Cancer, Radiation Therapy, and the Market

Barbara Bridgman Perkins

• Publisher: Routledge
• Year: 2017
• Print ISBN:
  9781138285248
• eBook ISBN:
  9781351978125
• Topic: History
• Subtopic: Social History
• Index: History

Appraising cancer as a major medical market in the 2010s, Wall Street investors placed their bets on single-technology treatment facilities costing $100-$300 million each. Critics inside medicine called the widely-publicized proton-center boom "crazy medicine and unsustainable public policy." There was no valid evidence, they claimed, that proton beams were more effective than less costly alternatives. But developers expected insurance to cover their centers' staggeringly high costs and debts. Was speculation like this new to health care?

Cancer, Radiation Therapy, and the Market shows how the radiation therapy specialty in the United States (later called radiation oncology) coevolved with its device industry throughout the twentieth-century. Academic engineers and physicians acquired financing to develop increasingly powerful radiation devices, initiated companies to manufacture the devices competitively, and designed hospital and freestanding procedure units to utilize them. In the process, they incorporated market strategies into medical organization and practice. Although palliative benefits and striking tumor reductions fueled hopes of curing cancer, scientific research all too often found serious patient harm and disappointing beneficial impact on cancer survival. This thoroughly documented and provocative inquiry concludes that public health policy needs to re-evaluate market-driven high-tech medicine and build evidence-based health care systems.

1Medical Care as Trade

Management consultants and business school professors advised American doctors, hospital administrators, and health care entrepreneurs in the late 20th century to make medical services more like Jiffy Lube® stations.¹ Patients also noted a resemblance; a breast cancer patient undergoing surgery, radiation, and chemotherapy blogged that she felt “like a car going thru Jiffy Lube.”² The consultants may have noticed that services specializing in clinical procedures like MRI scanning, kidney dialysis, colonoscopy, keratoplasty, cardiac catheterization, and radiation therapy had already applied market strategies to medical delivery. It would have been hard to miss the massive advertising.

Drive down a city street, open a newspaper, turn on the television, or go on the Internet, and you will be hit with a barrage of advertisements for doctors, drugs, and devices. Radiation therapy ads proclaim that their devices and treatment methods destroy tumors faster and protect surrounding tissues from radiation damage better than those of their competitors.³ One company exorbitantly claimed that patients receiving its new method of applying radiation became “cancer free in less than 3 hours.”⁴ Advertising like this misleads people with deceptive claims of treatment effectiveness. A Utah billboard featuring a brand-name device at a nearby hospital claimed “superior results” due to “superior technology.”⁵ What are the superior results, you might somewhat skeptically ask? But hospital ads are not legally required to base their claims on evidence.⁶ Although the ads reinforce popular (and professional) beliefs that there is scientific evidence demonstrating that the latest, most powerful (and most costly) treatments are the safest and most effective, it is not necessarily the case—as this book will show.

The New York Times Magazine provides a prominent platform for advertising medical services to the same market as its ads for diamond necklaces and wealth management. Many of its specialty service ads display the US News and World Report’s “best hospital” logo like a Good Housekeeping seal of approval. The Report’s major criterion for determining “best” cancer services—accounting for one-third of the total score—is reputation among its specialists (as conducted in a mail survey with a 37 percent response rate).⁷ Availability of the latest technology is another criterion (not unrelated to reputation). Patient survival is taken into account, but only survival for 30 days after hospital admission, which primarily means survival of the hospital experience itself—not an insignificant measure, to be sure. Some hospitals receiving the highest rating in every non-reputation factor still received low rankings. “Best hospital,” it seems, circularly identifies prestigious specialty services as best because they are prestigious. Prestige is the product being sold, and it trumps scientific evidence. “Best” hospitals are also profitable.

Markets and the Medical Business System

Business strategies and their market theories have infused their values into every sphere of society, permeating institutions and professions ostensibly dedicated to service. The recent advertisements are just the latest manifestations of a long history of medical marketing, much of which came out of the pharmaceutical industry and patent medicines before that.⁸ Earlier radiation therapy promotions included newspaper and magazine stories purporting the mysterious healing powers of radiation⁹ and went on to feature movie stars publicizing the latest treatment device (Figure 5.1). The ads reveal the extent to which medical services are commodities for sale in the market.

