THE CORPORATE GREED OF THE AMERICAN HEALTHCARE SYSTEM DEVASTATING PATIENT CARE: A CASE STUDY OF MULTI-FACILITY AND PHYSICIAN FAILURE WHICH SUGGESTS AN IMPERATIVE NEED FOR HEALTHCARE REFORM By Ashley Broughton A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah December 15, 2023 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY ii THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Ashley Broughton This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Robert Walker, PhD Chair, School of Radiologic Sciences ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________ Dr. Tanya Nolan, EdD Director of MSRS ______________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY iii Abstract This study explored the multifaceted shortcomings of the American healthcare system and their effects on healthcare providers and the quality of care delivered to patients. The American healthcare system is fragmented, with corporate greed prioritizing funds for top executives, while hospitals and providers struggle to obtain adequate reimbursements for their services. The literature review emphasized that in a system lacking equal reimbursements, there is also a lack of proper support and resources. These fundamental deficiencies create an environment where healthcare providers lack the necessary focus to make informed and responsible decisions, resulting in delayed diagnoses, medical errors, and diminished quality of care. To establish a foundation for the case study review, the clinical background of breast cancer etiology, epidemiology, pathophysiology, and treatment options were explored. Case studies involving four female patients who presented to an outpatient radiology facility between March 2021 and July 2021 with late-stage, metastatic breast cancer and exhibited extensive malignant breast disease with highly cutaneous and necrotic presentations were then analyzed. The aim of the qualitative analysis of the literature review themes and case studies was to determine whether a correlation between the fragmented American healthcare system and its various shortcomings could be considered as causal factors contributing to diagnostic errors observed in the case study subjects. Spearman’s rank correlation, a non-parametric statistical test, was utilized and results indicated a significant correlation between the various factors; however, it is important to note that correlation does not necessarily imply causation since these results were interpreted specifically in the context of the case studies, which also involved external factors to some degree. The study revealed a critical CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY iv link between the American healthcare system and its failures, which have given rise to a climate plagued by burnout, lack of support, and limited resources. This ultimately contributes to medical and diagnostic mistakes, leading to decreased quality of care. As such, complete healthcare system reform is deemed the only viable option to improve a patchwork system that is mostly driven by corporate greed. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY v Acknowledgements I would like to express my sincere appreciation to the following individuals and organizations, without whom this research would not have been possible: 1. Dr. Laurie Coburn - for her invaluable guidance, support, and encouragement throughout the entire research process. 2. Christopher Steelman - for providing insightful feedback and valuable suggestions that significantly improved the quality of this work. 3. Southtowns Radiology - for generously providing a conducive research environment and granting access to patient files. 4. My family and friends - for their unwavering belief in me and their continuous support throughout this challenging journey. 5. Colleagues and classmates - for creating a motivating academic environment, engaging discussions, and encouragement in sharing ideas and knowledge. I would also like to express my gratitude to Weber State University for its support and the resources made available for this research. Thank you for being part of this journey and for contributing to the successful completion of this thesis, which marks the culmination of my pursuit of a Master of Science degree in Radiologic Sciences. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY vi Table of Contents Chapter 1: Introduction ....................................................................................................1 Background ...............................................................................................................2 Statement of the Problem ...........................................................................................5 Significance of the Problem .......................................................................................6 Purpose of the Study ..................................................................................................7 Research Questions ....................................................................................................8 Nature of the Study ....................................................................................................9 Limitations and Delimitations .................................................................................. 11 Significance of the Study ......................................................................................... 11 Definition of Key Terms .......................................................................................... 13 Summary ................................................................................................................. 15 Chapter 2: Clinical Background ..................................................................................... 17 Introduction ............................................................................................................. 17 Etiology ................................................................................................................... 18 Epidemiology .......................................................................................................... 19 Pathophysiology ...................................................................................................... 22 History and Physical ................................................................................................ 23 Evaluation ............................................................................................................... 25 Treatment/Management Options .............................................................................. 26 Complications .......................................................................................................... 30 Summary ................................................................................................................. 31 Chapter 3: Literature Reviews ....................................................................................... 33 Documentation ........................................................................................................ 33 Introduction ............................................................................................................. 33 General Literature Review ....................................................................................... 34 Impact of Burnout on Healthcare Professionals ........................................................ 37 Challenges in Healthcare Infrastructure.................................................................... 38 Financial Stress and Reimbursement Models ........................................................... 39 Need for Healthcare System Reform ........................................................................ 41 Patient-Centered System Challenges ........................................................................ 42 Summary ................................................................................................................. 44 Chapter 4: Case Studies ................................................................................................. 46 Case Study: Patient 1 ............................................................................................... 46 Case Study: Patient 2 ............................................................................................... 51 Case Study: Patient 3 ............................................................................................... 54 Case Study: Patient 4 ............................................................................................... 58 Summary ................................................................................................................. 61 Chapter 5: Research Method .......................................................................................... 63 Introduction ............................................................................................................. 63 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY vii Statement of the Problem ......................................................................................... 64 Significance of the Problem ..................................................................................... 65 Purpose of the Study ................................................................................................ 66 Research Questions .................................................................................................. 67 Research Methods and Design ................................................................................. 67 Research design. ........................................................................................................ 68 Data collection........................................................................................................... 69 Case study review and its appropriateness to healthcare reform. ............................................ 70 Population ............................................................................................................... 70 Participants............................................................................................................... 70 COVID-19 and the chosen population. ............................................................................. 70 Sample ..................................................................................................................... 71 Sample selection. ........................................................................................................ 72 Instrumentation ........................................................................................................ 72 Data Collection, Processing, and Analysis ............................................................... 73 Data processing. ........................................................................................................ 74 Data analysis plan. ..................................................................................................... 75 Assumptions ............................................................................................................ 76 Limitations .............................................................................................................. 77 Delimitations ........................................................................................................... 78 Ethical Assurances ................................................................................................... 78 Validity and Reliability ............................................................................................ 79 Summary ................................................................................................................. 79 Chapter 6: Findings ....................................................................................................... 81 Results ..................................................................................................................... 83 Evaluation of Findings ............................................................................................. 84 Kruskal-Wallis test consideration. .................................................................................. 84 Originality of contribution. ........................................................................................... 85 Necessity of healthcare system intervention. ...................................................................... 85 Summary ................................................................................................................. 86 Chapter 7: Implications, Recommendations, and Conclusions ........................................ 88 Implications ............................................................................................................. 91 Limitations and Their Impact......................................................................................... 93 Practical Utility ......................................................................................................... 93 Recommendations.................................................................................................... 94 Adoption of a Single-Payer Healthcare System .................................................................. 94 Modification of Patient-Centered Care Models .................................................................. 94 Future Research Recommendations ................................................................................ 95 Conclusions ............................................................................................................. 96 References ..................................................................................................................... 99 Appendices .................................................................................................................. 103 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY viii Appendix A: ACR BI-RADS® Assessment Categories ............................................... 104 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY ix List of Figures Figure 1. Patient 1 right breast ultrasound image .............................................................48 Figure 2. Patient 2 right breast mammogram image .........................................................52 Figure 3. Patient 3 left breast mammogram image ...........................................................57 Figure 4. Patient 3 frontal chest radiograph ……..............................................................58 Figure 5. Patient 4 bilateral mammogram comparison .....................................................59 Corporate Greed of the American Healthcare System: A Case Study 1 Chapter 1: Introduction Governance framework and regulatory mechanisms wield significant influence over a nation's healthcare system. Diverse types of healthcare systems exhibit fundamental variations in their financial underpinnings and the accessibility of healthcare services. While the United States is often perceived as a leader in medical advancements and healthcare infrastructure, a more meticulous analysis reveals that its healthcare system operates as a poorly bound patchwork of private and market-driven components. Describing the United States' healthcare system is best accomplished by characterizing it as a mixed-market model, featuring an enterprise-like structure that prioritizes financial gains for those occupying its upper echelons. Healthcare providers and institutions find themselves subject to this multifaceted allocation of resources, encompassing not only the provision of healthcare coverage for the nation’s citizens but also the fair reimbursement for services rendered. 1 Within this intricate landscape of mixed-market, enterprise-driven, and ultimately corporate systems, both healthcare coverage and reimbursements become hard-fought battles, demanding arduous efforts to secure and maintain.1,2 While recent decades have witnessed certain strides aimed at enhancing the American healthcare landscape, such as the enactment of the Affordable Care Act in 2010, there have concurrently been regressive developments in the realm of patientcentered healthcare initiatives.1,3 As a result, reimbursement payments frequently hinge upon the perceived value and quality of care received by patients. 3,4 Considering the consistent reduction in reimbursements, both from government sources and private health insurance companies, it becomes increasingly evident that a comprehensive overhaul of CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 2 the American healthcare system may represent the sole viable solution to enhance the nation's healthcare landscape.5,6 Background Researching the structure of the American healthcare system is imperative for a multitude of reasons. It serves as a crucial tool for evaluating its impact on the quality of care provided to patients, offering valuable insights into areas of strength and opportunities for improvement, ultimately enhancing patient outcomes. Additionally, this research helps pinpoint inefficiencies within a system that represents a significant expenditure in the United States, offering opportunities for cost savings without compromising the quality of care.2 Furthermore, it sheds light on disparities in healthcare access and outcomes, facilitating the development of policies that address issues related to equity and access, including inequalities of care for underserved populations.1 This research is essential to making informed decisions regarding healthcare reform, and it serves as a guiding force in shaping policy development. Moreover, it allows for an assessment of its effects on the well-being of healthcare providers, where high levels of burnout and dissatisfaction can directly impact patient care. 7,8 Understanding the economic implications of various healthcare system structures and reforms is vital for both policymakers and businesses, as the healthcare industry significantly influences the U.S. economy. Research also fosters innovation by identifying areas in need of improvement and offering opportunities to enhance care delivery and efficiency. Also, it is critical for evaluating the readiness of the healthcare system to respond to public health emergencies CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 3 and for making informed global comparisons that reveal what aspects can be adapted or improved from other healthcare systems worldwide. 9 Most importantly, this research empowers patients and consumers with essential information, enabling them to play a pivotal role in shaping the future of healthcare in the United States. Total healthcare structure reform that results in a healthcare landscape that is more accessible, equitable, and attuned to the needs of its citizens is the goal of this research.1,10 American healthcare reform is a crucial social concern because it has the potential to address pressing issues in healthcare, ultimately enhancing the well-being of the nation's citizens and the overall health of society. 1,11 The American healthcare reimbursement system grapples with a multitude of pressing issues, engendering complexity, and inefficiency within the healthcare framework.1,10 Noteworthy among these challenges are fragmentation, where a multitude of payers, including private insurers, government programs (e.g., Medicare and Medicaid), and self-pay patients, contribute to a convoluted reimbursement landscape.2,5,10 This fragmentation complicates billing and reimbursement processes, fostering administrative inefficiencies. 10 Moreover, the intricacy of billing and reimbursement procedures escalates administrative costs, diverting significant resources away from patient care. The presence of varied reimbursement models, such as fee-for-service, capitation, bundled payments, and value-based reimbursement, adds to the predicament, creating inconsistencies that confound healthcare providers and hinder alignment of incentives toward high-quality care.2 Fee-for-service models, incentivizing service volume, contribute to overutilization, CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 4 potentially leading to unnecessary tests and procedures, amplifying healthcare costs without commensurate enhancements in patient outcomes. 2–4,10 The administrative burden placed on healthcare providers, stemming from intricate billing codes, documentation prerequisites, and prior authorization protocols, compounds the predicament, promoting provider burnout and detracting from patient care.7 Delays in reimbursement disbursement pose further challenges by straining providers' cash flows, jeopardizing their ability to meet operational expenses. Denials and rejections of claims submitted by providers necessitate additional administrative efforts to appeal these decisions, prolonging reimbursement cycles. 5 Disparities in reimbursement rates among various payers and geographic regions can perpetuate inequities in access to care, particularly impacting underserved areas. 1,5,6 The lack of pricing and reimbursement transparency bewilders patients, complicating informed decision-making, and giving rise to issues like surprise medical bills and out-of-network charges. The prevalence of billing errors exacerbates the situation, resulting in incorrect charges and reimbursements, thereby inducing financial strain for both patients and providers. 2 The complexity of the reimbursement system also creates fertile ground for fraud and abuse, with some providers resorting to fraudulent billing practices to maximize reimbursements.2,12 Additionally, the transition to value-based care models, which prioritize patient outcomes over service volume, introduces its own set of challenges, including accurate value measurement and equitable reimbursement practices. 3,4 Frequent changes in healthcare regulations further compound these issues, necessitating continuous adaptation of billing and reimbursement practices.1 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 5 Addressing these multifaceted challenges in American healthcare reimbursements is paramount to enhancing the efficiency, affordability, and fairness of the healthcare system, all while ensuring the delivery of high-quality care. This transformative endeavor demands the collaborative engagement of policymakers, healthcare providers, payers, and patients alike to drive reform and forge innovative solutions to these pressing issues. 