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Article by: PAUL JOHN SCOTT , Star Tribune Updated:
March 16, 2013 - 7:50 PM
The question about Mayo’s plan for a
Destination Medical Center isn’t whether it makes sense for Rochester and for
the state. (It does.) The
question is whether Mayo will seize this moment to lead change in an industry
gone awry.
Rochester – At the forum a couple weeks ago to discuss the big news, they
did not plan for the mad crush of bodies. They booked a too-small room, and the
mob spilled out the door. Open meetings around here are usually a snore, but
the surprise announcement of the Mayo Clinic’s plan for a Destination Medical Center drew the
largest crowd to ever show up for one of these things. Judging by some of the
faces, the proposal is especially inviting to the city’s growing corps of
creatives, culture mavens, biotech wonks, coastal transplants and TED Talk
fans. We in Rochester know this is a critical moment that may not come our way
again, and it feels close. Nearly everyone in the room wanted this thing to
happen.
Chances are the Legislature is going
to come around to the DMC idea as well — if not for its merits, simply because
of the way privately funded construction budgets with a B in them have a way of
focusing lawmakers’ minds. The numbers are unprecedented: The plan promises
$3.5 billion in local capital investments by Mayo over the next 20
years. It promises $2 billion in Mayo-leveraged private investment in
urban living, entertainment, dining, arts and cultural amenities. It promises 30,000 new jobs.
The catch: When new tax revenues from this expansion are produced, it asks for
10 percent of those funds, roughly $585 million over 20 years, for roads,
sidewalks, parking, transit and sewers needed to support the new buildings.
So it’s not a handout, not by any
stretch. Mayo is planning on growing faster than the tax base can keep up, and
has figured out a novel way to get around the problem. The financial model is a
first in the nation.
What’s not to like? Critics have objected to diverting any
revenues, even hypothetical ones, toward a prosperous city when state
revenues are scarce as it is. They object to the granting of special treatment to one employer over others,
even if that firm plays an outsize role in the state economy. (With 30,000
employees, Mayo is the largest private employer in the state.)
Others see trouble ahead, given the
likelihood of the need for eminent domain or the forced sale of private
property through court-appointed means. (To be honest, a lot of buildings in
this town make a good case for eminent domain.) One could also ask why the
state should subsidize Rochester’s new plazas in exchange for new Mayo
expansion when the clinic
was on track to spend $5 billion over the next 20 years anyway, given
its current spending patterns.
This presumes a bit. Mayo could
always build elsewhere (even if last month there were four tower cranes over
its two Rochester campuses). The complaint expressed by House Tax Committee
chair Rep. Ann Lenczewski that the project is a “massive public subsidy” that
will somehow cause “a tax increase for everyone else” is consistent with her
view on projects like this in the past. But it doesn’t track with the reality
of the bill.
The state loses no money; it only
gets less new money. She is essentially complaining about getting a little bit
less of funds the state was never going to get in the first place.
Now there’s an argument to make a
Democrat wince.
These criticisms may sound
high-minded, but there is a football stadium ready to break ground that
suggests any pushback to Mayo DMC has less to do with the sanctity of the
public purse than with residual regional rivalries too tedious to mention. In
other words, if you support the state of medical practice today, it’s a
no-brainer to support Mayo DMC. And I don’t say that just because I want more
public sculpture at the base of my street.
But the moment bears mention for
reasons other than Rochester’s options when it comes to sushi. Mayo says it is asking for this
partnership in order to retain its position in an evolving health care
marketplace. The clinic says there are 13,000 people coming into
Medicare coverage every day, 30 million new enrollees in private insurance next
year, and a future in which a small handful of global brands will serve
patients who travel to destination cities for their health care. It has watched
competitors in
Baltimore, Houston and Cleveland engage in an arms race to attract these
patients, and is determined to ensure its place on that list.
At the recent meeting, a Mayo
spokesperson could not spell out the precise use of the $3.5 billion in new
buildings the clinic plans to create — she only knew that more buildings will need to be
built. So this seems less like a need in front of Mayo officials than
like a strategic decision to stay
in front by staying big.
Going big may make sense in a
rational marketplace, but medicine is no rational marketplace. We’re not
talking here about the usual problems one associates with health care — the
lack of transparency in pricing, the lack of negotiated drug buying power in
the government, and the problems with fee-for-service medicine. Those are all
drags on the system, but they miss a deeper issue.
