Follow the Money

“Follow the money” is a catch-phrase that people (including myself) often say, as they point out some problem that they perceive — “look to see who is benefiting monetarily.” And there is a certain element of truth to that — greed is a powerful force. People will do a lot of things for money. So it is wise to “follow the money” and make sure that the people who are selling something (literally or figuratively) have anything to gain by it.

A frequent accusation against people of one stripe or another (and probably both, if the truth were told!), is that the person can’t be believed, because he is making money off it. For example, scientists employed by Exxon or other gas companies are frequently disbelieved by the folks at Greenpeace, because of course the scientists would say that their company isn’t causing environmental problems, or else they’d lose their job! But then, what about scientists who are employed by environmentalist groups? — the same thing could be said about them! After all, if being “environmentally conscious” doesn’t actually do anything or help the environment, then why should they exist?

Then you’ve got the whole swine flu and Tamiflu stuff — H1N1 doesn’t seem to be as bad as was first believed — follow the money? where? The vaccine manufacturers, sure. The maker of Tamiflu, which may not be as good as it first appeared? Certainly. All this hype, lining the pockets of… but wait a minute. What if there had been no hype and no hysteria, and the disease really was as bad as was predicted, only nobody had talked about, it to avoid mass hysteria (sort of like not shouting “fire” in a crowded theater)? Then what? Conspiracy theory would fault… probably the same people, saying they wanted thousands of people dead, so that everyone else would line up for shots and drugs. Or blame the eeeevil government (here or there or somewhere else) for covering things up, to kill off the weak, who just end up costing the government money with food stamps and medical care, or cost all of society in larger medical bills. Or whatever.

It only takes a couple of facts to make a really good conspiracy theory. In fact, the most believable ones have the fewest facts… but the most suspicion. Facts are stubborn things, and can trip you up because they might be able to be disproven; suspicion is impossible or at least difficult to allay. It’s easy to start a rumor that somebody fathered a child with a mistress — but that can be proven or disproven with a paternity test. But did Lee Harvey Oswald act alone? Ah, the suspicions!

Recently, a scientific panel concluded that mammograms are not warranted until a woman turns 50, and then only every other year — that the risks of mammography (including radiation exposure, false positives, medical error, finding slow-growing cancers that would never cause any problems but treating them anyway, etc.) are not worth the benefit (the rare younger woman who would actually have cancer). Personally, I’m not a big fan of mammograms, and hope never to have one — perhaps the technology will improve to the point that mammography will become a relic of the past, by the time I turn 40 or 50. But I have a friend whose mother died of breast cancer, who, in her early or mid-30s gave herself a “birthday present” of a mammogram, and will probably have one every year or every other year for the rest of her life.

When the news hit that this panel had made this conclusion, I thought, “Good! Less radiation!” but then I started wondering if there might be some “dark side” to the recommendation (perhaps I have an unhealthy dose of skepticism??). On one forum (not birth-related) that I’m on, someone started off the conversation on this topic by saying that she had previously been against mammograms (mostly because of the radiation exposure, and being a pretty “natural living, whole foods” kind of person), but now that they were being recommended against, she was sure that there was something nefarious about it! She said that had this panel come out saying that “mammograms are bad and should be discontinued because they cause cancer,” then she would have supported it; but she didn’t like the reasoning they gave, so had some alternate explanation for it. I think she blamed insurance companies, because if mammograms are beneficial, they have to pay for it; but if they’re “not supported by the evidence” and “not necessary,” then that’s less money they have to pay out, and more money in their pockets. “Follow the money,” she said.

Only problem is, this works both ways! I bet she or somebody else had previously complained about mammograms being done for no good reason, and pointed at doctors who made money off of mammograms, saying, “Follow the money!” Who makes money by mammograms being standard? Presumably the doctors who order them, the technicians who perform them, the medical equipment companies who make the machines (and the X-ray films, and the developing machines, and whatever other paraphernalia that goes with them), and perhaps other people or companies as well. Who makes money by them not being used? Insurance companies spend less, but so do consumers (who don’t have a co-pay). What if, for the past decade or two, doctors have been colluding with scientists to fudge the data, to make it look like mammograms are beneficial, and, finally, the jig is up! Could be. Why not? Most doctors do what they learned in med school, and what they might occasionally read about in journals (assuming they read any), but mostly just do what everybody else is doing; and what everybody else is doing, is following “the guidelines” of recommending mammograms starting at 40. They may even have thought they were doing the right thing, but never critically examined the evidence (or, the evidence may have been false or misleading, or nonexistent), just doing what they were told to do, by those whom they trusted. Think it couldn’t happen? If not, how did episiotomies come to be seen as needful or at least beneficial 100% of the time? and pubic shaves? [However, as someone pointed out in one of the articles or blogs I read about this, even though the science does not support things like elective C-sections and inductions and other birth-related non-necessary things, insurance companies are still paying for them, so that doesn’t necessarily mean that insurance companies will stop paying for mammograms in younger women.]