1 Statement of the Problem The American healthcare landscape is marked by a system in which insurance companies channel their funds toward top corporate entities, creating daunting obstacles for hospitals and healthcare providers seeking maximum reimbursement for their services.2,5 This arrangement significantly impedes the delivery of high-quality care. Physicians often find themselves burdened with additional responsibilities related to billing and coding, aimed at optimizing reimbursements for their services.7 These added clerical tasks, coupled with the ongoing shift toward patient-centered care and reimbursements based on perceived quality of care, contribute substantially to provider burnout. In healthcare facilities where staff burnout is more prevalent, an environment is cultivated in which healthcare decisions can suffer. 7,8 As highlighted by Panagioti et al., there is substantial evidence suggesting that physician burnout poses a tangible threat to patient care.7 Their study furnishes concrete proof of diminished levels of professionalism and patient care attributable to physician burnout, as documented in various medical databases in recent years. 7 Furthermore, M. Mitka in 2008 sheds light on the expansion of "near events" occurring during healthcare visits—incidents that both U.S. government and private CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY insurers are inclined to resist compensating. 5 This resistance to payment for services coincidentally linked with nosocomial infections and similar adverse reactions results in insurers pocketing these reimbursement funds, in a time when reimbursements have already been on a concerningly decreasing trend. 5 When considering the direct impact on patient care, the study conducted by Reisch et al. in 2020, titled "Communicating with Patients About Diagnostic Errors in Breast Cancer Care: Providers' Attitudes, Experiences, and Advice," delves into diagnostic errors in breast cancer care. 13 The research uncovers that healthcare providers are more inclined to disclose diagnostic errors to patients when they perceive responsibility for the error and believe it would be beneficial to discuss it with the patient.13 Additionally, providers who are less apprehensive about litigation are more open to discussing these errors. It's worth noting that apart from potential litigation concerns, reimbursements for services involving diagnostic errors are likely to be withheld, further obstructing essential facets of quality care such as timely communication.5 Significance of the Problem The overarching structure of the American healthcare system requires immediate attention, as its current state severely undermines the quality of patient care. Insurance companies, driven by inherent corporate interests, require a thorough reform of their service reimbursement practices, particularly given the substantial impact these reimbursements have on the success of healthcare providers and institutions. 1,10,11 The obligation imposed on healthcare providers by these reimbursement disparities only exacerbates burnout in an environment already fraught with numerous 6 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 7 stressors, such as the management of a global pandemic and public health crisis. A 2019 article published in The Lancet advocates for systemic changes in healthcare and government, with a specific focus on enhancing professional well-being and prioritizing tasks that directly benefit patient care.14 This approach is crucial, as it is within these environments, plagued by burnout, that medical errors often occur, ultimately leading to lapses in the delivery of quality care.14 Purpose of the Study Through an examination of the American healthcare system's direct influence on provider attitudes and burnout, the aim is to establish a compelling correlation between healthcare and insurance structures and the quality of care delivered by these providers.7,8 In response to an article originally published in the Mayo Clinic Proceedings, Dr. Edward Melnick, Dr. Seth Powsner, and Dr. Tait Shanafelt present a compelling argument that burnout is intricately linked to the job and its specific circumstances.15 This phenomenon is primarily induced by workplace factors such as unrealistic job demands, inadequate resources, a lack of control, and insufficient support.15 The doctors emphasize that while burnout may share symptoms with depression and sometimes coexist with it, these collinearities should not be misconstrued as implying that the two conditions are identical.15 This response stresses the resolute stance adopted by healthcare professionals working in the field, reflecting their profound understanding of and experience with burnout.15 The fact that physician burnout manifests as exhaustion, cynicism, and reduced levels of efficacy highlights its detrimental impact on patient care quality. 15 The assertion that unrealistic job demands and inadequate resources in the workplace contribute CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 8 significantly to burnout highlights the repercussions of health insurance reimbursements and the American healthcare system.2,5 This system often appears to primarily benefit those at the pinnacle of the industry, detrimentally affecting patient care. By comprehending the consequences of burnout on patient care and healthcare practice, we can study of medical errors that ensue. With breast cancer diagnoses and treatment errors as case studies, it becomes evident that overwhelmed healthcare providers and facilities tend to make suboptimal healthcare decisions. Research Questions The American healthcare system's framework is a significant contributor to provider burnout and a hindrance to delivering quality patient care. 7,8 This environment inevitably leads to an increase in medical and diagnostic errors, which is highlighted through several breast cancer diagnosis cases which ultimately emphasize the imperative need for healthcare reform.8 The research questions addressed through literature review and case study analysis include: Q1. How does the state of the American healthcare system hinder a healthcare provider’s delivery of care? Q2. How significantly does burnout and stress surrounding insurance reimbursement structure contribute to medical errors? Q3. What structural and systemic changes can be made to improve this healthcare system in terms of equal reimbursements, lightening provider load, and ensuring quality, responsible care for patients? CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 9 Nature of the Study Extensive research on the American healthcare system and its interactions with government and private insurance agencies reveals compelling evidence regarding their role in exacerbating burnout among healthcare providers. This body of evidence illustrates how a dysfunctional healthcare system adversely impacts the quality of patient care.7,8 In recent years, the prevailing patient-centered healthcare model, heavily contingent on insurance reimbursements, has proven ineffective in ensuring elevated standards of care.2,3 These systemic distractions permeate healthcare facilities, fostering an environment conducive to suboptimal medical decisions and resulting in an elevated frequency of medical errors.8 A comprehensive literature review, complemented by retrospective case studies highlighting instances of suboptimal care in breast cancer scenarios, furnishes substantial empirical support concerning prevalent medical errors within the contemporary healthcare landscape.8,13 The selection of case studies for this investigation was drawn from the patient archives of Southtowns Radiology, a private outpatient radiology group, with formal authorization obtained for data retrieval. Given the retrospective nature of this study and the unfortunate passing of most subjects after their treatment with the facility, individual patient consent is logistically unattainable. The consent granted by Southtowns Radiology, the custodian of these medical records, served as the requisite and appropriate permission for data access and analysis. Investigation of the medical facility encompasses an in-depth analysis of the healthcare environment prevailing during the period when these medical cases occurred. A comprehensive understanding of this healthcare climate, and the resultant burnout it CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 10 provokes among healthcare providers, is pivotal in connecting systemic deficiencies within the healthcare system to the lapses in care witnessed in these instances. 8,9 The case studies were meticulously detailed, offering a rich narrative that expounds upon the patient's treatment journey, medical history, and a thorough examination of how diagnostic or medical errors compromised their safety and overall care. Nonparametric statistical methods, including the Kruskal-Wallis test and Spearman’s rank, were used to assess the research data. The primary objective of employing this statistical test was to rigorously evaluate the potential connections and correlations among three critical variables: deficiencies within the American healthcare system, physician burnout, and the occurrence of substantial medical errors. The rationale behind selecting the Kruskal-Wallis test as the nonparametric method to assess the data lies in its appropriateness for the specific research context. Firstly, it accommodates the presence of mutually independent samples, which is essential in analysis, with the aim to scrutinize these variables in isolation and assess their individual impacts. Secondly, these tests are appropriate for assessing the existence and strength of correlations between variables.16,17 Although it was later discovered in data analysis that these variables cannot be assessed on an ordinal scale and the Spearman’s rank statistical test was instead used, by employing a nonparametric test, a methodical analysis was conducted to explore the intricate interplay of these variables, contributing to a more comprehensive understanding of the complex relationships within the healthcare system. 17,18 This statistical approach facilitated the derivation of meaningful conclusions and insights, ultimately advancing CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 11 our knowledge of the factors that contribute to the challenges faced by healthcare providers and the quality of patient care in the American healthcare landscape. Limitations and Delimitations Dealing with such intertwined issues in healthcare, there are of course limitations to research as well as delimitations that should be considered to control the range of the study. The vast amount of insurance companies and their varying reimbursement rates by region are a limitation to accurately representing how reimbursement rates as well as reimbursement payouts pocketed by insurance companies in situations of near events directly impact healthcare providers and healthcare facilities. Accuracy in reported medical errors are a limitation to correlating diagnostic and treatment errors with levels of burnout. A federal investigative report in 2012 estimated that only one out of seven medical errors are recognized and reported.12 This issue of underreporting significantly effects accuracy in assessing medical errors. To control the range of the study, research boundaries include assessing only the levels of burnout amongst physicians and healthcare providers as compared to all healthcare workers. Delimitations also include concentrating on diagnostic and medical errors in breast cancer care as compared to all medical errors in a healthcare facility in general. Focusing the research to surround burnout levels in recent years during the climate of the COVID-19 pandemic as well as using case studies within the past two years also influences the scope of the study. Significance of the Study The study holds substantial significance across multiple critical domains. First and foremost, it is poised to make substantial contributions to the realm of healthcare CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 12 system enhancement. By meticulously exploring the intricate connections among the shortcomings within the American healthcare system, the prevalence of physician burnout, and the occurrence of significant medical errors, this research endeavor illuminates key areas where systemic improvements can be made. 8 The insights garnered from this study are composed to inform and shape policy modifications and systemic enhancements, offering the potential to elevate both the quality of patient care and the well-being of healthcare providers. In addition to its implications for healthcare system reform, this study bears profound implications for the well-being of healthcare professionals.15 Given the pervasive nature of physician burnout in the healthcare landscape, identifying its nuanced associations with system deficiencies and medical errors is paramount. 7,8 Such discernment is positioned to reveal the fundamental underpinnings of burnout and, in turn, offers a pathway towards its mitigation. Addressing these root causes not only holds promise for bolstering the overall well-being of healthcare practitioners but also for curtailing turnover rates and elevating the standard of care they provide to their patients. Furthermore, this research bears direct relevance to patient safety, a cornerstone of healthcare quality. As medical errors represent a formidable concern in healthcare, their far-reaching impacts on patient safety and outcomes necessitate a comprehensive examination.7,8 The findings of this study stand to clarify the contributing factors that fuel such errors, thereby paving the way for the formulation of strategic interventions aimed at their reduction. Ultimately, these efforts hold the potential to usher in an era of heightened patient safety and higher quality of care CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 13 The research also employs a rigorous statistical approach alongside meticulous data analysis. This methodological rigor ensures that the study's conclusions rest upon a bedrock of robust empirical evidence. This data-driven orientation is of paramount importance, particularly in the context of healthcare, where informed decision-making in policy, practice, and management hinges upon the reliability and validity of the research findings. Lastly, the research makes a noteworthy contribution to the body of knowledge in healthcare management, policy, and patient safety. By delving into the complex relationships between healthcare system deficiencies, physician burnout, and medical errors, it strengthens the existing literature with new insights. These insights enrich our understanding of the multifaceted healthcare landscape, potentially catalyzing transformative changes. In summation, the profound significance of this study resides in its capacity to instigate positive transformations within the healthcare arena. These transformations stand to benefit healthcare providers and patients alike by fostering improvements in care quality, reducing medical errors, and addressing the pressing issue of physician burnout, thus amplifying the overall effectiveness and sustainability of the healthcare system. Definition of Key Terms The following terms are ones that are encountered throughout the research and its analysis. Understanding their definitions will be crucial to understanding the nature of the research and its outcomes. The terms include: ACR. American College of Radiology, a professional medical society what represents radiologists and other radiation-specific professionals. The ACR also offers CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 14 accreditation standards, with their accreditation often recognized as the gold standard in imaging.19 BI-RADS®. Breast Imaging Reporting & Data System. An ACR clinical resource atlas which standardizes breast imaging terminology, report organization, and assessment and classification structure for breast imaging. Final assessment and management recommendations are quantified as categories 0-6 (Appendix A).19 CC. Craniocaudal, referring to a mammographic projection routinely used in mammogram examinations.20 MLO. . Mediolateral oblique, referring to a mammographic projection routinely used in mammogram examinations.20 HER2. Human epidermal growth factor receptor 2, a protein that promotes the growth of cancer calls. HER@ is present in roughly 20% of cancers. HER2-positive breast cancers are typically more aggressive and require specialized treatment. 21 CDK4/6. CDK4 and CDK6 are kinase complexes which, when used in conjunction with HER2-targeted treatments, can antagonize HER2-driven mammary tumor growth.22 ER+. Estrogen receptor-positive, referring to hormone receptor-positive breast cancers which should be treated with hormone therapies that block estrogen receptors. 23,24 PR+. Progesterone receptor-positive, referring to hormone receptor-positive breast cancers which should be treated with hormone therapies that block progesterone receptors.23,24 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 15 Lymphadenopathy. Swelling of the lymph nodes, a common occurrence in axillary and mammary, and sometimes clavicular, lymph nodes in cases of breast cancer.24,25 Lymphedema. Extremity swelling which results from build-up of lymphatic fluid secondary to lymphadenopathy, a common occurrence in the ipsilateral upper extremity in cases of breast cancer.24,25 Reimbursement. In terms of healthcare and health insurance structure, reimbursement is the payment provided to healthcare providers to cover the expenses of the services rendered.2,6 Single-payer system. A healthcare system in which one entity, usually the government, collects all healthcare fees and pays for all healthcare costs as a single payer.10,26 Socialized medicine. A healthcare structure where the government owns and operates healthcare facilities, employs healthcare professionals, and is the single-payer for healthcare services. Socialized medicine systems are single-payer and universal coverage systems, but not vice versa.11,27 Summary Without a doubt, there exists a pressing and unavoidable necessity to undertake a comprehensive overhaul of the American healthcare system. This need becomes even more apparent upon conducting a penetrating analysis of the ramifications from a profitdriven insurance provider framework. Such an examination exposes the harsh effects of this model on the provision of high-quality patient care.7,8 Parallel to this, investigating the details of the pervasive burnout experienced by physicians and healthcare providers, CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 16 which directly stem from the flaws inherent in this system, intensifies the demand for healthcare reform.9,14 In addition to these compelling reasons for reform, a meticulous inspection of diagnostic and medical errors within the healthcare landscape, with a particular emphasis on breast cancer care, creates an ideal environment for exploring their source. 12,13 These errors are intricately woven into an environment characterized by relentless burnout within healthcare facilities.7,8 This extensive investigation, backed by empirical evidence, serves as an irrefutable testament to the necessity for systemic transformation. It resoundingly reinforces the urgency of addressing deeply ingrained systemic issues to create an environment that is conducive to the attainment of elevated patient care standards, thus ultimately safeguarding and improving the well-being of patients. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 17 Chapter 2: Clinical Background Introduction Breast cancer stands out as the most prevalent cancer affecting American women, with one in eight women expected to receive a diagnosis in their lifetime. 25 Beyond being the most commonly diagnosed cancer in women, breast cancer emerges as the leading cause of death in the 40-55-year-old age group, presenting a lifetime fatality risk of 3.4%.25 It secures the second position among factors contributing to cancer-related fatalities in women.25 Despite a notable decline in breast cancer incidence since 2003, diagnosis rates have remained stable since 2004. 25 This highlights the persistent and significant threat posed by breast cancer, despite far-reaching advancements in understanding risk factors. Screening, as the dominant public health strategy for mitigating breast cancer mortality, plays a crucial role in guiding preventative measures. 25 While screening guidelines exhibit slight variations among different organizations, the consensus recommends annual mammograms for women of average risk, initiating at age 40. 25 For individuals with heightened risk factors, including a personal history of specific cancers and familial predisposition to breast cancer, risk assessment models may advocate for early screening.25 Emphasizing the significance of adherence to breast cancer screening guidelines, it is crucial to recognize that these guidelines share a common objective—early detection. This underlines the essential role of early detection in enhancing the likelihood of successful breast cancer treatment, especially considering the absence of a definitive cure for the disease.28,29 The primary line of defense against breast cancer mortality lies in prevention, with options such as chemoprevention of prophylactic surgery deemed calid CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 18 for selected women at significantly elevated risk.25,28,29 For the broader population, secondary prevention through early detection and screening is the most practical, effective, and viable intervention.29 Notably, the lasting nature of the goals associated with early detection and screening over the past century underlines the decisive role early detection plays in ensuring survival.29 Etiology Breast cancer etiology is multifaceted, involving a complexity of genetic, hormonal, environmental, and lifestyle factors. Genetic mutations, most notably in the BRCA1 and BRCA2 genes, are well established contributors to an increased risk of breast cancer. 