Medical delivery has long been a market in which buyers with financial means purchase services that sellers choose to offer.¹⁰ The 19th century was noted for its “free trade in doctoring,” as historian Nancy Tomes observed.¹¹ At the turn of the 20th century, leaders sought to disassociate medical care from its commercial image and identify it as a science-driven profession dedicated to helping people. Elite American doctors’ travel to Europe to learn precepts of experimental science changed medical diagnostics.¹² Treatment in many areas, however, remained based on trial-and-error experience (which the medical profession confusingly calls empirical). The professionalization project supplemented more than it substituted for medicine’s commercial heritage. Medical leaders persuaded states to establish licensing laws that conferred monopoly status on graduates of schools that taught the new medical sciences. Monopoly strategy was intrinsic to the concept of profession. The claim that medicine rose above commerce, as economist Kenneth Arrow later noted, was itself part of professional marketing.¹³

My identification of 20th-century medicine as market driven contributes to a minority, but growing, view within the history of medical care and policy. In The Medical Delivery Business, I showed how evolving business environments shaped the specialties and practices of obstetrics and neonatology. James Schafer’s Business of Private Medical Practice mapped how market forces shaped the distribution of private specialists’ offices.¹⁴ Joseph Gabriel in Medical Monopoly called the development of American medicine in the early 1900s “part of the broader story of the rise of corporate capitalism.”¹⁵ Cancer, Radiation Therapy, and the Market shows how market strategies and interests shaped the development of American radiation therapy. The processes of specialization and professionalization embedded the economy into medical care as well as medical care into the economy.

This view means that the medical profession did not suddenly undergo an economic transformation in the 1970s, as many (pro and con) analysts saw it; it had emulated contemporary economic environments all along.¹⁶ But the profession had succeeded so well in convincing scholars, the public, and itself of its scientific and altruistic nature that rulings in the mid-1970s came as a shock. The US Federal Trade Commission (FTC) and Supreme Court used antitrust law to open up the medical market by once again defining medical care as trade.¹⁷ Prohibiting medical association restrictions against overt advertising, patient solicitation, and contract practice, the antitrust rulings (selectively) applied market rules to medical care. The rulings reinforced the development of medical care as business by treating it as such.

Medical discourse, however, did distinctly change in the 1970s. Some medical leaders celebrated the newly respectable precepts of self-interest, pronouncing that “the market has spoken,”¹⁸ even when it led to inequities and overtreatment. Others vigorously denounced greedy doctors. A 2013 New York Times opinion piece, signed by 22 medical and policy leaders, accused oncologists of using the latest drugs and radiation devices on their cancer patients—despite recognizing that cheaper alternatives led to equivalent results—because they made more money in the fee-for-service insurance payment system.¹⁹ The Wall Street Journal disclosed the following year that cancer specialists in radio- and chemotherapy were among the top beneficiaries of Medicare payments.²⁰

My analysis of the development of medicine as business does not necessarily imply that money drives individual physician decision-making. Like all population groups, doctors represent a broad spectrum of humanity. Paul Kalanithi, dying of lung cancer in his mid-thirties, wrote that he had chosen medicine as a link to human suffering and as a means of probing the meaning of life in the face of death.²¹ While greed has shaped medicine as much as other fields of work (contrary to professional theory), the individual incentive argument is simplistic and conceals a more profound reality.

It is the medical business system, which combines doctors and hospitals with manufacturers and Wall Street financial firms, that is greedy. My use of this term extends a (by now) conventional understanding of medical industrial complex²² to mean not just linkages between industry and medical care but also integrating industrial elements into the structure of medical care. The medical business system designs high-priced products and services for the market. It has made cancer a commercial product line that seeks to maximize productivity, profits, prestige, and market power. A high-tech hospital cancer unit advertisement, which popped up on my computer beside the online version of the Times’ opinion piece mentioned above, revealed the pervasiveness of the medical business system. (It also vied with the message of the piece.) In exploiting the public’s all-too-real fears of cancer, competitive growth of such specialty units multiplies remunerative entities needlessly and inflates medical costs with little gain in terms of people’s health. This system has been evolving for a long time and has shaped medical practice for over a century.

