and profit opportunities at national and international levels.  What empirical data exists demonstrating the benefits of licensing and/or NCQA standards?  In reality, these so called experts violate their own premise by intervening without demonstrating their expertise.  This isn’t to attack well meaning people but to frame an inquiry into the history and worthiness of quality control strategies.

Hired by the same Carnegie Commission to establish a system to approve and grove medical education, Abraham Flexner took the role of champion for licensing efforts in the field of medicine and social work.  As critiqued by feminist authors, Ehrenreich and English^[40], and in his own reports^[41], under the rubric of protecting progress, Flexner advocated for the closing of the only three women’s medical schools existing at the time and seven of the only eight African American medical colleges.  Altogether, Flexner’s efforts forced the closure of 62 of 131 existing medical schools while crowning allopathic medicine and all but destroying homeopathy and other “alternative” healing modalities.  But what was his expertise and authority based on?

In his autobiography^[42], Abraham Flexner openly muses about how he first began his project to accredit and discredit medical schools for the Carnegie Commission.  A personal friend of Carnegie, Henry Pritchett, the president of MIT, offered Flexner the help of noted physicians to develop a template for accreditation.  Flexner politely turned him down but shares that “an advisory committee would have proved a source of great embarrassment” --because he really knew nothing about what medical education should be.  So, he threw himself to the task and proudly announces that in six weeks, he taught himself to go into a medical school and “in half-hour or less” determine if he should close it.  A major criteria was the size of the endowment of the school, over which Carnegie exercised much influence.  Poorer schools didn’t just fail to gain an arbitrary accreditation, they eventually became illegal.  Well, at least belatedly, Flexner admits that he had no qualification for his class, gender, and racially biased quality control position--other than the connections he reveled in to the likes of J.P. Morgan, Rockerfeller, and Carnegie.  He summed the world view he served:  “the world has no considerable experience of culture except in connection with a leisure class.”^[43]

The Private Regulation Of American Healthcare^[44] gives a thorough account of a series of laws in the 1970’s and 1980’s regulating the health care industry including two amendments to the Social Security Act--passed over opposition by the AMA.  The 1972 amendment created Professional Standards Review Organizations [PSRO] to evaluate doctors.  By 1982, PSRO’s were eliminated by another amendment instituting private Peer Review Organization [PRO’s] which took on the task of using a newly created coding system, the Diagnosis and Related Group [DRG] billing system.  Hundreds of PSRO and PRO groups sprung up though it was more profitable to have nurses do the reviews rather than peers and only patient records were examined, not the doctors’ actual work.  Theoretically, PRO’s would gather data on how treatment went for each diagnostic code, establish statistical norms of services for each condition, and then declare the high end as overutilization!  In this way, proper utilization norms could be pared down year by year without fail--especially since severity of illness wasn’t considered in the government’s DRG system.

Contradictions abound between the ideal and intent of scientific medical review regulations and their actual implementation.  Aside from the simple fact that on the face of it the DRG system didn’t measure quality, a three year test failed to show that the system saved money.  Nonetheless, it was continued.  PRO’s became an industry unto themselves.  Despite the notion that consistency is the hallmark of “quality control”, there was tremendous variance between the PRO’s.  While one firm checked less than 19% of the 42,000 medicare cases HCFA expected, another survey showed that one firm out of thirteen conducted  “one tenth of the reviews but turned in more than half of the ‘serious’ violations^[45]”.  Several groups wrote DRG coding systems--the government’s version lacked an accounting for severity of illness making it possible to refuse services to the most seriously ill.  Thus, cutting down on “overutilization” meant cutting out utilization--by those who need it the most and, then, retabulating the stats.   As cited in Leyerle, The New England Journal of Medicine published a study correlating “HMO market penetration and stringent state regulations with higher mortality rates.^[46]

