Profession / Community vs Market perspectives

Belief is the lifeblood of political success and for social change but the ideologies that are blindly believed can be the cause of misery and mistakes that harm millions. Ideologies can divide nations and cause populations to split around issues.

When a culturopathy exists, the divides become greater and the struggle of those who are adversely affected more difficult and more traumatic. Because the beliefs in a culturopathy are blind and are not subject to evidence or logic, the issues are rarely resolved amicably and sensibly when a culturopathy is present.

I am going to give a few recent examples of this starting globally then locally.

In Health Care

As Oliver Wendell Holmes, a US doctor, indicated in 1861 the medical profession (and by implication other groups that have traditional ethical structures that are considered essential for their operation) are a part of society.  They are influenced by the patterns of thinking accepted by large sections of the broader community, of which they are a part.

So in any culturopathy, there will be a divide within professions where a smaller or larger proportion of the profession will join in the culturopathic thinking while others will oppose it. Medical ethics can be seriously breached and citizens harmed.

Dominant beliefs caused unethical behaviour among sections of the medical profession in Hitler's Germany, in Stalin's Russia and under apartheid in South Africa.  Others resisted and criticised.

Free markets in Australian health care

The imposition of economic rationalist thinking and free markets on health care has caused divisions in the USA and in Australia. Doctors have been among the founders and strongest exponents of corporate medicine in Australia. But the bulk of the profession have been opposed to this resulting in a divide within the profession, particularly during the Howard years, with the government backing and supporting the corporations and imposing its "reforms" against strong professional opposition.

Elsewhere on this website, I have described the standoff between the Howard government and the medical profession in 1998 in regard to managed care style contracts which would have allowed the corporate sector to control the profession. 

On other pages, I have described governments support of Mayne Health and Mayne's demise when the doctors walked away because of practices they saw as unethical.  There was so much animosity between the government and the medical profession because of the professions opposition to the government's marketplace policies, that the minister of health and the AMA president exchanged threatening lawsuits.

Divisions within the medical profession about markets

Doctors themselves have been among those who have adopted and strongly supported corporatisation.  Many of the entrepreneurs in the sector have been doctors and some like Primary Healthcare's founder have been very critical of the AMA and clashed with it.  Others have included McGoldrick and Edelsten, and Wenkart.  Barry Catchlove from Mayne Health was closely involved with the Minister for Health, Michael Wooldridge, also a doctor, in his attempt to introduce managed care and so give the market control over doctors in Australia in 1998.

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In Aged Care in Australia

A. Seniors organisations differ on aged care

Once again there is a division in perceptions, which is well illustrated in the community by the bitterness existing between the National Aged Care Alliance and its consumer members, who are driving government marketplace policies, and other seniors groups that are very strongly opposed to the way things are being done.  I will deal with this elsewhere.

B. Markets in aged care: Different views in the community, the government, and a group within physiotherapy

A particularly interesting example is the way the provision of physiotherapy services to the aged paid for by government, were understood and the way the different perceptions played out. Two professions, nurses and physiotherapists were involved, as was government and the media.

Some professional physiotherapy providers, who were strongly business focussed, had a very different idea of what was acceptable conduct in the sector when contrasted with the nurses who worked for government in overseeing the funding of aged care. As I interpret it, the businesses took a far more liberal approach to how they were entitled to run their business with a greater focus on what they could legally do to make money - much like any other business. The nurses were horrified and described what they were seeing as "treating the residents like a cash cow" and "rorting" the system.

The nurses' health department managers saw this as a legitimate business decision, did not see it the way the nurses did, and did not support them. The nurses were told to look the other way.  It was not their money. The nurses blew the whistle and spoke to the ABC.

The ABC reporters saw it like the nurses and as many in the community might have done. The program on ABC 7.30 on 16 August 2012, showed worrying advertisements by the physiotherapy business. These were directed to advising providers on their potential use of physiotherapy services. Other participants to the program included the minister and a representative from National Seniors.

Voiceovers of advertisements

"Find the hidden goldmines in your site. You'll be surprised at how many overlooked residents you could get from $100 to $160 or more."

(Company) Consultants help to find one of our clients over $1 million in funding..."

Source: Funding feeds profits over aged care - ABC 7.30 Report, 16 Aug 2012

The nurses interviewed claimed that false claims were being made and the system was being rorted. The physiotherapy business took exception to what was said and apparently supported by some providers, took legal action forcing the ABC to remove some sections from the transcript but enough remains to show the very different points of view.