The timing question depends largely on definition. In The Social Transformation of American Medicine, Paul Starr influentially dated the “making of a vast industry” from the mid-1960s by arguing that corporate forms of medical care started to supplant professional sovereignty around that time.²³ Despite fond memories (which I share) of family doctors making house calls, Cancer, Radiation Therapy, and the Market argues for an older business development of medicine by identifying different economic features. Throughout the 20th century, medical specialties divvied up markets and wove features of industry, commerce, and finance into medical care organization and practice.

Just as investigators have struggled with (or avoided) naming the contemporary economic system, no adequate label exists to describe medicine’s economic development. Its components encompass industrial divisions of labor in hierarchically managed institutions and technology-based production units that maximize productivity.²⁴ It employs strategies of business in valuing everything in monetary terms, producing for the market, seeking economies of scale and scope, and integrating institutions vertically and/ or horizontally.²⁵ It becomes capitalist or corporate by privatizing services, building complex delivery systems, prioritizing profits, and importing “forms of organization, governance, finance, compensation, and marketing from the larger corporate sector into medicine.”²⁶ To further obfuscate the issue, the term market may be applied to any or all of these economic strategies. Also overlapping with these terms, neoliberal theory prioritizes private property, promotes corporate roles, rejects government regulation (selectively), and holds that there is no alternative to a market economy.²⁷ While recognizing that the theoretical ideal market does not exist, I use the broad definitions of market and business when describing the incorporation of the economic elements identified above into medical care and particularly into medical specialties.²⁸

Medical Specialties and High-Cost Procedure Units

As the fundamental structure of 20th-century medical care, specialties contributed a great deal to its scientific progress. At the same time, they were products of the economies of their times. Specialties carved out the more lucrative portions of the medical market early in the century as they targeted selected technologies, organs, diseases, and populations. Although growth in scientific knowledge calls for (and is a product of) subdivision, the logic of modern specialty organization does not derive principally from medical science; it derives from medicine’s economic development. Physician–historian George Rosen held in 1944 that specialization resulted “at least as much” from economic and social factors as from scientific ones.²⁹ “Science and technology are not independent constructs that ‘cause’ scientific subdivision,” noted specialization scholar Rosemary Stevens, “rather they are embedded in a social process that may be driven by multiple personal, economic, and organizational agendas.”³⁰ In the monopolization process called professionalization, specialties actively controlled entry into their fields, standardized knowledge and production, produced distinctive products, enhanced demand, and eliminated competing products.³¹

Specialization commodified medical interventions by turning them into discrete, marketable surgical and technological procedures—although that was not necessarily leaders’ conscious intent. Many specialists and hospital administrators instead assumed that market strategies would enhance medical care’s efficiency and productivity without significantly altering its practices. Intertwined with specialty development, capital investment (including foundation funding) fueled consolidation of medical institutions creating large (academic) medical centers. Specialty services in these centers packaged clinical procedures in revenue-generating units. Becoming profit centers or strategic business units, specialty procedure units became the hub of hospital care, as later exemplified by the “best hospital” ads. Fee-for-service payment systems fueled their growth by itemizing charges for each procedure.

Inspired in part by American examples, specialized clinics in British teaching hospitals underwent similar development. Historian Roger Cooter described orthopedic surgeons’ fracture clinics between World Wars I and II not so much in terms of technology development and diffusion but in terms of the application of scientific management and efficient production techniques to medical care organization. The new clinic was “essentially a political innovation with significant implications for the distribution of power and authority in medicine.”³² Swiss hospitals around the same time also applied business strategies in organizing “rationalized X-ray institutes that operated according to a hierarchic structured division of labor.”³³

Enterprising physicians, managers, and investors in America later carved out procedure units as freestanding retail outlets like Jiffy Lube stations, as cartooned in Figure 1.1, often locating the units in shopping malls and industrial parks. Freestanding procedure units also resulted from private-practice growth as single-specialty medical groups purchased more and more equipment for their office-based practices. Specialty procedure units eventually grew into high-cost cancer centers and proton treatment facilities across America and Europe.

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Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Contents
• List of Figures
• 1 Medical Care as Trade
• PART I: Radiation Enterprise, 1895 to World War II
• PART II: Competitive Megavoltage, World War II to the 1970s
• PART III: Financializing Medicine, 1970s to the 2010s
• Acknowledgments
• Selected Bibliography
• Index