The market Mayo now seeks to dominate
is that of serving sick people, and if one is honest about it, these are
strange times to be fighting for market share of sick people. The reason: We
have witnessed a near
complete takeover of medicine by private industry. The product of this takeover —
let’s call it the medical-industrial complex — has shown that if its market is
sick people, it will not hesitate to create new customers.
How does the medical-industrial
complex create new sick people? Not by making people sick — not intentionally,
anyway. It markets
sickness. It lowers the threshold for being diagnosed with an illness.
It broadens the symptom profile of an
illness. It encourages doctors to treat symptoms as one would an illness that
meets the formal criteria of diagnosis. It develops tests that trigger
unnecessary procedures. It funds patient advocacy groups to “raise awareness”
about the need for ineffective screening methods and expensive treatments. It
funds medical societies, medical journals, clinical trials, the FDA, individual
doctors, health systems, magazine ads, television spots, social-media campaigns
and political campaigns in both parties, and it feeds illness-pushing stories
to overworked health reporters.
I know, because I have written a few
of them myself.
Private interests have merged with
the very organizations Mayo finds in its path to customers. The massive
Cleveland Clinic complex that has placed Mayo on its heels — it was going to be
called a “Medical Mart” until someone thought better of it — includes a
facility built by GE Heathcare, makers of our ubiquitous screening
technologies. But as Peter Gotzsche of the Nordic Cochrane Center has
demonstrated, 80 percent of Denmark has gone without mammograms for decades,
while 20 percent of the country has been screened regularly. This “makes for
the perfect control group,” he says, and when you compare the Danes who had
mammograms with those who did not, there is no difference in mortality. Both
groups experienced a drop in mortality around the introduction of drugs like
Tamoxifen, yet mammograms got all the credit. This is comparable to the way in
which device makers have taken credit for a drop in heart disease mortality
during a period in which millions of Americans quit smoking.
You don’t need to visit a specialist
— you can see the takeover
of medicine during an hour in the office of your primary care provider.
The creation of clinical practice
guidelines, directives conceived by doctors being paid by industry, has turned
family medicine away from listening to the experiences of patients and toward
the monitoring of blood markers denoting overblown risk factors for disease,
surrogates for illness that can then be controlled by expensive drugs. Some of
the most widely used drug treatments today serve the needs of the drug
industry, not patients. They lower cholesterol or blood sugar without reducing
the incidence of disease, and yet they are the sort of reasons we are so often
told to “Know Your Numbers.”
We cannot count on the medical literature to
clear up the problem.
Years of abuse have made it a repository of spin.
Clinical trials that used statistical slight of hand to make failed trials look
successful (see “Bad Pharma,” by Ben Goldacre). Review articles on new drugs or
illnesses written by drug industry ghostwriters, signed for pay by influential
doctors, then placed by professional publication planning agencies into
credulous journals in exchange for hefty reprint orders. Industry-funded
clinical trials of new drugs in which doctors never saw patient reports, only
summaries of data they were asked to trust.
And as government lawyers given
access to industry e-mails have learned, if a study still somehow failed to
show that a new drug is safe or indeed works, it was often either shelved, or
intentionally published in academic Siberia. In its own journal, Mayo Clinic
Proceedings, Mayo recently
published a proposed reform of these practices, but it was written by
representatives from the very ghostwriting and drug companies that created the
problem.
Disclosure of doctors’ conflicts was supposed to reform
the system, but since the new disclosure rules, something funny has happened:
Within medicine, long lists of side money have become a badge of honor.
As health policy expert Rosemary
Gibson argued last month at “Selling Sickness: People before Profits,” a global
meeting organized by Minneapolis health activist Kim Witczak, the problems in medicine today
share disturbing similarities with banking. Too big to fail. Inflated
salaries. Toxic assets, price bubbles, sophisticated products marketed to
unsophisticated buyers and subsidized profits followed by socialized losses.
The Mayo Clinic did surely not create
this environment, and when it comes to steering clear of unnecessary treatments
and resisting the influence of industry, it does many things better than most.
But Mayo is about to take a bold step forward within a system that has lost its
moorings.
Let’s hope that as it does so, it
seeks a way to reform, rather than simply prevail.
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