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.
Paul John Scott is a writer in Rochester.