Back to the 1980’s, “peer” reviewers were rarely peers and, like Flexner, they didn’t have any expertise at monitoring quality--of course, that was admitted only after the fact by trainings touting the new career paths with continuing education and certification programs to “improve the risk manager’s image.”  In disarray by the 1990’s, the quality control medical industry openly turned to corporate America, like Florida Power And Light or 3M Corporation, for inspiration.  Under their overt influence, terms like “total quality” control came more into vogue though such measures virtually lumped in cost benefit efficiency, management effectiveness, and clinical outcomes into one parameter.  Many protested the relative lack of clinical outcomes research all along the way.  Further, Leyerle reads a litany of highly critical analysis from within the quality control industry.^[47]  Those insider executives admit that many of their “poorly trained” colleagues are selling programs repackaged with new terminology but with “little chance of working.”

So we stand in the year 2000 with decades of promises about so called quality control mechanisms that 1) proved wildly inconsistent as well as ineffective, 2) short changed clinical outcomes research, 3) downplayed fundamental issues like severity of illness, 5) blurred cost and clinical issues rather than clarified choices, 5) were initiated and maintained by people without expertise in societal scale interventions, and 6) catered to the narrow financial interests of those designing and lobbying for such mechanisms.  In a society technologically advanced enough to explore the surface of mars or the detailed depths of a colon, incompetence may be ruled out as the cause of quality control follies.  A proper diagnosis indicates the overwhelming influence of monied interests in an industry prioritizing profit control over quality.

Commentary

Are there yet other effects of increasing regulation?  In 1974, to manage competition, the National Health Planning And Resources Development Act required certificates before any public or private construction of hospitals could begin.  That resulted in the closure of many hospitals serving the poor. When those certificate requirements “were highly stringent, the mortality rate was 106% of the expected rate; where they were not, the rate was 90%.^[48]  Studies of utilization rate reviews revealed a similar correlation.  We’ve already cited sexist and racist effects of licensing.  Illich^[49] documents the tremendous iatrogenic harm that comes from industrialized clinical interventions on individuals: backlash from overuse of antibiotics, unnecessary surgeries, wrong prescriptions, side effects, high accident and disease rates for children in hospitals, etc.^[50]  His documentation makes it unacceptable to simply dismiss those problems as side effects of otherwise beneficial medicine.  But much more importantly, he deconstructs the premises of commodified medicine and its socially iatrogenic effects--learned helplessness and a deep alienation in every facet of the accelerating commodification of life.   I can only refer the reader to Illich’s elaborate analysis of how at the arrival of industrialized medicine into a culture, birth and death become professionally guarded commodities while “mutual self care and self-medication” suffer.   Medical procedures ”transform the sick man into a limp and mystified voyeur of his own treatment.”^[51]  Increasingly, the same can be said of those giving the treatment.

 Psychological Iatrogenesis In the Multi-National Era

 When over saturated, analogs of licensing strategies degenerate, as Illich formulates it, into “radical monopolies...that disable people from doing or making things on their own.”  In this alienating process, we collectively relinquish a significant degree of evaluating our own experience --that’s cultural and psychological iatrogenesis.  This line of argument may be dismissed by pointing to a similar process pervading the nature and history of the human psyche:  On an individual level, the immature psychological compass necessarily points outward to mother whose psyche, in turn, grows out of the broader cultural context; at a collective level, Morris Berman^[52] traces a parallel external orientation through the emergence of a psychological identity across historical epochs.  It is clear that, whether charting object relational development through historical/cultural or individual time, less mature modes are characterized by or require that individual autonomy be given over to intermediaries for the church, state, or, more recently, corporate owned science.  The priest, politician, or “expert” then confine and define appropriate interpretation of immediate individual experience.  When groups, like the Cathars of France, reclaimed the right to define their own relationship to their bodies and god, a priest from Rome led a genocidal attack against them.  Reich^[53] argues that fascist regimes succeed only by divorcing people from their most intimate sexual feelings, it’s then a formality to impose an ideology. 

