Fee for service US sick care has been enshitified

The majority of Americans, including the health professionals who take care of them, are not happy with how the siloed, sick, US sick care system of systems treats them. They have not been happy for some time and the United Healthcare executive murder has stoked the flames of public resentment and disdain for the medical-industrial complex.

Delay and deny has caused disgust and distrust and doctors feel dissed.

Last year, Cory Doctorow coined the term “enshittification” to describe the way that platforms decay. That obscene little word did big numbers; it really hit the zeitgeist. The American Dialect Society made it its Word of the Year for 2023 (which, I suppose, means that now I’m definitely getting a poop emoji on my tombstone). So what’s enshittification and why did it catch fire? It’s his theory explaining how the internet was colonized by platforms, why all those platforms are degrading so quickly and thoroughly, why it matters and what we can do about it. We’re all living through a great enshittening, in which the services that matter to us, that we rely on, are turning into giant piles of shit. It’s frustrating. It’s demoralizing. It’s even terrifying.

In other words, US sick care fee for service medicine has substituted profits and greed over the primary patient's interests.

As Doctorow explains its meaning, let’s examine how enshittification works. It’s a three-stage process: first, platforms are good to their users. Then they abuse their users to make things better for their business customers. Finally, they abuse those business customers to claw back all the value for themselves. Then, there is a fourth stage: they die.

So do some patients.

He goes on to explain that there are four forces that discipline companies, serving as constraints on their enshittificatory impulses, including sick care:

Competition. Companies that fear you will take your business elsewhere are cautious about worsening quality or raising prices. Sick care becomes more consolidated, commoditized, and corporatized, and private equitized they are taking advantage of their unfettered pricing reigns.

Regulation. Companies that fear a regulator will fine them more than they expect to make from cheating, will cheat less. These two forces affect all industries, but the next two are far more tech-specific. The forces also apply to sick care and removing regulations appears to be the modus operandi of the future.

Self-help. Patients have been emasculated and powerless in the face of BIG MEDICINE and an opaque product and services billing system that makes it impossible to know what something will cost and why.

And, finally, workers. Sick care workers have very low union density, but that doesn’t mean that they don’t have labour power. The historical “talent shortage” of the sick care workforce sector meant that workers enjoyed a lot of leverage. Workers who disagreed with their bosses could quit and walk across the street and get another, better job. Now, about 70% of doctors wear the Golden Handcuffs working for the Man, like Optum. UnitedHealth Group has about 90,000 employed or affiliated doctors, approximately 10% of all physicians in the U.S.

The murder of Brian Thompson — and the public’s reaction to it — shows that frustration with corporations has reached a fever pitch. We seem to have moved from a world of “I don’t trust you” to “I hate you,” and, many Americans feel a great antipathy toward capitalism and capitalists. This is due, in part, to the failure of business, at large, to deliver value to customers, employees, and communities (as well as shareholders) simultaneously. Corporate leaders should step back in this moment and reflect on what role their organizations play in society and what trade-offs they’ll need to make to ensure that their businesses work for everyone, not just investors. Three case studies show that such strategic, socially responsible thinking pays dividends.

This all sounds great, but how do you reconcile the conflicts between the culture and ethos of capitalism with the culture and ethos of medicine?

Yeah, yeah, yeah. Blah, blah, blah. We'll just pull the photos of our execs on our websites and beef up our executive security and pass along the costs to patients.

If you don't like our Sh#t, too bad, so sad. We'll just keep talking the talk, buy as much of the government as we can and hope we can create enough shareholder value before we have to quit and take our marbles home and start a venture firm to do it all over again in some other industry.

We don’t care about caring. We don’t have to. We’re Sick care USA, Inc.

Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on Substack