It is possible that the activities the nurses complained of may have been legal.  Government took no action to investigate further. The full transcript at the link above illustrates the different ways in which different groups in society consider that the business of health and aged care can be legitimately conducted in Australia.

In February 2013, a Senate Committee quizzed the department about the allegations made and why no investigation had been carried out. The department described what the nurses called rorting  as "incorrect claiming" and did not indicate whether it was legal or illegal.  They indicated that they were concentrating on an educational program to address the problem:

Mr Coburn: - - - - the rates of incorrect claiming have remained high and, in fact, have edged up from around about 16 per cent when the review program started to around about 18 per cent on average for the last year and a half.
- - - - - - (they are) offering workshops for providers and their staff who make claims and working with the industry - - -

Source: Senate Community Affairs Legislation Committee Estimates - Wed 13 Feb, 2013

The Community Aged Care Hub

If the proposed hub had been in place, it would probably have avoided all this. Because of its work in the nursing homes and community, it would be well aware of what was happening and how businesses were operating. It would be working with all providers.

If it felt that the business was not serving the community as it believed was appropriate, it would use the normal social control pressures in communities as well as its power as a normal customer to get the sort of services it wanted in the way it felt was appropriate. The situation described here would hopefully not arise.

Prior to 1997, the professional associations including the Physiotherapy Association were able to set professional standards in regard to advertising and enforce these through the professional regulatory bodies. The advertisements shown would have been unacceptable professional conduct.  Professional restrictions on legitimate (read legal) business practices were made illegal by the Howard government in the late 1990s as these were considered to be obstructions to legitimate business activities and as anti-competitive.  If the proposed hub were in place these citizens might have something to say about conduct and advertisements in the sector that it thought were inappropriate.

Physiotherapy reports

Another example also illustrates the rather different approaches adopted to government funding policies by the physiotherapy association when contrasted to that by some physiotherapy businesses.

The Australian Physiotherapy Association did a survey of its members to ask what the impact of the ACFI (Aged Care Funding Instrument) had been. The findings were very critical of the outcomes as they were inappropriate for the sector.  They commented about the system encouraging rorts.


Respondents have identified the current funding model is prescriptive, rigid and not based on clinical assessment, need, or best practice.

The ACFI creates financial incentives to treat residents, which encourage rorts and over-servicing. It also channels funding to passive treatments to manage pain rather than evidence-based, active treatments and causes resident dependence, rather than developing independence and function and the quality of residents' life.

Source: ACFI Survey - Australian Physiotherapy Association, 2014

At the same time, the physiotherapy business involved in the ABC program did its own "Report into the Impact of ACFI on Resident Care 2014".

This quotes other physiotherapists and reaches a very different understanding about the ACFI Funding Instrument finding it beneficial.

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But these are only small red flags to corporate practices

Professional and civil values

In some of these situations these practices were introduced into sectors where professions have retained enough power to resist . The behaviour described on this page which most of us would hopefully see as undesirable and inappropriate, is only readily apparent because the nurses, the physiotherapists and even the ABC journalists come from and view this from within a culture that has values that see this as undesirable and to be exposed and stigmatised as unacceptable. It was a culture invading their space. This is also the culture of much of our civil society, a civil society whose values are under pressure.

Free market culture will exploit any weakness

But there is another culture that sees this sort of behaviour as quite normal and fully justified and that is the corporate world that our government supports and sees as the future for human services including aged care. As revealed in the example here the government was not unduly disturbed by this and was unwilling to stigmatise it. There is no one to constrain it.

On the web page Consequences of marketplace thinking I describe exactly this culture and this conduct in large health and aged care businesses in the USA and in Australia. They exploit the funding system in every way they can. It is normal behaviour for them and this is how they think. Self interest or loyalty to a corporation and its shareholders overrides our values.

As a consequence members living in this culture take advantage of any weakness in the system and exploit it to improve their profit - and in health and aged care the weaknesses are not just the funding system. Both the customer and the staff are vulnerable. Because civil society is not directly involved and lacks power this thinking and this culture are not challenged or stigmatised and the conduct is not challenged.

Addressing the problem of free market culture

If civil society and not the market is to decide on the sort of society we are going to be then civil society has to become involved and insist that the market behaves the way it expects it to do. The proposed Community Aged Care Hub would be the first step on that path in aged care.

We can do what the medical profession did in aged care and block conduct that is not socially responsible.  But we can go further. We can elect governments that will work with us in ensuring that the market behaves in a socially responsible way.

Please note: The first four sections of Aged Care Analysis are published and the remaining sections will be made available as soon as possible.

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