In the same vein, colonialist soldiers stole native land in the name of the King’s corpus (body) from which the word, corporation, derives.  To maintain it, they also had to invade the inner domains of sexuality and religion.  Again, today corporate employees patent much of the commons:  genes, animals, and plants for which they hope to collect royalties; but, to endure, those claims depend on cooptation of the most personal archetypal realms:  learning, building, or healing.  Illich details innumerable examples of a modernized violence by professional intermediaries--often more obvious at the onset of professionalized interventions into a culture.  When Harvard experts instituted eight grades as a minimum level of education in parts of Mexico where only three were affordable, the “inferiority” of Oaxacan Indians was “more precisely measured.”  Education wasn’t increased--only access to teaching and to the building trades denied for lack of a certificate.  Despite unimaginable and immoral suffering, such phenomena may be portrayed as an inevitable developmental process--after all that is the way things have evolved.  But it takes yet another new and dangerous twist at this historical juncture.  We have entered a new era of the multinational supra-state which has not been integrated with any culture.  In fact, the mission of the WTO virtually invalidates cultural, collective interiority by explicitly subordinating all to “economic benefit”--that turns life into, as Ken Wilber says, a “flatland”; as Illich puts it, “money devalues what it can not measure.”  If the contrast of colonialism and corporate globalization seems farfetched, consider that Merck^[54] just bought the exclusive rights to one half million species in the Costa Rican rainforest for $1.1 million dollars or $2 per species--an absolute steal compared to Manhattan. Statistical measures may inform, but they are simply not appropriate validity tests^[55] for the complex cultural and psychological issues at stake.  That’s critical to what is left out in the analysis of medicine in economic parameters. Culture and individual life have an interiority with depth and uniqueness which can not be assessed in terms of external/collective data.  A country or culture’s ability to maintain its values for protection of a species or to take moral responsibility for health care for all its members shrink in the face of WTO lawsuits and philosophy as do individual interior dimensions like well being, loving communion with a doctor, or compassionate suffering with one’s physical pain.

As we enter this next century, the overwhelming, high energy intrusiveness of commercialization almost instantly assimilates fresh cultural expression with media commentary, advertising, and a corporate logo and that does, indeed, endanger psychological well being in regard to the healing arts.  Barraged by commercial mantras, we are evermore confiscated by the corporate expert:  “go to qualified licensed professionals”, “buy trusted brand names”, and “talk with your family doctor” (about our product that we introduced to them last week on our free river cruise).  If that advertorial^[56] advice goes sour, later you can “go to a reputable lawyer” to sue.  The terms, “providers” and “consumers,” reduce people to their economic functions while ignoring feeling functions and moral muscle.  A super amplified orientation to commercial criteria for such basic life processes as the health of our loved ones yields a similar psychological profile as a fundamentalist church or state: decisions assigned to an external template are self-abandoning, amoral, and immature.  A moral function takes a ripened sense of psychological health with a developed sense of choosing, evaluating, and participating.  Yes, HMOs do elicit consumer ratings on 1 to 5 scales about “speed”, “parking availability,” and even “satisfaction with your provider”; but that doesn’t honor the depth and contours of the interior landscape: feeling disheartened, intimately connected, morally disengaged, or more to the point of this article, passionate and creative in one’s work.^[57]

Expropriation Of “The Very Ability To Do And To Make” In Medicine

Capital control of the means of medical production only superficially characterizes the issues explored here.  There is a much more fundamental problem than consumers not receiving quality medical services or going without health insurance.  So called “consumers” are also prevented from giving services, from creatively expressing themselves--as healers.  Consider healing as an archetypal activity, just as natural and essential as hunting and gathering, building, or making art.  Clearly, millions of people  have a compelling interest in herbs, exercise, and “alternative” healing; U.S. citizens make over 600 million visits for alternative treatments in 1997.^[58]  Calling this the “Age of Disabling Professionals,”^{[59], [60]} Illich underscores how past a certain point of saturation, external licensing and regulatory schemes inhibit people from the basic activities of building, using herbs, or teaching.  For example, increasingly restrictive construction and contracting laws reduced the number of people building their own homes in the US from about 30% in 1960 to less than 1% by 1980.  When exported to underdeveloped countries, building codes outlaw cheap adobe dwellings shaped by the hands, love, and aesthetics of those who could live in them.  Some still stand 5,000 years later^[61] irrespective of earthquake/contractor protection codes.  Rather than give refuge, those codes merely declare countless souls as illegal for living in hovels made of industrial garbage--while the worst industrial waste is the atrophy of the human spirit blocked not just from having a home, but from building a home. 

