The first part of a two-part interview with Daniel Goldstein, MD, an oncologist who also studies the influence of business interests on healthcare—from treating patients to conducting drug trials to holding health-related events. In the first part of this interview, we talk about capitalism and healthcare, what motivates physicians, and the effectiveness of healthcare systems in the U.S., the U.K., and Israel.
It is not uncommon to find economists studying other fields, such as medicine and healthcare: examples include Nobel laureates Sir Angus Deaton and Gary Becker, Janet Currie, David Cutler, Jonathan Gruber, and others. What is uncommon, however, is to find practicing physicians who use economic tools to study their own field. One such example is oncologist Daniel Goldstein.
On March 8, 2016, the Centers for Medicare and Medicaid Services (CMS) published a proposal to test new Medicare Part B prescription drug models.1 The idea was to “improve quality of care and deliver better value for Medicare beneficiaries,” by applying six alternative approaches that were meant to improve quality of care and make spending more efficient, such as cutting or eliminating patient cost-sharing, testing the practice of setting a benchmark rate for a group of therapeutically similar drug products, and allowing CMS to enter into agreements with drug makers to link patient outcomes with price adjustments.
On May 24, however, a letter by The Community Oncology Alliance (COA) said that the experiment is “Bad medicine, flawed economics, destructive policy, and legally invalid.” The letter went on to cite Jeffrey Vacirca, MD, vice president of COA, who said, “It’s alarming to think that some government bureaucrats, who have never practiced medicine, are telling me, a Board-certified oncologist with 18-years of experience, that I’m not treating my patients appropriately.”
The COA’s harsh letter caught the attention of Goldstein, who then went through the websites of the 61 organizations that co-signed the COA letter and looked for evidence of funding or support by the pharmaceutical industry as well as their membership options. Four of them were excluded because they did not have fully functional websites. Of the remaining 57 organizations, 51 (89.5 percent) received funding from the pharmaceutical industry. Only 3 allowed patients and caregivers to become members.
The results, concluded Goldstein, suggest that a potential conflict of interest may be present, possibly leading these organizations to prefer the business interests of the pharmaceutical industry. He also concluded that the lack of representation of patients and caregivers may result in an over-representation of clinicians’ interests, in the cases where they differ from those of patients and caregivers.
Goldstein did not keep the results to himself: he published them in the December 2016 issue of Mayo Clinic Proceedings.
This analysis is one of many on the intersection of healthcare and economics published by Goldstein. Many of them appear on the website of the Global Institute for Value in Medicine (GIVIM), an institute that aims to improve the value of medical care globally and of which Goldstein is the director. Goldstein’s strictly medical and economic-medical papers have appeared, among others, in the Journal of Clinical Oncology, JAMA Oncology, Mayo Clinic Proceedings, The Oncologist, Journal of Oncology Practice, and The American Journal of Managed Care. He was also featured in The Economist, The Wall Street Journal (four times)2, and CNN, and wrote for The Washington Post and Newsweek.
Being a physician with such an understanding in economics is not the only remarkable thing about Goldstein. The U.K.-born oncologist has a unique view on medicine: He studied medicine at Leeds University, interned at Birmingham Children’s Hospital, was a resident at the Montefiore Medical Center’s North Division in the Bronx, worked as a physician at New York City’s Memorial Sloan Kettering Cancer Center, was a fellow at Emory University’s Winship Cancer Institute in Atlanta, Georgia, where he is also an adjunct assistant professor, and is currently a senior physician at the Davidoff Center in Israel’s Rabin Medical Center. Thus, he has a deep knowledge of three different national public healthcare systems, with the U.K.’s and Israel’s being starkly different from that of the U.S.
“I believe in free markets,” said Goldstein, who describes himself as a capitalist, in an interview with ProMarket. “I believe in people being rewarded for the work that they do, and I believe that the capitalist system is, for the most part, an appropriate system for society to be well organized and have good results in many different aspects.”
Guy Rolnik: You grew up in Britain. Was your family Conservative or Labour?
Daniel Goldstein: Good question. Maybe somewhere in the middle. I like the quote that is often mistakenly attributed to Churchill: “If you’re not a liberal when you’re 25, you have no heart. If you’re not a conservative by the time you’re 35, you have no brain.” I’ve gone a little bit by that phrase. I do believe that a capitalist system is the appropriate way, but with certain constraints. I don’t think that a pure capitalist system is appropriate in all situations, particularly for healthcare. I don’t think the free market will work to run healthcare in an appropriate way, as we’ve already learned from the U.S.
GR: Let’s talk about what happens when capitalism and healthcare meet. When did you start to develop an interest in the intersection of capitalism and health?
DG: My primary work is [as] a physician. I treat patients. I care for patients with cancer. I’ve been qualified as a physician for 12 years now. Aside from just treating patients, I’ve also always been interested in the bigger system—the bigger picture of the healthcare system and how the healthcare system functions to appropriate care.
