Market forces in urological practice.

Market forces could be made strong enough to produce efficient healthcare systems, but it would take large changes.

Medical profession is confronted by unprecedented challenges posed by the explosion of technology, making it difficult for medical professionalism to survive in the current commercialized health-care market. The increasing international drive for the privatization of health care and continued prevalence and effective intrusion of market forces in financing and delivering health care, in addition to bankrupting the health-care system, will also inevitably undermine the ethical foundations of medical practice and dissolve the moral precepts that have historically defined this profession. Hence, reaffirming the fundamental and universal principles and values of medical professionalism which remain ideals to be pursued by physicians to preserve the integrity and values of the medical profession becomes the need of the hour. The physicians who care about these values must support major reform of both the insurance and delivery sides of the health-care system. This article is based on the Sitaraman Best Essay award of the Urological Society of India for the year 2015.

FIVE BASIC FORCES OF COMPETITION

To understand the influence of market forces in urological practice, it is essential to clearly understand the functioning of the health-care industry. “Five basic forces of competition” described by Michael Porter of the Harvard School of Business determine an industry's long-term attractiveness; present competitors, potential competitors, bargaining powers of suppliers and buyers, and threat due to substitute products.[2] Key forces in health care include rivalry among competitors (community hospitals, tertiary care hospitals, research institutes, surgical centers, and private practitioners) and bargaining power of suppliers (shortage of health-care workers) and buyers (patients). Needs-based projections, demand-needs based projections and benchmarked projections are important issues to be addressed.[3]

RIVALRY AMONG COMPETITORS

Market forces make medical care better, cheaper, and safer through rigorous competition among various medical facilities. State laws requiring government approval of new medical facilities are leading barriers to their competition. In urological practice, the demand for surgeons and hospitals treating urological diseases is forever escalating.

During the initial periods of their growth, time and competition will force practitioners to compete on the basis of price, unless they find a true competitive advantage. The next step would be value innovation defined as a means of creating new marketing space by looking across the conventionally defined boundaries of business and focusing on delivering superior value to the customer.[2] Thus, as health-care market for urological services becomes overloaded, profitable growth might not be sustainable without developing a clear differential advantage in the market which can be made possible only by value innovation. Hence, larger, security guarantee, horizontally integrated and decidedly interconnected, public hospitals in the settings of condensed, high “public payer” presence, competitive, and resource-rich environments will more likely engage in patient safety innovations.[4]

In response to legislative changes impacting management and financial performance of urology group practices, many urologists have adopted consolidation strategies through the formation of larger integrated entities to maintain their viability.[5] Research has shown urology groups to have demonstrated success with outstanding physician leaders who recognize the importance of creating a common culture built around a strong mission, vision, and set of values.[5]

BARGAINING POWER OF SUPPLIERS

Due to the increasing patients and limited availability of urologists, there is a urology workforce shortage in urological practices, especially in developing and populous countries like India. McCullough, based on US demographics, foresaw that the number of urologists in practice in 2020 may not be adequate to cater to the needs of the patient population.[3]

To achieve the strategy of using fewer inputs to achieve greater health outputs, less-trained clinicians (nurse practitioners and physician assistants) can be incorporated in the health-care team to perform tasks once performed only by highly trained physicians. They allow the surgeon to focus on more difficult problems and provide increased personalized attention to patients.[6]

BARGAINING POWERS OF BUYERS

Physicians must respect patient autonomy, must be honest with patients, and empower them to make informed decisions about their treatment.[7] As long as consumers do not really feel the pinch of the cost of medical services, they remain indifferent to questions of what amounts to necessary, appropriate, or cost-effective care.

THREAT DUE TO SUBSTITUTES

Medical management plays a significant role in urology. Alternative forms of medicine such as Ayurveda and Homeopathy are used in some chronic diseases such as interstitial cystitis, chronic prostatitis, and phytotherapy in benign prostatic hyperplasia. This is not a threat in the real sense and can be beneficial.

MARKET FACTORS IMPACTING COST OF HEALTH CARE

Various cost-control strategies in market economies have not been successful owing to the nature of the market system that encouraged the transformation of physicians into a class of manager-physician entrepreneurs. Studies have shown that more specialists in the medical market would result in a risk of overtreatment, especially in people with higher income as they have greater access to medical care and end up more likely to undergo invasive procedures. Some studies have demonstrated a direct correlation between income and rates of surgical procedures in the US medical market.[8]

Since urology is primarily an elective service, the cost of freedom (uncompensated emergency services) is small when compared to other outpatient and elective care-oriented specialties.[9] Another factor influencing cost of health care is dual job holding by public sector health professionals resulting in misappropriation of scarce public sector resources into the private sector. This can also result in doctors diverting patients from public facilities into private services.[10]

INFLUENCE OF MARKET FORCES IN EDUCATION AND RESEARCH

Current health-care delivery and finance systems are threatening Medical Education and Research. The growing influence of the pharmaceutical industry on the practice of medicine is a major de-professionalizing force. As long as the predominant vision of medical educators is acquiescence to market forces instead of resistance and constructive change, market medicine will thrive, to the detriment of doctors and patients alike, and medicine, as a profession, will suffer, along with the simultaneous erosion of the doctor–patient relationship. Hence, academic institutions, supported by public policies, are required to lead the way.[111213]

INFLUENCE OF MARKET FORCES IN DECISION-MAKING

Identification, grading, and use of the best evidence have moved to the forefront of clinical decision-making and have become a priority not only for physicians but also for patients, private and public payers, and entities involved in providing credentials and the development of performance measures. However, making health-care treatment decisions is a complex process involving a broad stakeholder base including patients, their families, health-care professionals, practice guideline developers, and funders of health care.

CONCLUSION

Medical practice is now widely viewed as a demanding and technical affair requiring considerable, credentialed education, and enormous personal responsibilities but a business nonetheless. This change in attitude has substantial consequences as the fundamental ethos of medical practice contrasts sharply with that of natural commerce, and marketing principles cease to apply to the relationship between the physician and patient. The physician–patient relationship should not be compromised by market forces, social pressures, and administrative crossroads. To maintain the fidelity of medicine's social contract during this turbulent time, physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health-care system for the welfare of society.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.