Medical certification laws are similarly destructive.  Between 70% to 90% of all healthcare in the world comes by alternative practices^[62], the legality of which is threatened.  Though women provide 95% of the healthcare worldwide and have long cultivated knowledge about delivering babies, in recent decades it more often took a political fight, a graduate degree, advanced certification, and/or malpractice insurance to practice midwifery in the U.S.--without tremendous exposure to legal consequences.  At the height of this cult of expertise, generations of Americans rarely witnessed death or birth, granted as the domain of hospitals.  Illich relates a sadly funny story about a nurse trying to push a baby back into the womb until a doctor could come.  Mortality rates go up after institutionalization.  Though 75% of the world still depends almost solely on herbal remedies, herbalists have been subject to prosecution for decades in the U.S.; today in France, “homeopathy is under attack.  Twenty-seven medical preparations essential to the practice of homeopathic medicine have recently been banned.”^[63]  If an herb gains acceptance expect a corporation to first unleash a media attack against its unknown risks then a marketing campaign to “brand” their standardized version of it.  Illich makes the case that a few dozen allopathic medicines are the most useful while easily administered by paramedical workers.   Developed only in barest outline, these few examples are offered here to underscore the displacement people suffer from actively initiating, deciding, and responding to their own bodies.  As of 1975, the “World Health Organization” advocated for “the deprofessionalization of primary care as the most important single step in raising national health levels.”^[64]

Again, at a certain level of intensity “consumer protections” distort our relationship to essential life processes.  More than alienation from the means of medical production, we increasingly face alienation “from the very ability to do and to make.”   No accounting and regulatory measurement schemes can simply assess interventions; they are interventions-- which, at high frequency and intensity, become the primary intervention, an economic one.  By relegating authority over the healing arts to external, corporatized templates, we collectively abandon our own authenticity and the human impulse to heal ourselves and others. “Healing” is a basic human activity and a “direct experience” fundamental to psychological vitality that, by its nature, can not be externally referenced.  Of course, most healing happens automatically, outside of human invention which, at best, catalyzes self-organizing functions.  Will that also be claimed for the king as corporations have already staked their patent flags over mice, microbes, and molecules?

Healing Arts

or Proprietary Technology of the Finance Capital/ Medical  Complex?

Clearly, the uncertified suffer the worst as outcasts from their avocations, but doctors and therapists also object to obstacles to creative expression or being able to work their craft at all.  Limits on the number of practitioners who are on panels is almost too obvious an example to see.  It may be asserted that limits on panels is just a choice under capitalist rights of corporations like Magellan of which there are many to apply for membership.  However, under their insurance policies, Magellan covers 79 million lives, more than the majority of countries in South America less Brazil; more than the population of the United Kingdom.  In effect, their network constitutes a single payer system, albeit not within geographic lines.  A therapist not on Magellan’s ship may be, in realistic economic terms, severely hampered from practicing work they love and are trained for.  What if Magellan gains even greater market share in that therapist’s town?  or decides to only endorse cognitive-behavioral therapy?  or requires a contract that a doctor doesn’t believe allows for proper treatment of clients?  Once that big, an HMO begins to define orthodox medicine by sheer domination of most of the medical decisions for vast numbers of people.  Certainly, therapists and doctors, not on their panel, may continue to hang their shingles, but will more often be practicing unorthodox medicine by default.  These questions aren’t hypothetical.  As already demonstrated, some insurers do promote certain types of therapy, have contractually prevented doctors from discussing alternatives with clients, do maintain a lion’s share of the market in some areas, and do maintain close associations with other HMO’s through groups like the NCQA to standardize their agenda.  Whole approaches to psychotherapy and medicine are imperiled. 