28 Hormonal influences, such as use of estrogen and similar hormone replacement therapies over extended periods, have also been linked to the development of breast cancer.28 Additionally, certain environmental factors, such as exposure to ionizing radiation, either therapeutically or otherwise, and lifestyle choices, including alcohol and tobacco use, lack of physical activity, and diet choices affecting obesity, can influence breast cancer risk.28 Understanding the various determinants influencing breast cancer development is crucial for designing targeted preventative strategies and personalized approaches to breast cancer screening. Screen-detected breast cancers are those identified during routine screening breast imaging in asymptomatic patients. This early detection is vital, allowing for the implementation of successful treatment and management options. 29 However, interval breast cancers and late-stage-detected breast cancers pose unique challenges to diagnosis and management.30,31 Interval breast cancers emerge between regular screening mammograms, often associated with rapidly growing tumors that may be missed during CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 19 routine screenings.32 Late-stage-detected breast cancers are diagnosed at advanced stages, when the cancer has already spread beyond the breast. 28,33 Factors contributing to late-stage detection include limited healthcare access, awareness, and reluctance to undergo regular screenings. Additionally, inadequate physical exams and care by primary care providers contribute to delayed diagnoses in the medical community. Diagnosing breast cancers at regular screening intervals and detecting externally metastatic breast cancer without regular screening differ in timing, contacts, and characteristics of the diagnosis. Breast cancer diagnosed outside regular screening protocols often occurs when symptoms prompt medical attention, leading to later-stage diagnoses, sometimes with externally metastatic presentations. 30,31 Detection of these interval, late-stage, or externally metastatic cancers are typically triggered by symptoms like a palpable lump or changes in breast appearance, indicating advanced disease. 34 Treatment challenges intensify with the cancer's advanced stage, often requiring a more aggressive approach.35 Timely and regular screenings are critical for early breast cancer detection, minimizing the risk of metastasis and enhancing overall health outcomes for patients.29 Epidemiology Breast cancer stands as a significant global health challenge, with its epidemiology influenced by diverse demographic and geographic factors. Disparities in breast cancer incidence worldwide are evident, with higher rates observed in developed countries.29 However, it is crucial to recognize that variations in screening protocols and reporting practices in underdeveloped nations may contribute to the observed differences. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 20 The prevalence of breast cancer is notably higher in women, and age emerges as a critical factor, correlating with an increased risk of developing the disease. 25,28 A multitude of risk factors, integral to the etiology of breast cancer, also shape its epidemiology. Genetic predisposition and family history, along with hormonal influences such as early onset of menstruation, late menopause, and the use of hormone replacement therapy, contribute to susceptibility.28 Specific genetic mutations, exemplified by BRCA1 and BRCA2 mutations, elevate the risk, emphasizing the intricate interplay of genetic and environmental factors.28 Furthermore, lifestyle choices, including excessive alcohol consumption, lack of physical activity, and obesity, play significant roles in shaping the overall epidemiological landscape of breast cancer. 28 The epidemiology of breast cancer is marked by ongoing efforts to improve early detection and treatment outcomes. Public health initiatives, including awareness campaigns and screening programs, strive to inform communities about risk factors, promote regular screenings, and ultimately reduce the burden of the disease. 29 Simultaneously, researchers intensively explore the molecular and genetic foundations of breast cancer, leading to the development of personalized prevention and treatment approaches.28 These individualized strategies contribute significantly to advancing our understanding of the epidemiology of this complex and prevalent cancer. The epidemiology of late-stage, externally metastatic breast cancer represents a critical aspect of the disease's progression and its impact on individuals. 28 Late-stage breast cancer, characterized by the spread of cancer cells beyond the breast and nearby lymph nodes, is often associated with more advanced disease and poses significant challenges for treatment and prognosis. 35 Several factors contribute to the epidemiology CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 21 of late-stage, externally metastatic breast cancers, encompassing their incidence and prevalence, demographic patterns, disease subtypes, molecular characteristics, detection challenges, and treatment and mortality rates. Late-stage breast cancer is diagnosed when the cancer has already metastasized to distant organs, such as the bones, lungs, liver, or brain. The incidence and prevalence of metastatic breast cancer vary widely, influenced by factors such as geographic location, access to healthcare, and screening practices. Demographic elements, including healthcare access, socioeconomic status, and education levels, may impact the stage at which breast cancer is diagnosed, with late-stage diagnosis potentially more common in populations facing barriers to healthcare. 28,29 Even within the developed landscape of the American healthcare system, late-stage breast cancer diagnoses have unfortunately become more prevalent due to barriers to appropriate care during the COVID-19 pandemic. The molecular subtype of breast cancer can also contribute to the epidemiology of metastatic disease, with certain subtypes being more prone to metastasis, influencing the likelihood of late-stage diagnosis.28 Ongoing research explores molecular and genetic factors contributing to the metastatic potential of breast cancer. 28 Metastatic breast cancer's epidemiology is further characterized by treatment patterns and survival rates.36 Advanced-stage disease often necessitates more aggressive treatment, resulting in lower survival rates compared to earlier stages. 36 Treatment effectiveness varies based on the extent of metastasis and individual patient factors. In cases where patients present with necrotic external wounds indicating severe metastasis, treatment options may be limited to palliative care, underscoring the high mortality rates CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 22 associated with advanced breast disease.35 Early detection remains a crucial focus due to its significant impact on treatment options and overall outcomes for individuals confronting metastatic or late-stage breast cancer.29 Pathophysiology Breast cancer, a complex and multifaceted disease, manifests through intricate interactions of genetic, molecular, and environmental factors that dictate its initiation, progression, and metastasis within the breast tissue.28 At the crux of its pathophysiology are genetic mutations, notably in the BRCA1 and BRCA2 genes, which significantly elevate the risk of breast cancer by disrupting DNA repair mechanisms and fostering uncontrolled cell growth, ultimately leading to tumor formation. 37 The inception of breast cancer involves genetic mutations within individual cells, primarily within the mammary ducts or lobules. 25 These aberrations can give rise to either ductal carcinoma in situ (DCIS), where abnormal cells remain confined within the ducts, or invasive carcinoma, where cancer cells invade surrounding tissues. 25 Hormonal influences, particularly estrogen and progesterone receptors, play a pivotal role, as a significant proportion of breast cancers are hormone receptor-positive, making them responsive to hormonal stimulation and contributing to their growth. 23 Further complexities arise in the molecular subtypes of breast cancer. Some tumors overexpress the HER2 protein, driving rapid cell growth and necessitating targeted therapies.31 The invasive potential of breast cancer cells introduces the critical phase of metastasis, wherein cancer cells gain access to blood vessels or lymphatic channels, disseminating to distant organs.38 This intricate process significantly complicates treatment regimens and diminishes the likelihood of a cure, let alone CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 23 survival.31 Additionally, breast tumors induce angiogenesis, the formation of new blood vessels, to sustain their growth by securing an adequate supply of nutrients and oxygen. 38 This adaptive process highlights the dynamic characteristics inherent in the pathophysiology of breast cancer. History and Physical Breast cancer often manifests through diverse presentations, with a key indicator being the. identification of a lump or thickening in the breast tissue.24 The tactile difference, though often painless, may signify the presence of breast cancer.24 It is crucial to note, however, that not all breast lumps are malignant. Another characteristic presentation involves changes in the breast's appearance, including alterations in size, shape, or overall contour, potentially indicating abnormal cellular activity. 24 Further indicators of breast cancer may appear in alterations to the skin over the breast, such as redness, dimpling, or a puckered appearance, resembling the texture of an orange peel—a presentation known as peau d'orange.24 Variations in the nipple, like inversion, discharge unrelated to breastfeeding, or changes in position, can also serve as notable signs of concern.24 While breast cancer is not universally accompanied by pain, some individuals may experience discomfort, tenderness, or localized pain in the breast or nipple.24,25 Swelling or enlargement of the breast or the lymph nodes under the arm can also be indicative of advanced breast cancer.24 Importantly, these symptoms may also arise from non-cancerous conditions, such as cysts or infections. In cases of lymphadenopathy or lymphedema without known source, evaluation for breast cancer is indicated. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 24 Late-stage breast cancer with external necrosis represents an advanced manifestation of the disease, characterized by distinct clinical features indicative of an aggressive course.33,35 A prominent aspect of this presentation is the visibility of external necrosis, manifested as a visible ulceration or wound on the surface of the breast.35 This observable necrotic tissue imparts a unique and alarming aspect to the physical presentation of the disease.35 In addition to the visible signs, the late-stage, externally necrotic breast cancer may be associated with a foul odor emanating from the affected area, arising from the breakdown of tissue and accumulation of byproducts associated with necrosis.35 Concurrent skin discoloration further marks the advanced nature of the disease, with affected skin exhibiting hues ranging from dark red to purple or black. 33,35 This discoloration reflects compromised blood flow to the area and the consequential death of tissue.24,35 Pain and discomfort are often integral components of the presentation of latestage breast cancer with external necrosis. 33 The intensity of pain tends to escalate as the disease progresses, adding to the physical and emotional burden experienced by affected individuals. Additionally, palpable and enlarged lymph nodes in the regional vicinity may signify the infiltration of the cancer into the lymphatic system. 24 Furthermore, the systemic impact of the disease may manifest in symptoms such as fatigue, unintended weight loss, and a general decline in overall health, indicating the widespread implications of the cancer.24,33,35 Given the severity of the presentation, individuals experiencing late-stage, externally necrotic breast cancer require immediate and comprehensive medical CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 25 attention.35 The advanced nature of the disease limits treatment options, and a palliative care approach may be adopted to alleviate symptoms and enhance the quality of life. The profound implications of this presentation stress the critical importance of early detection through regular screenings, reinforcing the significance of heightened awareness and timely intervention in the realm of breast cancer management. 29 Evaluation Breast cancer diagnosis is a comprehensive process that incorporates various imaging modalities as well as physical exam to identify and characterize abnormalities within the breast. The initial encounter typically involves a clinical breast examination (CBE), where a healthcare provider conducts a tactile exam for detection of palpable lumps or other changes in the breast tissue. 24 Diagnostic medical imaging studies play the most pivotal role in breast cancer diagnosis, where mammography, which uses x-ray technology, is the primary imaging modality to detect breast tumors, microcalcifications, or other abnormalities.24,29,34 Subsequently, ultrasound and magnetic resonance imaging (MRI) are used to further evaluate areas of suspicion or concern, particularly in patients with dense breast tissue, younger patients, and those with elevated risk factors for developing breast cancer.34 The definitive method of diagnosis is biopsy, involving the extraction of breast tissue samples for pathologic examination. 24 Various methods, including fine needle aspiration (FNA), core needle biopsy, or open surgical (excisional) biopsy, can be used to obtain a breast tissue sample.24 Core needle biopsies are the most common method, given their appropriate sensitivity and specificity for the clinical scenario.24 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 26 Biopsy is followed with pathology examination, where tissue samples are examined microscopically.25 This analysis provides critical information on the etiology of the breast lesion, the type of breast malignancy (if present), grade (referring to growth rate), and other characteristics, collectively contributing to an accurate diagnosis.25,31 In cases of biopsy positive for malignancy, biomarker testing is usually performed to determine hormone receptor status (estrogen and progesterone) and the presence of the human epidermal growth factor receptor 2 (HER2). 25 These biomarkers aid clinicians in predicting the cancer’s responsiveness to targeted therapies, therefore guiding treatment decisions.25 Additional imaging, such as computed tomography (CT) and nuclear medicine scans, may be performed for staging and assessing the extent of disease, including metastatic dissemination.25 The described holistic approach to breast cancer diagnosis provides clinicians with the clearest picture possible, allowing for the most comprehensive treatment planning. It is important to note that this holistic approach requires multidisciplinary collaboration among referring providers, radiologists, pathologists, and specialists. Treatment/Management Options Breast cancer treatment and management options are contingent upon factors such as cancer type, stage, and individual patient characteristics.24 A diverse array of treatment options is available, tailored to address specific aspects of the disease. Surgical interventions, including lumpectomy and mastectomy, serve as the foundational strategies to remove cancerous lesions. 24 Lumpectomy preserves breast tissue, while mastectomy involves removing the entire breast. 24 These procedures are often CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 27 complemented by radiation therapy, either external beam radiation or brachytherapy, to eliminate residual cancer cells and minimize the risk of post-surgical recurrence.24 The appropriate combination of surgical and radiation therapy treatments is determined on a case-by-case basis. Chemotherapy is a systemic treatment option, deploying drugs orally or intravenously to combat cancer cells throughout the body. 24,25,28 Chemotherapy can be used in neoadjuvant settings before surgery to shrink tumors and in adjuvant settings after surgery to eradicate any remaining cancer cells.24 Hormone therapy can be administered concurrently, addressing hormone receptor-positive breast cancers through pharmaceutical agents like Tamoxifen, aromatase inhibitors, and ovarian suppression, influencing estrogenic activity to impede cancer growth. 25 More targeted therapies are available, such as HER2-targeted drugs and CDK4/6 inhibitors, pinpointing specific molecular characteristics of cancer cells to enhance treatment precision. 22 Immunotherapy is an evolving frontier in breast cancer management, leveraging the immune system to target cancer cells. 24,25 Additionally, bone-directed therapies, including bisphosphonates, mitigate bone metastases and reinforce bone strength.39 Beyond these established strategies, patients may enter clinical trials, offering an opportunity to access cutting-edge treatments and contribute to the progression of breast cancer research. A multidisciplinary healthcare team approach is essential to the efficacy of personalized treatment plans.24 Surgeons, oncologists, radiologists, and pathologists collaborate to design individualized treatment plans aligned with the patient's specific diagnosis, preferences, and overall health. This decision-making process relies on CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 28 comprehensive discussions between patients and their healthcare providers, especially to discuss potential benefits and side effects of treatments. Metastatic breast cancer that has disseminated beyond the breast and associated lymph nodes requires a comprehensive treatment approach focused on disease management, symptom alleviation, and preserving overall quality of life. 24,25 Systemic therapies are key to this approach, with chemotherapy controlling cancer growth and offering relief from symptoms.24 Again, hormone therapy can be useful in hormone receptor-positive cases, combating cancer cells influenced by estrogen and progesterone.24,25 HER2-targeted drugs and CDK4/6 inhibitors can serve as targeted therapies to refine treatment precision. 22,25 Immunotherapy can empower the immune system to engage cancer cells through checkpoint inhibitors.24 Similarly, bone-directed therapies contribute to maintaining bone health in cases with bone metastases. 39 Surgical interventions and radiation therapy are considered in select scenarios to address specific primary cancer lesions, allowing for the most successful opportunity for treatment. Palliative care assumes a pivotal role, focusing on symptom management, emotional support, and preserving physical and mental wellbeing. 24 These treatment and management options are personalized based on the characteristics of the cancer, patient preferences, overall health, and wound considerations, providing a holistic approach to metastatic breast cancer treatment.33 Regular monitoring and adaptive adjustments to the treatment plan are expected as the patient’s status changes. Breast cancers that present with associated external wounds represent a crucial element in the comprehensive care plan. 33,35 Managing such wounds is intricately intertwined with the broader treatment plan, considering factors such as the wound’s CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 29 extent, the primary cancer stage, degree of metastases, and, of course, the patient's overall health.33,35 Surgical interventions, including debridement to remove necrotic or infected tissue, and reconstruction techniques, including flap reconstruction or breast implants, comprise the surgical interventions for extensive wounds. 24 Topical treatments and various wound dressings are commonly used to prevent infection and facilitate healing. 40 In cases where external wounds are linked to history of radiation treatment, radiation therapy may be considered to promote healing. 40 Systemic treatments, notably chemotherapy and hormone therapy, aid in treating underlying cancer and supporting wound healing.35 Pain management strategies cater to individual needs based on the level of pain associated with the wound. Supportive care, particularly palliative care, becomes integral in cases where wounds are linked to advanced or metastatic breast cancer, focusing on symptom management, emotional support, and quality of life preservation.24,40 The individualized nature of treatment plans for metastatic breast cancers presenting with external wounds again emphasizes the necessity for a multidisciplinary approach between surgeons, oncologists, wound care specialists, and other health care professionals to address both the wound and the underlying cancer. 40 Regular monitoring and adaptive adjustments to the treatment plan based on the patient's response and general condition are expected. It is important to recognize that when breast cancer progresses to the point where external necrotic wounds manifest, the clinical landscape shifts towards a palliative care approach.40 Given that these external necrotic wounds signify an advanced stage of the disease characterized by the death of tissue and compromised skin integrity, curative CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 30 interventions are limited. The primary focus transitions to preserving the patient's quality of life, managing symptoms, and providing holistic support. Palliative care in these cases is a comprehensive and compassionate approach, addressing not only the physical aspects of wound management but also considering the patient's experience. While palliative care is generally seen as in end-of-life option, in cases of externally metastatic breast cancer, this may be one of the primary considerations. The shift towards palliative care acknowledges the limitations of curative measures and emphasizes the importance of maintaining the patient's dignity and quality of life. Complications There is a spectrum of potential complications that accompany breast cancer treatment and management options. The nature and intensity of these complications are contingent upon factors such as the chosen treatment modalities, cancer stage, and individual patient characteristics. Lumpectomy or mastectomy surgical interventions, although fundamental in the treatment of breast cancer, are not without potential complications. Risks include incision site infections, hematoma formation, or seroma formation at the surgical site. 24 Radiation therapy, instrumental in eradicating residual cancer cells, also comes with its own set of complications. Common side effects range from mild skin irritation to blistering. 24 Patients may also experience radiation-induced fatigue, nausea, or general weakness. 