Free markets running wild in healthcare will not work. It’s clear from the U.S. and other places that you need certain regulations in order to ensure that at least the minimum appropriate amount of care is provided to all members of society. Having free markets run healthcare purely is inappropriate, and there needs to be regulation.
GR: In most cases, when I was in front of a physician, I used to believe that the physician had only one focus, and this is my health. Only in the last decade, especially in the U.S. (but not only there), I started understanding that the person with the stethoscope on the other side of the table is more like my banker. That that person is a for-profit entity. When did this happen to the medical profession?
DG: That’s a good question. It’s different in different countries. Let’s start with the U.S. Physicians are human beings. In an ideal world, physicians would have higher, purer ethical principles and be on a higher level than everybody else in society, perhaps like Mother Teresa. But unfortunately, it’s simply not true. We have to be honest and accept that physicians are human beings and are somewhat motivated by profit, perhaps more often than we would like. Profit provides part of the explanation for how medicine works. This isn’t necessarily a bad thing—it’s just the reality—and so we have to develop policies to enable us to ensure that the system provides the best possible outcomes for society, while accepting this reality.
GR: What about the Hippocratic Oath? Does it mean anything?
DG: Actually, I qualified in England, and we don’t take the Hippocratic Oath anymore. The idea of the Hippocratic Oath is that your pure, prime aim in life is your patients. Should physicians be 100 percent for the patients and 0 percent for their own family and own health? To me, I think it’s important to have a balance. It’s not realistic to imagine that my sole interest is going to be my patients as a physician. I think this is one of the greatest personal challenges for many physicians: finding the balance between caring for their patients while at the same time caring for themselves and their own family. It is not easy at all.
Physicians do want to make a living—and a comfortable living at that. When we became doctors, we didn’t assign ourselves to poverty. People want to make money, but there has to be some type of a balancing act about being willing to make money within ethical guidelines. I don’t think it would be fair to say that the other person on the other side of the table is not interested in your health. There’s been a movement within medicine to make it run more like a business, but that’s not to say that you can never trust your doctor—you often can.
GR: How have things changed in the U.K.?
DG: I think it all depends on how the system is set up, what rules are in place to allow private practice. Here, we are talking about physicians’ behavior with regard specifically to patients, but there’s other factors, such as more involvement [from] drug companies, the influence that the information they provide has on physicians and on how clinical trials are run. I am talking about all the different issues with regard to how the pharmaceutical industry may influence how drugs are prescribed, which drugs get approved by the FDA, which drugs get used, and even which patient support groups may be influenced and funded by the pharmaceutical industry. The pharmaceutical industry has many different areas of influence within medicine.
GR: We will get to this later. In the meantime, you have a very special point of view, because you know the U.K. health system, the American health system, and now the Israeli health system. You are like a lab. How would you characterize each of the three, and how would say that the American health system could improve, using examples from the U.K. market and the Israeli market?
DG: I get asked this question a lot, and I think I’ve had a very interesting perspective by working in three different countries. Everybody wants to claim that their health system is better than other people’s health system. The perspective that I have is that, in the American healthcare system, they spend a huge amount of money. For people that have large amounts of money, perhaps you get marginally better care there.
GR: Only marginally better?
DG: Marginally better. However, the big issue is that there’s massive swaths of the population without coverage, and this is only going to increase now with the destruction of Obamacare. It’s all very well if one subsection of society has marginally better care, but a big subsection has no care. That’s horrendous, and people are dying because of that. In the U.K., everybody has coverage.
GR: This may not be self-evident to all. Can you elaborate?
DG: By a matter of law. There’s the National Healthcare Service, which provides full coverage to every person within society. You have to sign up and go through some paperwork, but essentially, everyone’s covered, which is a great system. However, there are also inefficiencies within the system, because you work in a system which is a socialized system. Some view it as quite inefficient.
GR: Is it indeed inefficient? When you use acceptable standards, is it inefficient? World Bank data show that, compared with the U.K. and Israel, the U.S. has a mixed record [concerning] life expectancy and infant mortality.
DG: The data is interesting, but I don’t think it’s fair to look at mortality rates and life expectancy and put this all down to healthcare. Much of these differences are likely related to other lifestyle and cultural issues such as diet, exercise, smoking rates, education, etc. We know that the greatest improvements in such metrics in the twentieth century were not due to healthcare but rather due to improvements in sanitation and hygiene.
I think that things that are very important, from what I’ve seen—diseases and illnesses that are serious, ones that need to be treated quickly or diseases where there are treatments that have a major impact on survival and life—they’re available in the U.K. and Israel. There are other things, such as drugs that are available in America but not in England because they haven’t been deemed to be cost effective, so they’re not available, such as drugs that increase life expectancy by just a few months.
GR: Let me ask it this way: where would you prefer to be a patient, in the U.K. or in the U.S.?
DG: If I have good quality health insurance, I would actually prefer to be in the U.S. I can choose my doctor. I have a certain amount of control. If I have good quality health insurance, I can choose where I go. I’m an educated consumer, so I can think about what’s being done, what’s not being done, and why. As a person without good insurance, I might be better off being in the U.K.