Once more, this isn’t just a case of big capital restricting doctors and therapists.  Only in this HMO era of medical cost inflation did JAMA finally publish on the benefits of acupuncture, herbs, and chiropractory which the AMA relentlessly opposed over this century.  But just as allopathy restrained homeopathy one hundred years ago, psychiatrists work to keep prescribing privileges from psychologists who, in turn, sought to curtail social workers from working with people diagnosed with schizophrenia.  The Medical Society of the State of New York [MSSNY] currently proposes that all mental health providers must get clearance from a physician before and during treatment^[65]”--despite their complete lack of expertise in psychotherapy.  Income and control sway in the balance of the ensuing fight over that proposal but a much greater stake is the creative passion of therapists and clients hampered by one more template put up between them.  “Therapists” and “doctors” don’t just refer to categories of “providers.”  They are also “consumers”; people, that is, pulled to a creative relationship with others seeking the well being that comes with dynamic, self-organized living and giving. Ironically, intensive quality control dictums, posed as accounting standards or boundaries within which healing occurs, undermine creative engagement for the very people who supposedly provide this for others. 

 Summary and One Alternative Proposal

As a collective inheritance, healing is imminently endangered by a commodity intrusive model of medical care as an industrial market process:  services delivered in packages at cost benefit margins by providers to consumers.  The  NCQA’s mission as the daddy of all licensing boards blurs important distinctions.  Obviously, the “national” in NCQA does not indicate it represents the people of this country anymore than the “National Cash Register Corporation” does.   Associating with a political agenda against national health care in the US or elsewhere in favor of its own economic agenda, NCQA players stand in opposition to their self appointment as protectors of consumers’ interests.  Further, their investment in the science of healthcare clearly conflicts with and takes a secondary position to a greater commitment to the science of big business. While professionals historically benefited from the exclusivity that licensing provided, it is now clear that the sheer intensity of accounting, accrediting, licensing, insuring, and standardizing requirements severely distort their relationship to themselves, clients, and  fundamental life processes.  When differentiated from its grandiose projections, under the NCQA’s shell lies nothing more than a multinational corporate superego insisting on what good science, good politics, and good economic policy should be--for virtually everyone else on this planet!  Endorsing the NCQA reinforces the society’s sense of alienation by modeling abandonment of vital human responsiveness to our loved ones, our bodies, our direct experience, and the need for creative work.

I have one modest proposal to address the bias of the NCQA:  A democratically maintained archive for material on appropriate health care.  The web would be an obvious location; the archive might be carried on multiple sites. Currently, there is a US government site, the National Guideline Clearinghouse.  However, it’s co-sponsored by one industry group, the American Association of Health Plans, and the AMA along with the sponsoring government agency.^[66]  The material on a scientifically spirited site must be shared freely and protected from ownership and patents--similar to the Linux operating code, for example.  Certainly, noted experts could log their opinions but others could freely do so.  There would be a need for protection from corporate domination of such a site.  At the very least, full disclosure of financial interests would be necessary.  Opinions would not be accepted or rejected according to licensure categories, but could be hyper cross indexed to any number of vectors--science according to the U.S. FDA, according to other governments, by who paid for the research, by theoretical orientation, etc.  People wouldn’t be limited to endorse just one treatment, but could voice their opinions about the appropriateness of any number of treatment protocols.  For instance, with regard to the treatment of depression, rather than have a few corporate forces promulgating that only cognitive behavioral treatment with anti-depressants is a “best practice,” this archive might hold extended expositions from many approaches (Jungian, gestalt, object relational, or simply the enormous research literature that comes to different conclusions about anti-depressants).  Professional people will freely register to endorse not just their approach but may recognize others as appropriate.  Granted, such a scheme presents significant logistical problems but it reflects the reality that 1) there isn’t general agreement about how to treat many health matters, 2) individual cases require unique approaches, and, most importantly, 3) many informed people wish to do more than just passively participate. Creative control is a critical aspect of their healing process.  Obviously, a large part of the population prefer healing modalities outside the orthodox medicine of big business.  That, in turn, widens the scope of possibilities for people to fulfill the archetype of healer for others.  Eventually, such an archive might serve as a reference for research, case law, or people searching for help.