24 Chemotherapy poses complications such as nausea and vomiting, alopecia, bone marrow suppression, and fatigue.24 Hormone therapy for hormone receptor-positive breast cancers can induce menopausal symptoms in postmenopausal women and may contribute to long-term loss of bone density (osteoporosis). 25,39 Other targeted therapies designed to CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 31 address specific molecular characteristics of cancer cells introduce unique complications, such as risk to cardiac health, and skin and nail changes. 24 Immunotherapy treatments may present with skin rashes, diarrhea, or thyroid dysfunction. 24 It is essential to note the psychosocial complications that breast cancer treatment can evoke. Coping with cancer diagnosis and undergoing treatment can lead to significant emotional distress, anxiety, and depression for patients. 24,25 Body image issues may further contribute to psychological challenges. 24,25 Lymphedema can occur due to the disruption of lymphatic drainage during surgery or radiation therapy.24 Certain treatments, notably radiation and specific chemotherapy agents, may elevate the risk of secondary cancers. 24 Additionally, breast cancer treatments, particularly chemotherapy, may impact fertility.24 These complications call for supportive care that not only encompasses symptom management and rehabilitation but also psychosocial support to mitigate the impact of these complications and improve the patient's quality of life. As discussed, treatment plans can be tailored to individual needs to address any emerging concerns. Summary Breast cancer poses a substantial health challenge, affecting approximately one in eight women.25 Despite stable diagnosis rates, the need for effective screening remains evident.25,29 The disease's etiology involves complex relationships of genetic, hormonal, environmental, and lifestyle factors, stressing the importance of targeted preventive strategies and personalized screening approaches. 28 The pursuit for early detection necessitates comprehensive clinical examinations, imaging studies, biopsies, and CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 32 biomarker testing.25,29 Challenges, such as interval and late-stage diagnoses, highlight the ongoing imperative for improved screening methods and heightened awareness. A comprehensive approach to breast cancer treatment includes surgical interventions, radiation therapy, chemotherapy, hormone therapy, targeted therapy, immunotherapy, and bone-directed therapies.24,25,39 Multidisciplinary collaboration ensures personalized and informed decision-making. Metastatic breast cancer demands a holistic approach, considering systemic therapies, surgical interventions, radiation, and palliative care.24,36,40 Clinical trials offer novel options, and regular monitoring with adaptive adjustments is crucial for optimizing outcomes. Treatment for external wounds associated with late-stage diagnosis of externally metastatic breast cancers integrates surgical, topical, radiation, systemic, and supportive approaches, emphasizing the requisite of multidisciplinary collaboration. 33,35,40 Palliative care becomes crucial for late-stage breast cancer with external necrotic wounds, focusing on pain management, emotional support, and holistic care. 24,25,40 The complexity of breast cancer treatment introduces complications, including surgical, radiation, chemotherapy, hormone therapy, targeted therapy, and immunotherapy-related issues.24,25 Psychosocial challenges, lymphedema, secondary cancers, and fertility concerns further impact patient well-being. In conclusion, breast cancer's nuanced landscape calls for a collaborative strategy for optimal outcomes. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 33 Chapter 3: Literature Reviews Documentation The literature search strategy employed a combination of academic and online resources to ensure a comprehensive review of relevant literature. The primary source utilized was Weber State University Stewart Library’s OneSearch platform, offering access to a diverse range of scholarly, peer-reviewed articles, books, and journals. This academic database was instrumental in retrieving peer-reviewed articles and academic publications related to the various facets that represent failures within the American healthcare system. Additionally, Google Scholar® was used to broaden the scope of the search, providing access to a wider array of more recent academic sources, including articles, theses, and conference papers. The Lange Q&A™ resource was applied particularly for information related to extensive breast disease, its clinical features, etiology, and treatment and management options. This resource also examines the importance of preventative breast screening. These sources were chosen strategically to ensure a well-rounded and evidencebased exploration of clinical information related to patient case studies, as well as the pitfalls in the American healthcare system that can lead to such drastic medical errors as those encountered in the reviewed case studies. The combination of academic databases and search engines allowed for a comprehensive and diverse review of the existing literature. Introduction In the exploration and review of pertinent literature, it is understood that burnout is an emotional and physical manifestation of the stresses that surround the practice of CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 34 healthcare.15,41 Literature review reveals sources for this endless fatigue amongst healthcare providers as well as the effects that it has on their practice. Careful examination of diagnostic and medical errors shed some light and how healthcare structure creates an atmosphere of burnout where medical errors are more common.7 Specifically, the recent COVID-19 crisis shows a prevalence of pandemic-related burnout in healthcare workers.42 The Brucee Li Study evaluated a range of frontline, second line, and non-COVID healthcare workers.42 Overall, one in seven healthcare workers reported burnout.42 This high prevalence of emotional and physical fatigue and distress undoubtedly dictates the level of care provided to patients. It is scenarios like these that lead to medical errors and mistreatment. General Literature Review The recognition and study of burnout amongst healthcare professionals gained much attention during the onset and height of the COVID-19 pandemic. It is then that the medical community as well as the public became aware of how the American healthcare system and treating the public health crisis was mentally and physically impacting healthcare providers. Tawfik et al. offers tangible evidence from their study that shows a profound need for interventions to improve physician well-being and work unit safety which ultimately impacts work unit safety grades and associated major medical errors. 8 The 2018 study by Panagioti et al. uses system review and meta-analysis to suggest that there is sufficient evidence that physician burnout jeopardizes patient care. 7 Likewise, Dick Benson’s recent 2021 interview with Dr. Greg Hammer, a pediatric intensive care physician, pediatric anesthesiologist, medical professor, publish author, and Chair of the Physical Wellness Task Force for the California Society of CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 35 Anesthesiologists, sheds light on the reality of burnout in healthcare professionals. 41 Dr. Hammer notes that burnout is experienced by both physicians and most other healthcare professionals, only exacerbated by the COVID-19 pandemic.41 While management in healthcare understands the struggles contributing to this emotional and physical fatigue, it becomes clear that even administration and leadership roles cannot solve the underlying problems of healthcare infrastructure which are the framework for a failing system. A perfect example of this lack of support comes from David Bates’s July 2021 article “COVID-19 and changes in health care in North America”, where he addresses the overnight telehealth switch secondary to the onset of COVID-19 that burdened many providers with quickly sorting out digital programs and analytics to treat their patients.9 The assumption that physicians would have to handle these IT tasks and setups with little to no notice in crisis situations speaks to the enormous stress contributed from the pandemic.9 Lack of organization and support for healthcare providers during great times of change and public health crises, specifically in the realm of technology and telehealth services, creates more opportunity for error. Dissecting the patchwork that is the American healthcare system shows how government and private insurance companies alike strive to diminish reimbursements. The stress that this puts on healthcare facilities contributes to an already stressful atmosphere. Provider focus heavily revolves around billing and coding and serving a patient-centered system to maximize reimbursements in a manner that jeopardizes responsible medical decisions. As early as 2011, there are articles published speaking to the need of reforming payments to healthcare providers. M. McClellan describes how the growing trend of personalized medicine discourages the flexibility needed for any type of CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 36 healthcare innovation with reliable potential. 2 He goes on to express how the American mindset refutes restrictions on access to treatment which has proved otherwise successful in many other countries that have employed price limits and quality regulation to healthcare services and treatments. 2 Despite efforts of the Affordable Care Act of 2010 to reform provider payments, insurance reimbursements rely significantly on service quality and customer satisfaction now more than ever.1 The personalized practice of healthcare drives provider payment to be based on sometimes unrealistic measures, consequently adding to the stress and burnout for healthcare providers. 2 It is this domino effect that creates dangerous situations in healthcare settings. A study from Mayfield et al. studies Medicare reimbursements for hip and knee arthroplasties from 2000 to 2019.6 The article concludes that reimbursement models for physicians are continuously evolving. By evaluating monetary trends in Medicare reimbursement rates from 2000 to 2019 for hip and knee arthroplasty procedures, a very a common orthopedic surgery, and querying the American Academy of Orthopedic Surgeons coding reference and the Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services, monetary data for reimbursements from 2000 to 2019 were obtained.6 After adjusting for inflation, the average physician reimbursement for all hip arthroplasty procedures decreased by 31.9% and all knee arthroplasty procedures decreased by 33.3% from 2000 to 2019. 6 In other words, the inflation-adjusted reimbursement rate for these procedures decreased by an average of 1.7% per year.6 While this study focuses on common orthopedic procedures, this trend likely applies to all specialty medical fields during this timeframe. It is these vast decreases in reimbursements that put stress on hospital facilities and providers alike to CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 37 practice and bill in a manner that guarantees them the highest rate of reimbursement in a climate where seemingly everyone is fighting for the minimal reimbursements these insurance companies are willing to offer. Impact of Burnout on Healthcare Professionals The impact of burnout on healthcare professionals is a prevalent and concerning issue, particularly magnified during the COVID-19 pandemic.9,41,42 Extensive literature acknowledges burnout through in-depth studies, shedding light on the profound implications it has on the well-being and working conditions of healthcare professionals. Studies conducted by Tawfik et al. and Panagioti et al., have delved into the complexities of burnout within the healthcare sector, revealing compelling evidence that demands urgent attention.7,8 In their respective studies, Tawfik et al. and Panagioti et al. have examined the multifaceted nature of burnout, exploring its presence among healthcare professionals. 7,8 These findings emphasize both the existence of burnout as well as its detrimental impact on the mental health and job satisfaction of those working in the healthcare industry.7,8 The interplay of factors contributing to burnout, including high workload, long hours, and the emotional toll of dealing with critical situations has been thoroughly explored. 7,8 A significant aspect highlighted in the literature is the need for targeted interventions aimed at improving physician well-being and ensuring workplace safety.7 Burnout not only affects individual healthcare workers, but also has broader implications for patient care and the overall functioning of the healthcare system. Dr. Greg Hammer, in his insightful interview, brings a real-world perspective to the stark reality of burnout in the healthcare industry and how these challenges have been exacerbated by the CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 38 unprecedented circumstances of the COVID-19 pandemic, including healthcare worker shortages, unmanageably high patient volumes, lack of proper safety equipment and supplies.41 The literature collectively calls for a comprehensive approach to address burnout, incorporating measures at both the organizational and individual levels. Interventions may include strategies to alleviate workload, promote work-life balance, and provide mental health support for healthcare professionals. Recognizing and actively mitigating burnout fosters a healthier and more resilient healthcare workforce and contributes to the overall quality of patient care and the effectiveness of the healthcare system, particularly during times of crisis. Challenges in Healthcare Infrastructure The challenges in healthcare infrastructure, particularly during the COVID-19 pandemic, have been a focal point in literature, examining the significant hurdles faced by healthcare providers.9 David Bates, in his discussions, delves into the multifaceted issues surrounding the lack of support and organizational shortcomings that have exacerbated the complexities of healthcare delivery in times of crisis. 9 The literature highlights the strain on health care providers imposed by the sudden and overwhelming demands on technology and telehealth services. The pandemic prompted an unprecedented need for rapid implementation and scaling of telehealth solutions to facilitate remote patient care. 9 However, the lack of adequate support and organizational preparedness placed a considerable burden on healthcare providers. 9 The sudden surge in IT tasks and setups, often with little notice or comprehensive training, CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 39 created an additional layer of stress and challenges for providers who were already grappling with the intense demands of managing a public health crisis. 9 The impact of these challenges goes beyond the immediate technological concerns. These challenges in healthcare infrastructure significantly contribute to healthcare providers’ stress and burnout, creating an environment where the very individuals tasked with delivering essential care are contending with systemic issues that impede their effectiveness.41,42 Highlighted in the literature is also the point that addressing these challenges is not just about improving technological infrastructure but responding with broader organizational support for healthcare providers in times of crisis.41,42 The unexpected nature of the strain on healthcare providers, particularly in the realm of technology, focuses on the importance of proactive organizational strategies and support systems.9 Literature in this area advocates for investments in training, infrastructure, and organizational frameworks that can better equip healthcare systems to navigate unforeseen challenges, ensuring that providers can focus on patient care without being overwhelmed by the demands of rapidly evolving technology and service delivery models.9,41 In essence, the literature accentuates the need for a resilient and adaptable healthcare infrastructure that can effectively support healthcare providers, especially during crises like that of the COVID-19 pandemic.9,41,42 Financial Stress and Reimbursement Models Financial stress within the healthcare system is exacerbated by diminishing reimbursements from both government and private insurance companies. 6 This is a pervasive issue that significantly impacts healthcare providers and the facilities in which CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 40 they operate. This challenge is discussed in the literature where the complex stressors faced by healthcare professionals, extending beyond the clinical realm into the intricacies of financial management, is explored. 6 The literature also highlights the increasing pressure on healthcare providers to navigate complex billing and coding processes, driven by the imperative to maximize reimbursements.2,5 This emphasis on financial considerations can potentially divert attention from the primary focus of patient care, creating a delicate balance for healthcare who must navigate the intersection of responsible medical decision-making and financial imperatives.2 The literature further discusses the ethical and practical challenges posed by this split focus, emphasizing the need for a healthcare system that allows providers to prioritize patient well-being without compromising financial viability. 2 One specific area of concern highlighted in the literature is the evolution of reimbursement models. For instance, studies, such as the examination of Medicare reimbursements for hip and knee arthroplasties from 2000 to 2019, provide insights into the inequalities embedded in the American healthcare system. 6 These studies and their findings reveal disparities and shifts in reimbursement patterns over time, impacting the financial stability of healthcare facilities and influencing the quality of care delivered. The financial stress emanating from reimbursement challenges is systemic, affecting both individual practitioners and the broader healthcare infrastructure. 2,6 It is suggested that addressing these issues requires a comprehensive approach that considers not only the financial sustainability of healthcare providers but also the ethical implications of reimbursement models on patient care. 2 Advocacy for fair and transparent reimbursement practices, coupled with policies that prioritize the alignment of financial CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 41 incentives with patient outcomes, emerges as a key theme in the literature. The critical need to address financial stress within the healthcare system is acknowledged, recognizing its impact on providers’ decision-making and the overall quality of care. 2 It advocates for reforms in reimbursement models to promote fairness, transparency, and a system where financial considerations align with the overarching goal of improving patient outcomes.2,5,6 Need for Healthcare System Reform The overbearing need for healthcare reform is a complicated challenge requiring comprehensive solutions and is articulated in discussions and study analysis. McClellan's article discusses pressing need for reforming payments to health care providers, shedding light on the inherent complexities within the existing healthcare setting. 2 Literature suggests that the current payment structures may not adequately support the evolving demands of healthcare delivery, especially in the context of personalized medicine and patient-centered care models.3,4 The growing trend of patient-centered medicine represents a significant paradigm shift in healthcare, emphasizing individualized treatment approaches based on patients’ unique genetic, pathologic, and clinical characteristics.3 While this approach holds promise for more effective and targeted care, it also poses challenges to traditional reimbursement models.3,4 The literature discusses how the intricacies of personalized medicine come with its focus on tailored and often intricate treatment plans, necessitates a reevaluation of payment systems to ensure fair compensation for healthcare providers.3,4 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 42 Efforts initiated by the Affordable Care Act of 2010 are acknowledged in the literature as an initial step towards healthcare reform. 1 The act, also commonly termed Obamacare, aimed to improve the quality of services, enhance patient satisfaction, and implement reimbursement models that incentivize positive health outcomes. 1 However, the literature critically examines the implementation and enforcement of these intentions, highlighting potential gaps and shortcomings in achieving the envisioned reforms. 1 Moreover, for healthcare reform to be effective, it requires a commitment to the principles outlined in reformative policies. Merely enacting legislation without stringent adherence to the intended goals may render the reform ineffective. Literature analysis suggests that a sustained and vigilant approach to implementing reform measures is crucial to realizing the desired improvements in the healthcare system. 1 The need for payment structure adaptation and healthcare system reform is a recurring theme.1,2 Advocating for ongoing efforts to align policy intentions with effective implementation fosters a healthcare environment that prioritizes quality, efficiency, and equitable compensation for providers. 1,2 Addressing these issues is seen as pivotal in achieving a healthcare system that is responsive to the evolving needs of both healthcare professionals and the patients they serve. Patient-Centered System Challenges The patient-centered healthcare model presents many challenges that health care providers grapple with daily. Healthcare providers face considerable pressure to meet specific satisfaction levels in patient interactions and appointments, stemming from the emphasis on patient experience as a key indicator of healthcare quality. 