A similar controversy arises over C-section rates. Some people claim that doctors like to perform C-sections because they can get done faster and make more money per birth, while others claim that a vaginal birth is really the quickest and easiest birth for doctors to attend. I can see it going both ways, and “the truth” may depend on the situation. If a doctor comes into a hospital and is with the woman 10 minutes before the baby is born, and his job is done in another 10 after the birth, then that is much less time than would be spent on a C-section, which takes about an hour, depending on circumstances. But, if the doctor is going to be interrupted at supper, or dragged out of bed in the middle of the night to attend a vaginal birth, he may very well spend more time driving back and forth to the hospital, and/or waiting for the mom to finish dilating or to push for a couple of hours than he would spend on a quick C-section. And he’d make more money since he used his surgical skills, rather than just receiving the baby in a vaginal birth. So, a doctor might have a reason other than a true medical reason, to speed up a birth or to call for a C-section — both in making more money, as well as in being able to go home and just relax.

“Follow the money” may have some truth in it. However, there are two very important caveats that immediately leap out at me. First, not everybody who stands to gain from something will do something wrong just because there is the possibility of money. True, “a bribe blinds the eyes of justice,” but there is a thing called integrity, which some people have. Let’s not be too quick to condemn our fellow man, just because he receives money. And usually, the person who creates something or provides a service actually benefits others. Plumbers and electricians come to mind. They could be crooked, but just because they stand to earn money by fixing your toilet or wiring your house doesn’t mean that they will sabotage their job, so that you’ll call them back. [And, actually, while you can make a quick buck by being crooked, you’ll also be quickly put out of business as word gets around that you can’t be trusted; the real way to get money is by being honest and trustworthy, so you get repeat business and referrals — that’s a steady income stream!] Also, many people do things out of charity, or altruism. Many people will provide a service for free, or at a reduced price, to those who cannot afford it. Or just because they’re nice. And this includes doctors. Don’t you sometimes do things without money, just because it’s the right thing to do? or just because it’s nice? Are you motivated solely by money? Would you do something you knew to be wrong, if someone offered you a few hundred dollars, or a few hundred thousand dollars?

What if I told you that the American Cancer Society, despite their high-sounding words about being “dedicated to eliminating cancer” was a bunch of hooey? What if I said that they had a vested interest in cancer being common and prevalent, because if cancer were actually defeated, then there would be no more reason for them to exist, and they’d be out of a job? What if instead of fighting cancer, they were actually dedicated to fighting alternative medicines or therapies that actually cured cancer?  Sound wacky? I’ve heard it! And who’s to say it’s wrong? After all — “follow the money”! The ACS gets a lot of money every year in donations, after all!

No, I don’t really think that the American Cancer Society is a corrupt organization. But based solely on “follow the money,” it could be! Based solely on “follow the money,” there is ample space for either proponents or detractors of annual mammograms to point fingers at the other side for being wrong. As well as global warming (there is a lot of money available for “going green,” — just ask Al Gore; but there is probably enough money for corruption on the “skeptic” side, as well). And just about everything else, as well. But just because there isn’t a lot of money doesn’t mean that a person or organization is right or not corrupt, either! After all, many panhandlers will take your money you give them for food and use it to buy liquor. A lot of people have a vested personal interest (monetary or not) in a particular ideal. I daresay that most of the people involved in Greenpeace or other environmental organizations do not make a lot of money from it, but they are as deeply committed to the environment and the ideals of the group as if they stood to earn millions from it. It doesn’t make them wrong; but it doesn’t necessarily mean that they’re right, just because they don’t make money from it.

Some people are just jerks who like to screw around with people — take the guys that are always introducing viruses and worms and trying to hack data. Some of the programs are done just for the heck of it. Sure, some of them are done to steal people’s financial information and to make/take money; but not all of them. Some people are just mean, and do it because they get a thrill out of screwing up people’s lives, or getting away with something, or just because they like to make a mess bogging down email servers. Childish. Low. But just because they don’t make a dime off of it, doesn’t mean they’re fine, upstanding citizens. Nor that just because Norton and McAfee make a lot of money on virus protection, that they’re somehow colluding with the hackers, to provide a reason for people to buy their product.

I’m sure “follow the money” is accurate some of the time. But not all of the time; so be careful what conspiracy theories you read about. Just because someone makes money doesn’t mean they’re unethical, any more than if someone does not make money, that he’s correct. Yes, money can be a very powerful draw; but sometimes, the money trail could be hidden (deliberately or accidentally), so just because you can’t see it, doesn’t mean it isn’t there. And it doesn’t always have to be “filthy lucre” — it could be power, prestige, or some less tangible asset. Accusations can be very powerful, though. And all the worse because often they can’t be disproven. How could you disprove the accusation that the American Cancer Society was actually happy that cancer kills thousands of Americans per year, because that meant that more money would likely be given to them? You couldn’t. So, be careful. Just be careful.