This article was first published on the website of the National Coalition for Mental Health Professionals and Consumers.  It is reprinted here by permission of the author, who holds the copyright.

Bernard McDowell is a Clinical Social Worker in Portland, Oregon.  He is a member of the American Mental Health Alliance-Oregon.  Contact e-mail: healingart@hotmail.com

^[1]  www.NCQA.org/pages/main/toc.htm

^[2]  One of the remaining three is the National Pharmaceutical Council to which 8 of 9 NCQA drug sponsors belong.

^[3]  Commercial Banks and Their Trust Activities:  Emerging Influence On The American Economy, House Committee On Banking And Currency, 1968.

^[4]  That committee considered 5% of stock ownership as enough to hold controlling interest of a company whose stock ownership is otherwise very diluted, but they speculated that 1% might be a better measure.  There are cases in which it would take more; the point is that a small amount sways many critical decisions.

^[5]  Green, D.S. & Schwelke, S.,  The Trust Activities Of The Banking Industry.  Stanford Research Institute, 1975 [This work summarizes several investigations into the issue of conflicts of interests.]

^[6]  www.ahcpr.gov  Follow links from Quality Interagency Coordination Task Force through the Presidents Advisory Commission On Consumer Protection and Quality Health Care Industry to the National Guideline Clearinghouse which, in turn, is sponsored by one government agency plus the AMA and an Industry group, the American Association of Health Plans.

^[7]  www.yahoo.com.  On the Yahoo finance site, it is possible to investigate many of the companies discussed here very quickly by typing in their name under “look up symbol” and then clicking “profile” which gives a  brief summary of the company’s business; there you’ll find a link for “institutional ownership”.

^[8]  www.uscsi.org  (find links for finance leaders group)

^[9]  Price, D, Pollock, A.M., Shaoul, J., How The World Trade Organization is Shaping Domestic Policies in Health Care. The Lancet, The British Medical Association, Vol. 354, November 27, 1999.

^[10]  www.vshiva.org/biodiversity/piracy.htm   This site also contains extended discussion of corporate intrusions into agriculture worldwide and particularly in India where there is now a national “Quit India” campaign against Monsanto wholly owned subsidiary of NCQA sponsor, Pharmacia until 2000.  Clearly, the same issues have everything to do with people’s health and I propose it is obvious that the corporate tactics involved are similar.

^[11]  Toronto Star, Feb. 19, 2000  Trade Talks Threaten Canadian Health Care

^[12]  www.yahoo.finance, Newsweek”  Cover: ‘HMO Hell’, Sunday October 31, 1999; 4:25pm EST

^[13]  Leyerle, B.,  The Private Regulation Of American Health Care. M.E. Sharpe Inc.  Armonk, NY 1994

^[14]  Stelfox, H. T., Chua, G., O’Rourke, K., & Detsky, A.,  Conflict of Interest in the debate Over Calcium Channel Antagonists.  The   New England Journal of Medicine, Vol. 338 No. 2, Jan 8, 1998.

^[15]  Tanouye, E.,  Does Corporate Funding Influence Research?  Wall Street Journal Jan 8, 1998.

^[16]  This is, of course, standard operating procedure among much of the major media which often sign contracts with major corporate advertisers not to publish stories negative to those companies or even their industries.  Some contracts call for the media to alert the advertisers to any potential controversial stories.