3,4 Providers are increasingly evaluated and reimbursed based on patient satisfaction metrics. While this CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 43 sounds like it is a method to ensure quality patient care, the concept of customer satisfaction driving healthcare reimbursements contributes to the collapse of an already faulty multi-payer system. One of the core principles of the patient-centered model is enhancing the overall patient experience through fostering better communication between providers and patients.3,4 However, there are potential pitfalls in the execution of this approach. The consequences of personalized practice, where provider payments are tied to sometimes unrealistic measures of patient satisfaction, emerged as a significant source of stress for healthcare professionals.7 Providers find themselves navigating a delicate balance between meeting clinical standards, adhering to evidence-based practices, and satisfying patient expectations, which are often influenced by subjective factors. There is a domino effect created by these challenges, where the pressures within the patient centered system lead to potentially dangerous situations in healthcare settings. For instance, the emphasis on patient satisfaction metrics may inadvertently incentivize providers to prioritize patient preferences over clinical best practices or to over prescribed treatments to meet expectations.2,4 This introduces risks to patient safety and compromises quality of care. Moreover, the described domino effect suggests that the challenges within the patient-centered system are interconnected and can exacerbate each other. 4 The pressure to achieve high levels of patient satisfaction may lead to rushed appointments, increased workload, and further burnout among healthcare providers.4 These factors, in turn, contribute to decreased quality of care, strained provider-patient relationships, and overall dissatisfaction within the healthcare workforce. 2 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 44 A literature review highlights the challenges within the patient-centered healthcare model, emphasizing the need for a new and balanced approach. While patientcentered care is laudable in its intent, careful consideration of the unintended consequences urges holistic reform that aligns incentives with patient well-being, provider satisfaction, and overall healthcare quality. 3,4 Summary The comprehensive literature review emphasizes a pressing call for reform across various facets of the American healthcare system. The prevailing challenges, as discussed, reveal a landscape that significantly disrupts the well-being and effectiveness of healthcare providers, ultimately affecting the quality of care deliver to patients. The pervasive issue of burnout among healthcare professionals emerges as a central concern, with evidence suggesting an impact on physicians’ well-being, mindset, and their capacity to provide optimal care. 7,8,14 The interconnections of burnout with systemic issues such as inadequate support, organizational challenges, and the burden of IT-related tasks during the COVID-19 pandemic amplify the urgency for reform.9,41,42 Addressing burnout becomes a crucial aspect of healthcare system improvement, as it directly compromises healthcare providers’ ability to make sound medical decisions ultimately contributing to a higher likelihood of medical errors. 8 Financial stress and ineffective reimbursement models further compound the challenges faced by healthcare providers. The focus on billing and coding, coupled with the pressure to maximize reimbursements, introduces a potential conflict of interest that may divert attention away from appropriate, evidence-based practices. The inequalities highlighted by shifting reimbursement models, exemplified by the study on Medicare CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 45 reimbursements for hip and knee arthroplasties, demonstrates the need for more equitable structures within the healthcare system. 6 Moreover, the call for payment structure reform is echoed through the challenges posed by growing patient-centered care models and their impact on the level of even bare minimum reimbursement for medical services because of the pressure on healthcare providers to meet satisfaction metrics. 3,4 While initiatives like the Affordable Care Act of 2010 represent initial steps toward reform, the literature accentuates the need for a more stringent commitment to the intended restructurings to drive meaningful change in the healthcare landscape.1,2 In summary, this literature review paints a vivid picture of a healthcare system in need of total reform. The broken aspects of the current system, from burnout-induced challenges to financial stress and ineffectual reimbursement models, collectively contribute to an environment where the delivery of quality care is at risk. A thorough examination and reformulation of health are policies and practices are imperative to adopt a system that prioritizes both provider well-being and patient outcomes. The synthesis of evidence across these areas strongly advocates for an all-inclusive and well-coordinated effort to reshape the American healthcare system for the benefit of all participants. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 46 Chapter 4: Case Studies Four specific case studies were used, all of which took place during the height of the COVID-19 pandemic, from March to July 2021. This time frame allows for the analysis of cases in a recent time frame, as well as during the height of the pandemic. The cases will be outlined in chronological order. For the sake of anonymization of patient records and adherence to patient privacy stipulations, the patients involved in these four cases will be referred to as Patient 1, Patient 2, Patient 3, and Patient 4. Case Study: Patient 1 Patient 1 is a 65-year-old female who visited Southtowns Radiology on March 18, 2021. She presented with a complaint of a right breast lump accompanied by a worsening skin lesion persisting for approximately eight years. Additionally, there was a noted "lump" in the left breast, which, upon physical examination, is more accurately described as a complete hardening of the left breast over the last six months. The day prior to her visit to Southtowns Radiology, on March 17, 2021, the patient had sought attention at her primary care provider's office. The primary care physician's assistant ordered a diagnostic bilateral mammogram. During the mammogram appointment at Southtowns Radiology, a comprehensive patient history relevant to mammography was gathered. The patient mentioned that her last mammogram was more than ten years ago, leading to the unfortunate realization that these records had been destroyed by the facility in accordance with the standard retention period of ten years for breast imaging records. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 47 The patient, with a negative family history of breast cancer, disclosed an unintentional weight loss exceeding 50 pounds over the past several years, in addition to her breast-related concerns. A bilateral diagnostic mammogram was performed in the CC and MLO projections using 3D tomosynthesis at one-millimeter increments. Synthesized 2D (Cview) images were reviewed. The breasts exhibited heterogeneously distributed dense breast tissue, which has the potential to obscure small masses. Mammographic findings revealed a solid, oval mass in the upper aspect of the right breast, measuring 4.8 centimeters in length, with internal coarse calcification. The left breast displayed diffuse, malignant-appearing disease with a central, spiculated mass measuring approximately 1.7 centimeters. Diffuse pleomorphic, malignant-appearing microcalcifications were also seen throughout the breast tissue. Skin thickening and nipple inversion were evident. The mammographic impression emphasized a solid right breast mass with central coarse calcifications that extends to the skin surface, warranting a core biopsy recommendation. Additionally, mammographic findings concerning for inflammatory left breast cancer require the need for a core biopsy to confirm the diagnosis. The mammogram aligns with the American College of Radiology (ACR) BI-RADS 5 classification, indicating a high suspicion of malignancy for which appropriate action should be taken (Appendix A). Bilateral breast ultrasound to include all four quadrants and retroareolar regions was completed immediately following mammogram assessment. Additional live scanning, conducted in the presence of the radiologist, included images of the bilateral axillae. In comparison to the mammogram, the breast tissue displayed a heterogenous fibroglandular echotexture. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 48 In the right breast, a large hypoechoic well-circumscribed lobular mass was identified in the 12:00 position, corresponding to the palpable area of concern. This mass extended to the skin surface with mild overlying hypoechogenicity, measuring 3.9 x 3.0 x 2.9 centimeters. Color doppler analysis revealed internal vascularity. No other masses were detected in the right breast, and there was no right axillary adenopathy. Figure 1. Patient 1 right breast ultrasound image demonstrating lobular mass in the 12:00 position The left breast exhibited diffuse heterogeneity and thickening of the glandular tissue with multiple mass-like areas and pleomorphic calcifications. Overlying skin thickening and subcutaneous edema were noted. Evaluation of the axilla revealed three discrete lymph nodes, one of which displayed a thickened cortex and possible internal calcifications. The overall impression from the bilateral breast ultrasound was a large, wellcircumscribed lobular mass in the right breast of intermediate nature, for which a core biopsy would be performed following this ultrasound. The left breast presented an overall diffuse infiltrative malignant appearance suggestive of inflammatory breast cancer with CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 49 probable axillary spread. Core biopsy for diagnostic confirmation would also be performed same day. The assessment was classified as ACR BI-RADS 5, highly suggestive of malignancy and appropriate action should be taken. As outlined in the ultrasound report, core biopsies were conducted on the patient during her office visit that day. The procedure was thoroughly explained to the patient and informed consent was obtained. The risks, benefits, and possible alternatives were discussed with the patient. The patient was then positioned on the ultrasound table, and images of both the right and left breasts were obtained to confirm the presence and location of the solid mass in the most suspicious area. Biopsy site A was identified in the right breast at the 12:00 position. The right breast was prepared using standard sterile procedures. Chlorhexidine was used to cleanse the skin and 1% lidocaine was used as local anesthetic. A skin incision was made with a #11 scalpel blade, and under direct ultrasound guidance, three core samples were obtained using a Bard® 12-guage marquee biopsy device. Ultrasound confirmed proper needle positioning. Similarly, biopsy site B was identified in the left breast at the 12:00 position, retroareolar. The left breast was prepped in the usual sterile fashion, with chlorhexidine used for skin cleansing and 1% lidocaine for local anesthetic. A skin incision was made with a #11 scalpel blade, and under direct ultrasound guidance, three additional 12-guage core samples were obtained from the suspicious area in the left breast. Ultrasound once again confirmed accurate needle positioning. Due to the visibly apparent and large size of the right breast mass, no tissue marker was placed. Additionally, given the diffuse involvement of the left breast, a tissue CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 50 marker was not deemed necessary. Manual pressure was applied to the breasts until hemostasis was achieved, followed by the application of a sterile dressing and ice pack to the biopsy sites. The patient tolerated the procedure well, and post-biopsy instructions were provided. Both breast core biopsies were successful, with no tissue markers placed. Specimens were sent to X-Cell Laboratories of Western New York, Inc. On the following day, March 19, 2021, the anatomic pathology report was received. Right breast pathology revealed invasive ductal carcinoma, characterized as architecturally well-differentiated, intermediate nuclear grade, and SBR grade I. These findings are consistent with the imaging results and confirmed malignancy. Breast surgical consultation and a breast MRI were recommended. Similarly, the pathology of the left breast indicated invasive ductal carcinoma, showing architectural intermediate differentiation, intermediate nuclear grade, and SBR grade I. The imaging findings were again in agreement, confirming malignancy, and breast surgical consultation and breast MRI suggested. On March 22, 2021, the laboratory issued a supplemental anatomic pathology report, providing estrogen and progesterone receptor results. The right breast mass showed 100% positivity for both estrogen and progesterone receptors, indicating a favorable prognostic significance. HER2/NEU results for the right breast were negative. In the left breast, the sample was also 100% positive for estrogen receptors, indicating a favorable prognostic significance; however, the progesterone receptor result was negative, signifying an unfavorable prognostic significance. Again, HER2/NEU was negative. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 51 Patient 1 followed up with both a breast specialist and oncology. On December 5, 2022, the patient returned to Southtowns Radiology for a CT of the chest without contrast to monitor pulmonary nodules which had been identified on imaging from an outside facility. The CT scan revealed interval development of areas of pleural thickening with nodularity in the bilateral thorax, along with the development of a small to moderate pleural effusion. Additionally, irregularly shaped scattered pulmonary nodules were present in the lungs. This appearance had drastically changed from the previous study. Considering the patient’s history of breast cancer, the possibility of primary malignancy was a notable concern. Case Study: Patient 2 On May 28, 2021, Patient 2, an 88-year-old female, visited Southtowns Radiology with an order from her primary care physician. The provider had issued a prescription for a diagnostic mammogram, bilateral breast ultrasound, and a right breast biopsy on May 19, 2021, citing a right breast mass as the reason for the exams. During the physical examination and collection of mammography history, right nipple inversion with a lump and significant skin changes were observed, symptoms the patient reported having for the last two years. No issues were noted with the left breast. The patient had a negative personal history of cancer and no family history of breast cancer. She did, however, report a history of polio earlier in life. The patient reported that she had never undergone a prior mammogram or any other form of breast cancer screening. A bilateral diagnostic mammogram with 3D tomosynthesis was performed in the CC and MLO projections at one-millimeter increments. Synthesized 2D C-view images CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 52 were reviewed. The breasts exhibited scattered areas of fibroglandular tissue. In the right breast, deep to the nipple-areolar complex, a large, spiculated mass measuring 3.3 x 2.2 x 3.2 centimeters in size was identified, consistent with primary breast malignancy. Coarse calcifications along the posterior margin of the mass were also noted. The left breast, in contrast, showed no suspicious mass, areas of architectural distortion, or suspicious clustered microcalcifications. Vascular calcifications were present in the left breast. Figure 2. Patient 2 right breast mammogram image demonstrating large, spiculated mass The overall impression from the diagnostic mammogram aligns with ACR BIRADS criteria 5, indicating a high suspicion of malignancy for which appropriate action should be taken. The patient would undergo an ultrasound-guided core biopsy of the right breast mass during her visit on that day. Following the diagnostic mammogram, a right breast ultrasound including all four quadrants and the retroareolar region was performed. The breast tissue showed homogeneous fatty echotexture with a solid irregular lobular and spiculated mass located CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 53 directly behind the nipple, measuring 1.7 x 1.7 x 2.4 centimeters with internal coarse calcifications. The small calcification observed separately on mammogram was not distinct on ultrasound. No other masses were identified in the breast, and the chest wall appeared intact. Evaluation of the axilla indicated a benign-appearing lymph node measuring 1.3 x 0.8 x 1.2 centimeters. The general impression from the right breast ultrasound also aligns with ACR BIRADS criteria 5, indicating high suspicion of malignancy, warranting prompt action. Subsequently, the patient underwent an ultrasound-guided core biopsy of the solid, malignant-appearing right breast retroareolar mass immediately after the ultrasound. The separate right breast ultrasound core biopsy report states that the procedure was thoroughly explained to the patient, and informed consent was obtained. The risks, benefits, and possible alternatives were discussed with the patient. The patient was then positioned supine on the ultrasound table, and images of the right breast mass were obtained to again confirm the highly suspicious right retroareolar breast mass located at the 9:00 position, measuring 2.8 x 1.6 x 1.7 centimeters. The right breast was prepared in the usual sterile fashion, with Chlorhexidine used to cleanse the skin. Local anesthesia was administered with 1% lidocaine and a skin incision was made with a #11 scalpel blade. Under direct ultrasound guidance, three core 12-guage samples were obtained using a Bard® marquee biopsy device. Ultrasound confirmed proper needle positioning. At that point, a twirl-shaped tissue marker was deployed to mark the location of the biopsy site. Manual pressure was applied to the breast until hemostasis was achieved, followed by the application of a sterile dressing and an ice pack to the biopsy site. A post-procedure mammogram confirmed the placement of CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 54 the tissue clip. The patient tolerated the procedure well, and post-biopsy instructions were provided. The specimen was sent to X-Cell Laboratories of Western New York, Inc. for histopathologic analysis. On June 1, 2021, the final pathology results became available. The pathology indicated invasive ductal carcinoma with architecturally intermediate differentiation and intermediate nuclear grade. These results were malignant and concordant with the imaging findings. A consultation with a breast surgeon and a pre-treatment breast MRI were recommended. A supplemental anatomic pathology report issued on June 2, 2021, revealed that the right breast mass was 100% estrogen receptor positive, signifying favorable prognostic significance. However, the mass was progesterone receptor negative, indicating unfavorable prognostic significance. HER2/NEU results for the right breast mass were 2+, indicating positivity. A HER2/CEP17 fluorescence in situ hybridization (FISH) report was issued on June 16, 2021, interpreting the right breast carcinoma as amplified positive. Assay analysis showed a HER2/CEP17 ratio of 2.4 with 80 total tumor cells counted. The average number of HER2 signals/nucleus was 4.13, and the average number of CEP17 signals/nucleus was 1.75. Four observers were involved in the analysis. The fixation used was 10% neutral buffered formalin with a fixation time of 58-66 hours. Case Study: Patient 3 Patient 3, a 74-year-old female, presented to Southtowns Radiology on June 22, 2021, with an imaging script issued by primary care provider on June 2, 2021, for a chest CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 55 x-ray and screening mammogram. The reason for the exams was noted as “swelling right arm, smoker”. During the mammography history intake, the patient mentioned that her last physical breast exam by a physician was unknown, indicating that a breast exam was not conducted during her recent office visit. Additionally, she reported having prior breast imaging, but her last mammogram was performed well over ten years ago, resulting in the destruction of those images and reports. The patient had no personal history of cancer and a negative family history of breast cancer. She complained solely of unexplained right arm swelling for the past seven months. The patient recalled being seen at an emergency department satellite facility six to seven months prior, around the onset of her right arm swelling. The facility conducted a right upper extremity doppler to assess the swelling, and the exam was interpreted as negative. She was discharged with a diagnosis of unexplained right arm swelling and right arm lymphadenopathy without source. Since that initial encounter, the patient had not sought further evaluation for this issue. Upon presentation, it was evident that the patient exhibited right upper extremity lymphadenopathy with borderline pitting edema. The right breast displayed extensive cutaneous manifestations assumed to be indicative of primary right breast malignancy, extending considerably into the right axilla. The patient reported that this had been present in the right axilla for some time and was present at the time of right upper extremity doppler, but not observed in detail at that encounter. Breast imaging on June 22, 2021 included a diagnostic left breast mammogram and an attempted ultrasound of both breasts, covering all four quadrants and retroareolar CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 56 regions. Physical examination of the right breast revealed diffuse necrosis and discoloration of the right breast with an active and open ulcerative wound. Due to the condition of the right breast, mammography could not be performed. Limited ultrasound of the right breast displayed diffuse skin and subcutaneous thickening and infiltration. Evaluation of the right axilla showed hypoechoic tissue. Left-sided diagnostic mammography was performed, with 3D tomosynthesis imaging reconstructed at one-millimeter intervals, and synthesized 2D images were reviewed. The mammogram of the left breast revealed diffuse skin and glandular thickening, without any discrete mass or architectural distortion. Scattered coarse calcifications and vascular calcifications were observed. Ultrasound of the left breast indicated diffuse skin and subcutaneous thickening, also without discrete mass or architectural distortion. In summary, the impression from the left breast diagnostic mammogram and bilateral limited breast ultrasound emphasized diffuse discoloration and necrosis of the right breast, with areas of wound formation. The involvement extended diffusely into the axilla. These findings were highly suspicious for inflammatory breast cancer, but no further radiologic services could be rendered due to the condition of the breast. Additionally, diffuse edema of the left breast was noted. While this could be reactive, extension of lymphatic involvement could not be excluded, and a punch biopsy was suggested. These findings were consistent with ACR BI-RADS category 5- highly suspicious of malignancy for which appropriate action should be taken. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 57 Figure 3. Patient 3 left breast mammogram image demonstrating diffuse skin and glandular thickening The patient’s same-day chest radiograph was performed for symptoms of shortness of breath for one to two weeks, accompanied by right arm swelling. Posteroanterior (PA) and lateral views of the chest were obtained, with no comparison studies available. Findings from the chest x-ray shown well-inflated lungs with small areas of consolidation within the right upper lobe. Mild blunting of the right costophrenic angle was noted, indicative of a small right pleural effusion. Left hilar fullness concerning for left hilar adenopathy was observed with adjacent spiculation. Aortic calcifications were observed, and no bony destruction was identified. Evidence of prior spinal surgery with placed hardware over the lower thoracic spine was present. No definitive bone lesion was observed. Asymmetric soft tissue thickening overlying the right breast and axilla was consistent with known diffuse breast disease, as described in the mammography report. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 58 The chest radiograph impression described right upper lobe consolidation with a question of infectious versus neoplastic infiltrate. A small right pleural effusion with left hilar adenopathy and/or mass was also defined. Asymmetric thickening of the right breast and axillary soft tissue, compatible with known infiltrative breast disease, was once again observed. Figure 4. Patient 3 frontal chest radiograph revealing left hilar fullness with adjacent spiculated mass and right upper lobe consolidation concerning for neoplastic process Case Study: Patient 4 Patient 4, a 71-year-old female, sought medical attention from her primary care physician on July 14, 2021. During this visit, her doctor’s office contacted Southtowns Radiology, conveying that the patient had not seen a doctor in the last 40 years and presented to her primary care appointment with a large right axillary mass. In response, the doctor’s office issued a script and scheduled the patient for a bilateral diagnostic CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 59 mammogram, citing the reason for the exam as a large right axillary mass and the observation that the right breast was approximately five times larger than the left breast during the physical exam. Notably, the patient had never undergone mammogram or any other form of breast imaging. On July 15, 2021, Patient 4 visited Southtowns Radiology, expressing concern about a painful lump in her right axilla that she claimed had been present for several months. The patient remarked that her right breast had significantly enlarged compared to the left, a change that occurred over the last two months. The patient reported a negative personal history of cancer, as well as a negative family history of breast cancer. A bilateral diagnostic mammogram with 3D tomosynthesis was conducted in the CC and MLO projections at one-millimeter increments, and synthesized 2D images were reviewed. Scattered areas of fibroglandular tissue were observed in the breasts. The right breast appeared enlarged compared to the left, exhibiting diffuse trabecular and skin thickening. Figure 5. Patient 4 bilateral mammographic image comparison demonstrating right breast enlargement CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 60 The findings raised concerns for diffuse inflammatory breast carcinoma, especially given the ulcerative and necrotic clinical appearance of the skin. Additionally, a large irregular mass was identified in the right axilla. This mass had suspicious features which would be further evaluated with ultrasound. In the left breast, a small irregular mass with associated pleomorphic microcalcifications at the 12:00 position measured 1.1 centimeters, prompting further sonographic evaluation. The diagnostic mammogram impression indicated suspicious findings in both breasts, with a final BI-RADS category of 5, highly suggestive of malignancy, necessitating appropriate actions. Ultrasound imaging of the right and left breasts, covering all four quadrants and the retroareolar regions, revealed a large irregular hypoechoic mass in the right axilla, corresponding to the palpable area of concern and measured upwards of 3.5 centimeters in diameter. The entire right breast displayed induration with skin thickening and diffuse tissue edema, raising concerns for inflammatory breast carcinoma. In the left breast, an oval hypoechoic mass with associated calcifications at the 12:00 position measured 1.2 centimeters, aligning with the mammographic concern. These findings were discussed with the patient during her visit, and a recommendation was made for ultrasound-guided core biopsies of the right breast, right axilla, and left breast mass. However, the patient declined biopsy on that day and preferred to follow up with her referring physician before considering any intervention. The overall impression of the exam indicated findings in the right breast worrisome for inflammatory breast carcinoma, with a large suspicious mass in the right axilla, and a suspicious mass at the 12:00 position in the left breast requiring further CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 61 evaluation. Once again, this examination met ACR criteria for BI-RADS category 5, highly suggestive of malignancy, prompting the need for appropriate action. A same-day chest x-ray was performed as per the referring provider’s order. The indication for the chest radiograph was a slight cough and swelling in the right breast. Frontal and lateral views of the chest revealed clear lungs with no signs of pneumonia or edema. The mediastinal and cardiac contours appeared normal, with no soft tissue or osseous abnormalities. The chest radiograph impression indicated no acute cardiopulmonary disease. There was lack of follow-up on the part of the patient after the diagnostic breast workup. The interventional nurse spoke with the patient over the phone on August 20, 2021, who stated that she had breast biopsies performed at Roswell Park Cancer Institute in Buffalo, NY. According to the patient, the left breast pathology showed atypia, and she was unsure if the right breast pathologic findings indicated cancer. The patient mentioned that was continuing her follow-up with MRI and oncology care at Roswell Park Cancer Institute. Summary In the presented case studies, several patients sought medical attention with various breast-related concerns, highlighting the importance of comprehensive diagnostic evaluations. Patient 1, a 65-year-old female, presented with longstanding breast complaints, including a right breast lump and skin lesions, ultimately diagnosed as breast cancer. Chest CT for pulmonary nodule follow-up raised concern for primary lung malignancy. Patient 2, an 88-year-old female, underwent diagnostic mammogram and ultrasound due to a right breast mass, leading to the identification of invasive ductal CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 62 carcinoma. And, Patient 3, a 74-year-old female, showed interval development of pleural thickening and nodularity in chest radiograph following her diagnostic breast workup, raising concerns about metastasis from prior breast cancer. Patient 4, a 71-year-old female, sought medical attention after 40 years without medical care, presenting with a large right axillary mass. Imaging and ultrasound evaluations indicated findings worrisome for inflammatory breast carcinoma in the right breast and a suspicious mass in the left breast. Despite clinical suspicion for malignancy, the patient declined a biopsy and opted to follow up with her referring physician. These case studies accentuate the complexity of breast-related concerns, emphasizing the need for timely and thorough diagnostic evaluations, patient follow-up, and collaboration between healthcare providers to ensure comprehensive care and informed decision-making. Each of these four case studies also demonstrate the detrimental impacts of lack of physical exam during medical encounters at the height of the COVID-19 pandemic. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 63 Chapter 5: Research Method Introduction Research into how the American healthcare system and government and private insurance agencies alike contribute to high levels of burnout in healthcare providers delivers evidence that the broken healthcare system hinders quality patient care. The patient-centered healthcare model that insurance reimbursements heavily rely on in recent years proves to be ineffective in guaranteeing higher levels of care.4 These distractions create atmospheres within healthcare facilities that foster irresponsible medical decisions and lend to higher levels of medical errors. 8 Literature review in combination with retrospective case studies of failure of care in breast cancer situations provide tangible evidence regarding medical errors in today's healthcare climate. All case studies were gathered from a private outpatient radiology group, Southtowns Radiology, who granted permission for data collection in their patient archives. Given that this is a retrospective review of cases and that most of the subjects are deceased since their treatment, consent from individual patient cases was nearly impossible to obtain. Permission from Southtowns Radiology, the facility that houses these medical records, served as proper consent. Research into the medical facility itself addressed the climate of healthcare during the period in which these medical cases took place. Understanding the climate of healthcare and the burnout that results from it was crucial to applying healthcare system faults that raise stress for healthcare providers and facilities to the failure of care that took place in these specific cases. The level of detail provided by the specific case studies CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 64 elaborated on the care that the patient received, their history, and how the diagnostic or medical errors failed in the case of their safety and care. Statement of the Problem The American healthcare landscape is marked by a system in which insurance companies channel their funds toward top corporate entities, creating daunting obstacles for hospitals and healthcare providers seeking reasonable reimbursement for their services.2,5 This arrangement significantly impedes the delivery of high-quality care. Physicians often find themselves burdened with additional responsibilities related to billing and coding, aimed at optimizing reimbursements for their services. 7 These added clerical tasks, coupled with the ongoing shift toward patient-centered care and reimbursements based on perceived quality of care, contribute substantially to provider burnout. In healthcare facilities where staff burnout is more prevalent, an environment is cultivated in which healthcare decisions can suffer. As highlighted by Panagioti et al., there is substantial evidence suggesting that physician burnout poses a tangible threat to patient care.7 Their study furnishes concrete proof of diminished levels of professionalism and patient care attributable to physician burnout, as documented in various medical databases in recent years. 7 Furthermore, M. Mitka in 2008 sheds light on the expansion of "near events" occurring during healthcare visits—incidents that both U.S. government and private insurers are inclined to resist compensating. 5 This resistance to payment for services coincidentally linked with nosocomial infections and similar adverse reactions results in CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 65 insurers pocketing these reimbursement funds, in a time when reimbursements have already been on a concerningly decreasing trend. 5 When considering the direct impact on patient care, the study conducted by Reisch et al. in 2020, titled "Communicating with Patients About Diagnostic Errors in Breast Cancer Care: Providers' Attitudes, Experiences, and Advice," delves into diagnostic errors in breast cancer care. 13 The research uncovers that healthcare providers are more inclined to disclose diagnostic errors to patients when they perceive responsibility for the error and believe it would be beneficial to discuss it with the patient.13 Additionally, providers who are less apprehensive about litigation are more open to discussing these errors.13 It is worth noting that apart from potential litigation concerns, reimbursements for services involving diagnostic errors are likely to be withheld, further obstructing essential facets of quality care such as timely communication.5 Significance of the Problem The overarching structure of the American healthcare system requires immediate attention, as its current state severely undermines the quality of patient care. Insurance companies, driven by inherent corporate interests, necessitate a thorough reform of their service reimbursement practices, particularly given the substantial impact these reimbursements have on the success of healthcare providers and institutions. The substantial burden imposed on healthcare providers by these reimbursement disparities only exacerbates burnout in an environment already fraught with numerous stressors, such as the management of a global pandemic and a public health crisis. A 2019 article published in The Lancet advocates for systemic changes in healthcare and CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 66 government, with a specific focus on enhancing professional well-being and prioritizing tasks that directly benefit patient care.14 This approach is crucial, as it is within these environments, plagued by burnout, that medical errors often occur, ultimately leading to lapses in the delivery of quality care.14 Purpose of the Study Through an examination of the American healthcare system's direct influence on provider attitudes and burnout, we aim to establish a compelling correlation between healthcare and insurance structures and the quality of care delivered by these providers. In response to an article originally published in the Mayo Clinic Proceedings, Dr. Edward Melnick, Dr. Seth Powsner, and Dr. Tait Shanafelt present a compelling argument that burnout is intricately linked to the job and its specific circumstances.15 This phenomenon is primarily induced by workplace factors such as unrealistic job demands, inadequate resources, a lack of control, and insufficient support.15 The doctors emphasize that while burnout may share symptoms with depression and sometimes coexist with it, these collinearities should not be misconstrued as implying that the two conditions are identical.15 This response stresses the resolute stance adopted by healthcare professionals working in the field, reflecting their profound understanding of and experience with burnout.15 The fact that physician burnout manifests as exhaustion, cynicism, and reduced levels of efficacy highlights its detrimental impact on patient care quality. 15 The assertion that unrealistic job demands and inadequate resources in the workplace contribute significantly to burnout highlights the repercussions of health insurance reimbursements CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 67 and the American healthcare system. This system often appears to primarily benefit those at the pinnacle of the industry, detrimentally affecting patient care. By comprehending the consequences of burnout on patient care and healthcare practice, we can study of medical errors that ensue. With breast cancer diagnoses and treatment errors as case studies, it becomes evident that overwhelmed healthcare providers and facilities tend to make suboptimal healthcare decisions. Research Questions The American healthcare system's framework is a significant contributor to provider burnout and a hindrance to delivering quality patient care. This environment inevitably leads to an increase in medical and diagnostic errors, which is highlighted through several breast cancer diagnosis cases which ultimately emphasize the imperative need for healthcare reform. The research questions addressed through literature review and case study analysis include: Q1. How does the state of the American healthcare system hinder a healthcare provider’s delivery of care? Q2. How significantly does burnout and stress surrounding insurance reimbursement structure contribute to medical errors? Q3. What structural and systemic changes can be made to improve this healthcare system in terms of equal reimbursements, lightening provider load, and ensuring quality, responsible care for patients? Research Methods and Design The research method and design employed for this study involved literature review coupled with case study analysis. This approach was deemed appropriate as it CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 68 allowed for an in-depth analysis of the multifaceted nature of burnout and its direct consequences, particularly during the COVID-19 pandemic. To begin, a comprehensive literature review was conducted to explore the various aspects of the American healthcare system failure and the main contributing factors that have led to a pervasive atmosphere of burnout. This review aimed to understand the challenges faced by healthcare providers and shed light on the urgent need for healthcare reform. Additionally, it studied the recognition and reporting of medical errors in recent years, thereby highlighting the impact of these errors on patient outcomes. Subsequently, specific case studies related to breast cancer were examined to gain a deeper understanding of how the failures of the American healthcare system directly impacted these patients. By analyzing these real-life cases, the research provided concrete examples of the consequences of systemic failures, further emphasizing the need for improvements within the healthcare system. Through this combined approach of literature review and case study analysis, the research achieved its objectives by not only exploring the recent literature that calls for healthcare reform based on critical factors but also by drawing direct comparisons between these failures and real-life instances. This method provided a comprehensive overview of the challenges faced by healthcare providers and the urgent need for improvements within the system. By linking the findings from the literature review to the specific case studies, the research provided a more holistic understanding of the intricacies involved in addressing burnout and improving patient care. Research design. The chosen research design employs a case study review to comprehensively investigate instances of breast cancer characterized by external CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 69 metastatic presentation with extremely delayed diagnosis. Focusing on cases exhibiting metastatic dissemination beyond the breast, coupled with cutaneous manifestations, provides a unique opportunity to understand the challenges and complexities associated with advanced breast cancer. The qualitative nature of a case study design allows for indepth exploration, contextualization, and synthesis of information from individual cases. This research method is particularly well-suited to reveal the complicated dimensions of breast cancer progression, viable treatment options considered, and the impact on patients’ lives. Data collection. The cases under review were selected through a systematic process with prioritization of the following inclusion criteria: documented history of external metastatic spread of primary breast cancer and involvement of the skin with necrotic wounds. Both primary and secondary data sources were used, including medical records, imaging reports, pathology findings, and narratives of radiologist consult and patients’ understanding of their condition. While this selection offers only a small drop in the metaphorical ocean of delayed diagnosis in patients with progressed disease, the studies emphasize a recurrent pattern of healthcare provider and overall facility failure. Data collection involved a meticulous examination of the patients’ medical records and imaging studies, along with concordant pathology reports. A thematic analysis approach identified recurrent patterns, challenges, and unique aspects across the selected cases. The qualitative data, including textual information from medical records, was categorized to derive emergent themes. Through this process, key factors influencing external metastatic presentation of breast cancer, treatment outcomes, and the broader implications for healthcare delivery considering delayed diagnoses were uncovered. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 70 Case study review and its appropriateness to healthcare reform. This case study review aligns with the broader purpose of healthcare reform by providing a granular understanding of the challenges and gaps in the diagnosis and subsequent management of advanced breast cancer. By shedding light on individual experiences, treatment trajectories, and the impact of delayed diagnosis for patients with metastatic disease, the research emphasizes the need to advocate for comprehensive and adaptable healthcare models which can only be achieved through total healthcare reform. Population The population of interest for this retrospective case review is patients who experienced a diagnostic error resulting in extremely delayed care for breast cancer. It is important to review cases from this population since it demonstrates occurrences of absolute worst-case scenarios when irresponsible medical decisions are made. Participants. The participants included in this study are those chosen from the same facility, Southtowns Radiology, who experienced breast cancer diagnosis at an extremely advanced stage where only palliative care was a reasonable approach due to prior diagnostic errors. By limiting inclusion criteria for the population so significantly based on participants from one facility, a boundary is established to assure manageable research and review. COVID-19 and the chosen population. The pandemic brought forth unique challenges, with healthcare systems grappling with a surge in cases, resource constraints, and shifting priorities. For patients requiring diagnostic breast imaging during this period, the implications were profound. The research population encapsulates individuals navigating a healthcare environment strained by the pandemic's demands. The critical CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 71 aspect lies in understanding how this population, seeking diagnostic services during a public health crisis, reflects broader systemic issues, particularly provider burnout and a reduction in comprehensive care. The strain imposed on healthcare providers during the pandemic, coupled with challenges such as reduced physical examinations and increased workloads, raises critical questions about the impact on patient care, especially in the context of breast health. Sample The choice of a qualitative research sample for this study, despite its small size, is deliberate and justified by the unique nature of the cases under investigation. While breast cancer is indeed a prevalent health concern, the focus on specific cases of externally metastatic breast cancer presents a targeted exploration into a critical aspect of healthcare delivery. Given the advanced and complex nature of the cases, a qualitative approach allows for an in-depth examination of the multifaceted factors contributing to the delayed diagnosis and presentation of advanced breast cancer. The small sample size can be rationalized by the understanding that these cases are emblematic of broader systemic issues within primary care and medical facilities. The emphasis is on the quality and richness of the data obtained from these cases rather than the quantity of cases themselves. In situations where the aim is to uncover deep-seated problems within the healthcare system, a larger sample size may not necessarily yield substantially different findings. The qualitative nature of the study allows for a nuanced exploration of the intricate dynamics surrounding the delayed diagnosis of externally metastatic breast cancer. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 72 Furthermore, the use of a convenience sample acknowledges the practical challenges in accessing and recruiting participants for this specific research focus. The rarity and severity of externally metastatic breast cancer cases may limit the availability of suitable participants. A convenience sample, therefore, becomes a pragmatic choice, ensuring that the study can progress with available cases while still addressing the research question effectively. This approach aligns with the qualitative research goal of providing rich insights and understanding rather than aiming for statistical generalization, given the unique and contextual nature of the cases under scrutiny. Sample selection. From this population, four specific cases were drawn, focusing on patients presenting to Southtowns Radiology for diagnostic breast imaging. These cases were purposefully selected to represent instances of externally metastatic breast cancer, underlining the severity and complexity of their conditions. The sample's unique characteristic lies in its manifestation of advanced breast cancer, reflecting the potential consequences of reduced care during the pandemic. By honing in on these cases, the research aims to unravel the specific challenges faced by both patients and healthcare providers, emphasizing the nuanced interplay between the pandemic-induced healthcare landscape, provider burnout, and the timely diagnosis and management of advanced breast cancer. Instrumentation To collect data for the retrospective case study, patient charts were collected from Southtowns Radiology and anonymized to protect patient identity. Careful review of these cases allowed for similarities in diagnostic errors to be compared. Similarities and CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 73 differences in the cases in terms of time frame, pre-existing comorbidities, and previous treatment were also evaluated. Literature that is pertinent to understanding the structure of American healthcare and the corporate greed of insurance companies was reviewed. Peer-reviewed articles and editorials that speak to how the climate of a broken healthcare system heightens burnout and creates situations where medical errors are increased, but perhaps their reporting is not, were evaluated in its relation to the domino effect that insurance reimbursements ultimately have on patient care. Reviewing previous research on these common themes was instrumental to understanding the progression of irresponsibility and error from the top down. Data Collection, Processing, and Analysis To collect the data needed for the research, the following process was adhered to: • A literature review was performed on the corporate greed of insurance companies and the broken American healthcare system and how they related to medical errors. • A research proposal was created and reviewed by the Institutional Review Board. • Permission was obtained from Southtowns Radiology to access and analyze patient files for the purpose of case study reviews. • Data, reports, and radiographic images that were pertinent to the case study for several patients who had experienced extremely delayed breast cancer diagnosis with abysmal prognosis were carefully CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 74 collected. These items were then anonymized to protect patient identity. The data collection process for this research began with a comprehensive literature review focusing on the dynamics of insurance reimbursements and the overarching issues within the American healthcare system. The intricate connections between corporate interests, systemic flaws, and their potential correlation with medical errors, particularly in the context of breast cancer diagnosis, were explored. This phase of research established a strong theoretical foundation for the subsequent case study investigation. Following the literature review, a research proposal was developed for submission to the Institutional Review Board (IRB). The proposal outlined the research objectives, methodology, ethical considerations, and the significance of the study. IRB approval was obtained since the research design aligns with ethical standards and safeguards patient privacy and welfare. Data processing. After securing IRB approval, patient files from Southtowns Radiology were accessed and anonymized. Strict adherence to privacy regulations and protocols were maintained to safeguard patient confidentiality and comply with ethical standards. The data collection process then focused on systematically gathering relevant information, reports, and radiographic images pertaining to patients who have experienced significantly delayed breast cancer diagnoses with grim prognoses. This comprehensive approach involved obtaining holistic analyses of the cases, including the diagnostic journey, healthcare interactions, and outcomes. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 75 Data analysis plan. Retrospective case study review provided evidence of provider and healthcare facility failure. Relating these errors to the climate of healthcare plagued with physician burnout showed how physician well-being is related to the delivery of patient care. A nonparametric statistical test, namely the Kruskal-Wallis test, was used to test the correlation between American healthcare system shortcomings, physician burnout, and major medical errors. This statistical test was assumed to be most appropriate given the mutually independent samples and the ability to measure on an ordinal scale. Given the nonordinal nature of the comparison data, the Kruskal-Wallis test was ultimately deemed ineffective for analyzing this data. Instead, the Spearman’s rank test was used in a more appropriate fashion for determining correlation and causation of the data. The data analysis plan provided an exploration of provider and healthcare facility failures, particularly in the context of delayed breast cancer diagnosis. This analysis exposed systemic issues that contribute to adverse patient outcomes. A connection was established between these errors and the prevailing climate of health care marked by physician burnout, shedding light on how physician well-being is intricately linked to the delivery of patient care. The first phase of the analysis was detailed examination of each case study, identifying specific instances of provider and facility failure. This narrative analysis extracted critical information about diagnostic timelines, communication breakdowns, and other systemic shortcomings contributing to delayed diagnosis. By scrutinizing the CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 76 details of each case, a comprehensive understanding of the nature and extent of these failures was developed. Statistical tests were used to establish a correlation between healthcare system shortcomings, physician burnout, and major medical errors. Nonparametric statistical tests were chosen for their appropriateness in analyzing mutually independent samples in its compatibility with ordinal scale measurements. The Kruskal-Wallis test was meant to evaluate statistically significant differences in the observed medical errors across varying degrees of health care system shortcomings and physician burnout. The nonordinal nature of this data, which represents different levels of system shortcomings, physician burnout, and medical errors, did not align well with the KruskalWallis test since the test itself is intended to handle non-normally distributed data. Spearman’s rank test was used to examine the nonordinal data scale, where this statistical analysis provided an assessment of the relationships among these variables, offering insights into how deficiencies in the healthcare system and physician burnout contributed to major medical errors. The results of the Spearman’s rank were interpreted to discern any statistically significant associations and trends. This formed the basis for drawing conclusions about the interconnectedness of healthcare system failures and the burnout that their physicians are facing in a climate of increasing major medical errors. The findings contribute valuable evidence to the broader discourse on health care reform, emphasizing the urgent need for systemic changes to address a multitude of issues. Assumptions In the context of the population, it was presumed that patients facing a diagnostic error leading to significantly delayed breast cancer care essentially fell through the gaps CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 77 of their primary care providers. The irresponsible medical decisions in these cases, including the absence of a physical examination or comprehensive evaluation, directly contributed to their late-stage diagnosis, evident when cancer manifests externally, leaving palliative care as the sole management option. Through the chosen research design and an extensive literature review, the assumption was that the shortcomings of referring providers stemmed from inherent pitfalls within the American healthcare system. When scrutinizing the case studies, it became apparent that these patients initially presented with their conditions during the COVID-19 pandemic, a period when healthcare resources and providers were strained to their limits. This recent public health crisis exacerbated the existing flaws of the American healthcare system, with the examined patients becoming collateral damage in a deeply defective system. Limitations Addressing these complex healthcare issues involved acknowledging certain limitations in the research to refine the scope of the study. The multitude of insurance companies, each with distinct reimbursement models varying by region, limited the accuracy in portraying how the disparities in reimbursement rates and actual payouts, where payouts often remain with insurance companies in instances of near events, affect healthcare providers and their practice facilities. The precision in reporting medical errors and their correlation with diagnostic and treatment errors and levels of burnout was also subject to limitation. A federal investigative report in 2012 estimated that only one out of seven medical errors is identified and reported, significantly compromising the accuracy of these assessments. 12 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 78 Delimitations To control the range of the study, research boundaries were established, specifically concentrating on assessing burnout levels among physicians and midlevel healthcare practitioners in contrast to the broader category of all healthcare workers. Delimitations further narrowed the focus to studying diagnostic medical errors within breast cancer care, as opposed to including all medical errors within a healthcare facility. The research was specifically designed to investigate burnout levels in recent years, particularly during the context of the COVID-19 pandemic, and utilized case studies within the past three years, thereby defining the parameters of the study. Ethical Assurances Special attention was paid to ethical considerations, approvals, and safeguards in this research study. First, approval was secured from the Institutional Review Board, ensuring that the underwent thorough ethical review and obtained the necessary endorsement. Given the retrospective nature of this research, informed consent was not applicable, as the subjects of the selected case studies have since passed away. Despite this, measures were implemented to ensure the confidentiality and anonymity of the research patients and their cases. This was mainly achieved by eliminating personal identifiers from patient charts and imaging before securely storing the data on a protected device. The research has adhered diligently to the principles of honesty, integrity, and respect throughout the investigation of the chosen case studies. Furthermore, the research methods and design strictly align with the codes of conduct and legal requirements set CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 79 forth by Southtowns Radiology. Lastly, there are no relevant disclosures of conflicts of interest in this study. Validity and Reliability Validity and reliability are highly considered in this study's methodology. The reliance on peer-reviewed literature sources and comprehensive case studies adds to the validity, offering a solid foundation for the study. The literature review, featuring firsthand accounts from physicians experiencing burnout, enhances the consistency and reliability of the research, providing a well-rounded understanding of the challenges in healthcare settings. Lastly, statistical tests were analyzed for the significance of correlations, ensuring the reliability of the findings. Summary This retrospective case review focused on patients who experienced diagnostic errors leading to extremely delayed care for breast cancer, all of which were imaged at Southtowns Radiology. The study investigated the worst-case scenarios resulting from irresponsible medical decisions. Four cases, featuring externally metastatic breast cancer, were purposefully selected from this population to highlight the complexities of their conditions. Patient charts were anonymized and evaluated for similarities and differences in diagnostic errors, time frames, comorbidities, and previous treatments. The literature review will explore the structure of the American healthcare system and its flaws which impact insurance reimbursements, burnout, and medical errors. Assumptions include the studied patients falling through the gaps of primary care, with the COVID-19 pandemic exacerbating existing flaws. Limitations include the multitude of insurance company reimbursement models and the underreporting of CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 80 medical errors. Delimitations refine the scope of the study, concentrating on burnout among physicians and providers only and studying diagnostic medical errors only in the realm of breast cancer care. The research provided insight into the complex nature of the flawed healthcare system and its effect on provider burnout and, ultimately, patient care. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 81 Chapter 6: Findings This study explores the direct influence of the American healthcare system structure on healthcare provider attitudes and burnout, establishing a compelling correlation between healthcare and insurance structures and the quality of care delivered. In response to literature review, the study emphasizes the intricate link between burnout and workplace factors such as unrealistic job demands, inadequate resources, lack of control, and insufficient support. The focus on understanding the impact of burnout on patient care quality, highlights that the symptoms of burnout, including exhaustion and reduced efficacy, contribute to suboptimal healthcare decisions. 8,15 Using breast cancer diagnoses and treatment errors as case studies, the study delves into the consequences of burnout, particularly in overwhelmed healthcare provider and facilities, shedding light on the potential for medical errors in patient care. The research questions presented explore several facets of the intricate relationship between healthcare system structure and healthcare provider burnout which ultimately impacts patient care quality. The study uncovers the systemic challenges hindering healthcare delivery as well as proposes structural changes to ensure equitable reimbursements and promote responsible patient care. The Kruskal-Wallis test is a non-parametric method used to evaluate whether there are statistically significant differences among three or more independent groups.16 In the context of the four case studies presented, applying the Kruskal-Wallis test to examine the correlation between American healthcare system shortcomings, physician burnout, and major medical errors was deemed inappropriate. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 82 The Kruskal-Wallis test is typically suited for ordinal or interval data. 16,17 However, the variables in question—healthcare system shortcomings, physician burnout, and major medical errors—were not easily quantifiable in that manner.16 Furthermore, the intricate and multifaceted nature of these variables made it nearly impossible to measure them as numerical values. It is essential to acknowledge that the relationship between these variables is likely influenced by various factors beyond a straightforward statistical correlation. Additionally, the issues of physician burnout and medical errors involve qualitative and subjective aspects, suggesting that statistical tests alone may not adequately capture these nuances.17 Addressing these issues necessitates a multidimensional approach, considering organizational, cultural, and systemic factors within the healthcare environment. While statistical tests are valuable tools, the complexity and nature of these variables call for a more comprehensive analysis beyond the scope of a statistical test like the Kruskal-Wallis test.17 To explore the potential correlation between healthcare system shortcomings and medical errors in late diagnosis, a correlation analysis using appropriate statistical tests can be conducted. It is crucial to note that correlation does not imply causation. 18 Establishing causation requires additional evidence and a deeper understanding of the underlying factors. Additionally, the complexity of healthcare systems and medical errors may involve various contributing factors that extend beyond a simple statistical analysis. Given that the data from the four cases is more qualitative and narrative, nonparametric correlation tests that don't rely on assumptions of normality or linearity are recommended. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 83 Spearman’s rank correlation, a non-parametric test with no assumption of linearity or normality, was used to assess the strength and direction of monotonic relationships between interval variables.18 Spearman’s rank correlation was employed in this situation to determine whether a significant correlation between various factors in the qualitative data exists. Again, it is important to emphasize that correlation does not imply causation, and these results are interpreted in the context of the specific case studies.18 Results In response to Research Question 1: “how does the state of the American healthcare system hinder a healthcare provider’s delivery of care,” the state of the American healthcare system poses significant hindrances to healthcare providers' delivery of care.8 Through a qualitative analysis of case studies, it was evident that issues such as inadequate reimbursement structures, burdensome administrative tasks, and a lack of standardized protocols contribute to delays in diagnosis, reduced quality of care, and increased stress on healthcare professionals. The second research question asks, “how significantly does burnout and stress surrounding insurance reimbursement structure contribute to medical errors?”. Burnout and stress related to the insurance reimbursement structure were identified as significant contributors to medical errors in the analyzed cases. The narratives revealed that overwhelmed healthcare providers, facing extensive administrative pressures and uncertainties in reimbursement, were more prone to lapses in judgment, communication breakdowns, and delayed diagnoses, all contributing to medical errors. The last research question addresses the structural and systemic changes that can be made to improve the American healthcare system in terms of equal reimbursements, CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 84 lightening provider load, and ensuring quality, responsible care for patients. To enhance the American healthcare system, structural and systemic changes are imperative. Case analyses highlighted the need for reforms in reimbursement policies to ensure equal and fair compensation for healthcare services. Additionally, reducing the administrative load on healthcare providers emerged as a crucial aspect, necessitating streamlined processes, and improved technological support. Furthermore, ensuring quality and responsible care requires standardized protocols, enhanced interdisciplinary collaboration, and a focus on preventative measures. Evaluation of Findings The findings from the analysis align with expectations derived from both existing literature and a thorough examination of the case studies. The literature review indicated a prevailing concern regarding the impact of the American healthcare system's state on healthcare delivery, emphasizing issues such as reimbursement challenges and provider burnout.7,8,42 The case study analysis further corroborated these concerns, providing realworld examples of how these challenges manifest in delayed diagnoses, diminished quality of care, and an increased likelihood of medical errors. Kruskal-Wallis test consideration. The decision not to use the Kruskal-Wallis test was based on the nature of the variables involved. 