8 Responses

  1. Great essay…I enjoyed reading it. You make excellent points. I often get frustrated by the “damned if you do, damned if you don’t” dilemma. This subject can be applied to counseling women…I advised a woman that she might not be a good candidate for a VBA2C (I didn’t say that she couldn’t have one, just that she might not have a very good chance of being successful), when she clearly felt that there weren’t any problems. But I didn’t want her to think we were pulling a bait and switch on her, at the end of the pregnancy. She told the next midwife she saw I was full of gloom and doom. But had no one said anything and she got to the end of the pregnancy to be told it wasn’t gonna happen….would she have been crying that someone should have told her sooner? This doesn’t really follow the money thing but still very similar.

    • Yeah, it’s a tough line to follow — trying to be realistic w/o being too negative; trying to tell of the (negative) possibilities w/ “pulling the dead baby card”; trying to be honest w/o overwhelming the listener with *all* the possibilities, no matter how remote.

  2. It’s a fallacy to believe that physicians earn more money from c-sections versus vaginal births. They receive a global fee for prenatal care and delivery – one fee only. The same fee, whether it’s 1 prenatal visit and a c-section, or 17 prenatal visits and a 24 hr labor and vaginal birth. Same exact fee.

    However, there is a definitely true statement about the amount of time and physician (im)patience in waiting for labor to complete itself. I know several physicians who want to be home in time for dinner, and will do a c-section for a bogus reason so they can get out of the hospital.

    • I’ve wondered about that — what difference in payment (if any) a physician receives for a C-section. I remember in the past few months or so reading that the state of Oregon (?) is changing its Medicaid reimbursement, so that doctors will receive the same remuneration regardless of whether the birth was vaginal or Cesarean. Perhaps it’s different, depending on the state and/or type of insurance?

      My former CPM’s backup doctor has stopped taking insurance entirely because it’s too much hassle, and just has a set fee of $2500 for attending a vaginal birth and $3000 for a C-section (I’m assuming the prenatals are included as well?). Of course, as a cash-pay only, he doesn’t have to deal with any rules or regulations by insurance or Medicaid.

  3. To comment on what atyourcervix said. I think its probably the HOSPITAL itself that makes all the extra money at a c-section. When I was looking at hospital birth costs with my first baby (ended up at home) in Oregon there was a huge difference in fees, 7000 or so for a vaginal birth, upwards of 32000 for an ‘uncomplicated’ c-section. And that’s just the hospital’s fee, it didn’t include any of the doctor’s fees or anethesologist fees. I think, realistically, a lot of the time when we say ‘doctor’s push’ or ‘doctor’s benefit’ we aren’t actually talking about an individual doctor, we’re talking about the hospital. I’m trying to be more aware of this in my own conversations and ‘blame’ the hospital instead of the doctor when I am talking about things that aren’t really individual doctor’s fault or choice.

    • Re: difference in hospital fees — that’s true — there’s a chart I have somewhere (from Childbirth Connection?) that shows the “average” cost of birth, for birth centers, as well as (un)complicated vag or C/s hospital births. Uncomplicated vaginal births cost an avg of $7000 while a complicated C/s cost an average of $15000; but that wasn’t broken down to show *why* the difference — more nurses? more drugs? longer recovery? One of my friends’ C-sections cost $25,000, and she didn’t even stay a full 48 hours!

      Of course, if these procedures actually *cost* the hospital that much, then their profit margin may be no different for a vaginal birth or a C-section — it only becomes a money-maker if hospitals can charge more and earn a higher profit.

      This is sort of why I’ve tried to stay out of this topic — I just don’t know all the answers (and it may vary, depending on the hospital, state, or locality). I’ve heard both that maternity wards are money-makers for hospitals, and also that they are “loss leaders” for hospitals — that they actually lose money on maternity services, but that they keep them open so that families will choose the same hospital for other medical needs — needs that *are* money-makers. {Shrug} I don’t know which is right. Of course, both may be right, depending on the area — for example, hospitals that have a lot of low-reimbursement Medicaid/insurance clients may lose money, while hospitals that have a higher percentage of better-paying insurance may make money.

  4. Mammograms are very dangerous and not only the ionizing radation harmful , but the compressions as well. No age is a good age for a Mammogram. They should classify them along with sexual assault against women.

  5. My mom was diagnosed with a very aggressive form of breast cancer when she was 42. She didn’t have a mammogram; she felt a lump. She finally had it biopsied and that is when we found out it was cancer. I haven’t really done my homework on mammograms as I’m in my mid-20’s and never really thought about it. I think self exams and getting exams by a medical professional are one way to prevention. Perhaps some new, safer technology will arise to help in the early detection of breast cancer.

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