16,17 The examined factors—healthcare system shortcomings, physician burnout, and major medical errors—were predominantly qualitative and narrative. The Kruskal-Wallis test, designed for ordinal or interval data, was ultimately not suitable for these aspects. 16,17 The complex, nuanced nature of these variables required a more holistic and qualitative analysis, which was appropriately CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 85 addressed through narrative examination and Spearman’s rank non-parametric correlation tests.17,18 Originality of contribution. This research contributes original insights by bridging the gap between existing literature and real-world case studies. While literature often provides theoretical frameworks, the case study analysis offers concrete illustrations of the identified issues. The combination of these sources strengthens the understanding of the challenges faced by healthcare providers, grounding theoretical concepts in practical scenarios, and highlighting the urgency for intervention. Necessity of healthcare system intervention. The research underscores the imperative need for intervention in the structure of the American healthcare system. The findings elucidate that the identified challenges—unequal reimbursements, provider burnout, and medical errors—are interconnected and systemic. Addressing these challenges requires a comprehensive restructuring of policies and practices. Equalizing reimbursements, streamlining administrative processes, and fostering a culture of support and collaboration are essential interventions to ensure the resilience and effectiveness of the healthcare system.1,2,9 In conclusion, this research not only affirms existing concerns within the literature but also contributes substantiated evidence from real-world cases. The originality lies in the synthesis of theoretical and practical insights, advocating for structural changes to create a healthcare system that prioritizes both the well-being of providers and the delivery of quality, responsible care to patients. CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 86 Summary The research findings shed light on the multifaceted challenges within the American healthcare system, revealing their profound impact on healthcare providers and patient outcomes. The first key theme pertains to the system's inherent hindrances, including issues of inadequate reimbursement structures, burdensome administrative tasks, and a lack of standardized protocols. 8,9,42 These challenges collectively contribute to delays in diagnosis and a diminishing quality of care, highlighting the pressing need for systemic improvements. A critical link emerges between burnout, stress, and the occurrence of medical errors.8 The research illustrates that overwhelmed healthcare providers, grappling with administrative pressures, are more susceptible to lapses in judgment, communication breakdowns, and delayed diagnoses—factors that significantly contribute to medical errors.7,8 The study identifies these challenges and proposes structural and systemic changes essential for mitigating these issues. 1 Reforms in reimbursement policies are highlighted as critical, ensuring equal and fair compensation for healthcare services.5,6 Simultaneously, there is urgency to reduce administrative burdens on healthcare providers through streamlined processes and enhanced technological support. Achieving quality and responsible care necessitates the implementation of standardized protocols, fostering interdisciplinary collaboration, and prioritizing preventative measures. 9 By presenting these observations, the research makes an original contribution by bridging theoretical concepts from existing literature with real-world case studies. The synthesis of theoretical and practical perspectives provides concrete illustrations of the CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY identified challenges, grounding theoretical concepts in the complexities of healthcare delivery. The core of the research lies in advocating for comprehensive interventions to address systemic challenges and enhance the overall effectiveness of the American healthcare system. Equalizing reimbursements, streamlining administrative processes, and cultivating a culture of support and collaboration are essential components for creating an effective healthcare system. 87 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 88 Chapter 7: Implications, Recommendations, and Conclusions The introduction sets the stage for an exploration into how the American healthcare system, along with government and private insurance agencies, contribute to healthcare provider burnout and how this, in turn, affects the quality of patient care. The patient-centered healthcare model, often reliant on insurance reimbursements, is depicted as ineffective and creating an environment conducive to irresponsible medical decisions and increased medical errors.3,4 The research methodology involved a combination of literature review and retrospective case studies, primarily sourced from Southtowns Radiology. The lack of consent from individual patients, due to the retrospective nature of the study and the deceased status of most subjects, is addressed by obtaining permission from the facility, Southtowns Radiology. The problem statement identifies the American healthcare landscape as marked by a system where insurance funds prioritize top corporate entities, creating obstacles for hospitals and healthcare providers seeking optimal reimbursement. 5,6 This results in additional responsibilities for physicians related to billing and coding, contributing significantly to provider burnout. The prevalence of burnout is linked to an environment where healthcare decisions can suffer, impacting patient care. 8,41 Significant literature is cited, emphasizing the tangible threat of physician burnout to patient care.7,8,14,15,41,42 Resistance to compensating "near events" by both government and private insurers is highlighted, affecting reimbursements for services associated with nosocomial infections and adverse reactions.5 A study on communicating diagnostic CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 89 errors in breast cancer care underscores the importance of providers disclosing errors, while acknowledging potential litigation concerns and the impact on reimbursements. 13 The significance of the problem is stressed, calling for immediate attention to the structure of the American healthcare system. Insurance reimbursement practices are identified as needing reform due to their substantial impact on healthcare providers and institutions. The burden imposed on providers exacerbates burnout, especially in the context of a global pandemic.9,41 Systemic changes are advocated, with a focus on enhancing professional well-being and prioritizing tasks benefiting patient care. The purpose of the study is clarified, establishing a correlation between healthcare and insurance structures and the quality of care provided by healthcare providers. 1 The link between burnout, job demands, and inadequate resources is explored, emphasizing the detrimental impact on patient care quality. 7,9 The study sets out to comprehend the consequences of burnout on patient care and healthcare practice, particularly in the context of medical errors using breast cancer diagnoses and treatment errors as case studies.8,13 The research acknowledges the profound understanding of burnout held by healthcare professionals, emphasizing the need for systemic changes to benefit patient care.7,14 The limitations of the research are conscientiously addressed, recognizing the complexity of healthcare issues. The variability in reimbursement models among different insurance companies across regions poses a challenge in accurately depicting the impact of reimbursement rate disparities on healthcare providers and facilities. Additionally, the reporting precision of medical errors, especially their correlation with CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 90 diagnostic and treatment errors and burnout levels, is compromised by the underreporting estimated in a federal investigative report from 2012. 12 Delimitations are clearly outlined to refine the study's focus. The research specifically concentrates on assessing burnout among physicians and midlevel healthcare practitioners, excluding the broader category of all healthcare workers. The study narrows its scope further by focusing on diagnostic medical errors within breast cancer care, omitting consideration of all medical errors within a healthcare facility. The temporal boundaries are also defined, investigating burnout levels during recent years, particularly within the context of the COVID-19 pandemic, and utilizing case studies from the past three years. Ethical assurances are prominently addressed. Approval from the Institutional Review Board ensures thorough ethical review and endorsement. Given the retrospective nature of the research and the deceased status of the subjects, informed consent was not applicable. Measures were implemented to guarantee the confidentiality and anonymity of the research patients and their cases, including the removal of personal identifiers from patient charts and imaging. The research adheres to principles of honesty, integrity, and respect, aligning with the codes of conduct and legal requirements set forth by Southtowns Radiology. Notably, there are no relevant disclosures of conflicts of interest in this study, reinforcing its ethical integrity. The status of the American healthcare system has profound implications for provider well-being and the quality of patient care. The intricacies of insurance reimbursement models, administrative burdens, and the shift towards patient-centered care contribute significantly to provider burnout, ultimately hindering the delivery of CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 91 high-quality care.1,3,4 The study explores how these systemic issues impact patient care, especially in the context of diagnostic errors and delayed treatment. The implications focus on the urgent need for healthcare reform, with a recommendation to transition towards a single-payer, socialized medicine system.10 The existing fragmented reimbursement practices, varying across insurance companies and regions, create disparities and burdens that exacerbate burnout among healthcare providers.1 A single-payer system promises to streamline reimbursement, reducing administrative complexities and enabling providers to focus more on patient care. 10 Moreover, the study suggests that the move towards a socialized medicine system can address the overarching challenges faced by healthcare professionals. 10,11 By prioritizing equal reimbursements, reducing administrative loads, and fostering a culture of collaboration, such a system could create a more resilient and patient-centric healthcare environment.11 The findings advocate for systemic changes that go beyond incremental adjustments, emphasizing the necessity of a comprehensive reform to optimize both provider well-being and patient outcomes. Implications (Q1): How does the state of the American healthcare system hinder a healthcare provider’s delivery of care? The research reveals that the American healthcare system, with its complex reimbursement structures and administrative burdens, significantly hinders the delivery of care by healthcare providers.7 Issues such as inadequate reimbursement models and burdensome administrative tasks contribute to delays in diagnosis and reduced quality of CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 92 care.5,9,41 This hampers healthcare professionals' ability to provide timely and efficient services. Addressing these hindrances requires structural reforms that focus on equitable reimbursement policies, streamlined administrative processes, and standardized protocols.1,10 The implications suggest the need for a systemic overhaul to enhance the efficiency and effectiveness of healthcare delivery. 10 (Q2): How significantly does burnout and stress surrounding insurance reimbursement structure contribute to medical errors? Burnout and stress related to insurance reimbursement structures are identified as significant contributors to medical errors. Overwhelmed healthcare providers, facing administrative pressures and uncertainties in reimbursement, are more prone to lapses in judgment, communication breakdowns, and delayed diagnoses, leading to medical errors.7,8 The study emphasizes the importance of interventions aimed at reducing burnout and stress related to insurance reimbursement. It underscores the need for support mechanisms and reforms to alleviate administrative burdens, ultimately improving patient safety and reducing medical errors.10,11 (Q3): What structural and systemic changes can be made to improve this healthcare system in terms of equal reimbursements, lightening provider load, and ensuring quality, responsible care for patients? The study identifies the imperative for structural and systemic changes to enhance the American healthcare system. Reforms are needed in reimbursement policies to ensure CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 93 equal and fair compensation, reducing administrative burdens on healthcare providers, and fostering a culture of collaboration and preventative care. 1,10,11 Recommendations include equalizing reimbursements, implementing technologies to streamline administrative processes, and fostering a collaborative and preventative care culture. These changes aim to create a more resilient and patient-centric healthcare system, addressing the identified shortcomings. 1,4,10,11 Limitations and Their Impact The limitations include the complexity of insurance reimbursement models and the retrospective nature of the case studies, limiting the generalizability of findings. The precision of reporting medical errors is compromised by underreporting. These limitations may influence the interpretation of results and suggest caution in extrapolating findings to broader contexts. Contextualization and Contribution to the Literature This study's results align with existing literature highlighting the adverse effects of reimbursement structures and burnout on patient care. The findings contribute by emphasizing the interconnectedness of these factors and the need for holistic reforms. The study extends literature by proposing practical reforms and underscores the urgency of systemic changes in the healthcare landscape. Practical Utility The study's practical utility lies in its potential to guide policymakers, healthcare administrators, and professionals in implementing concrete reforms. The recommendations offer practical ways to address the identified challenges, fostering improvements in healthcare delivery, provider well-being, and patient outcomes.1,10,11 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 94 In conclusion, this study not only identifies critical issues within the American healthcare system but also provides actionable insights for meaningful reform. The findings reinforce the importance of considering systemic and structural changes to optimize the healthcare environment for both providers and patients. 1,10,11,11 Recommendations The findings of this study feature the significant impact of the current fragmented reimbursement structures on both healthcare providers and patient care. The complexities and disparities inherent in existing reimbursement models contribute to burnout, delays in diagnosis, and an increased incidence of medical errors. 3,5,6 Considering these findings, the following recommendations are proposed for practical applications, grounded in the outcomes of the study. Adoption of a Single-Payer Healthcare System The evidence gleaned from the study strongly supports the notion that transitioning to a single-payer healthcare system could address the shortcomings identified in the current healthcare landscape. 10 Such a shift is recommended to simplify reimbursement processes, ensuring equal and fair compensation for healthcare services.1,10 By streamlining administrative procedures and alleviating the burden on healthcare providers, this structural change is expected to contribute to a more efficient and provider-friendly healthcare system, ultimately enhancing patient care.1,10,11 Modification of Patient-Centered Care Models The study reveals a nuanced understanding of the patient-centered care model, highlighting its unintended consequences on provider burnout and the occurrence of medical errors.3,4 In response, it is recommended to modify these care models to CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 95 prioritize evidence-based decisions and proven best practices. 4 This adjustment involves realigning reimbursement incentives with practices that enhance patient outcomes while simultaneously reducing unnecessary administrative tasks. 10,11 By promoting evidencebased care, this modification aims to improve overall quality and ensure providers can focus on delivering care according to established medical standards. 4 Future Research Recommendations Longitudinal study on single-payer system impact. To assess the long-term impact of transitioning to a single-payer healthcare system, a longitudinal study is recommended. This research should delve into aspects such as provider satisfaction, patient outcomes, and system efficiency over an extended period. 10 Comparative analysis of patient-centered and evidence-based models. Further research is needed to conduct a comparative analysis of patient-centered care models and modified models prioritizing evidence-based decisions. This study would evaluate their respective impacts on provider burnout, medical errors, and patient satisfaction, providing valuable insights for healthcare reform. 1,3,4 Exploration of interventions to address burnout. Research focusing on specific interventions to address burnout within healthcare settings is crucial. This may involve assessing the effectiveness of support programs, mental health resources, and workload management strategies in mitigating burnout and improving overall provider wellbeing.8,9,14,41 Investigation into patient outcomes post-reform. Post-reform, research should concentrate on patient outcomes to determine the effectiveness of implemented changes. This includes evaluating whether modifications in reimbursement structures and care CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 96 models lead to improved diagnostic accuracy, reduced medical errors, and enhanced patient satisfaction.10,11 Examination of global healthcare systems. A comparative analysis of healthcare systems globally, especially those with successful single-payer models, can offer insights into best practices.10 Understanding how other nations navigate reimbursement and care models may provide valuable lessons for reforming the American healthcare system.10,11 Future research conclusions. These recommendations emerge organically from the identified challenges and opportunities revealed in the study. Implementing a single-payer healthcare system and modifying patient-centered care models align with the overarching goal of enhancing provider well-being and improving the quality of patient care. 3,4,10 These recommendations, when considered collectively, provide a comprehensive framework for ongoing efforts to reform and optimize the healthcare system. 1,11 Conclusions The exploration into the intricate interplay between the American healthcare system, provider burnout, and medical errors has illuminated critical facets of the challenges faced by healthcare professionals. The evidence gleaned from retrospective case studies and a comprehensive literature review emphasizes the profound impact of fragmented reimbursement structures and patient-centered care models on the well-being of healthcare providers and the quality of patient care. The study substantiates the claim that the current state of the American healthcare system, marked by intricate reimbursement models and administrative complexities, CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 97 significantly impedes the delivery of high-quality care.7,8 The burden placed on healthcare providers to navigate convoluted billing processes, coupled with the shift towards patient-centered care, contributes substantially to provider burnout.3 These findings emphasize the urgent need for structural reforms to streamline reimbursement procedures and alleviate administrative burdens on healthcare professionals. Moving forward, the study unearths the substantial influence of burnout and stress surrounding insurance reimbursement structures on the occurrence of medical errors. 5 Overwhelmed healthcare providers, burdened with administrative pressures and uncertainties in reimbursement, are prone to lapses in judgment and communication breakdowns, contributing to diagnostic and treatment errors.7–9 Mitigating burnout through targeted interventions becomes imperative to enhancing patient safety and improving overall care quality.7,8 Moreover, the case studies highlight the pressing need for systemic changes to address healthcare disparities, emphasizing equal reimbursements and measures to lighten the provider load. Structural reforms should prioritize equalizing reimbursements, implementing technologies to streamline administrative processes, and fostering a culture of collaboration and preventative care. 1,10,11 These changes can contribute to a more resilient and patient-centric healthcare system.10,11 Considering these revelations, the study recommends a paradigm shift towards a single-payer healthcare system, which emerges as a viable solution to simplify reimbursement processes, ensure fair compensation, and alleviate the burden on healthcare providers.10 This transition aligns with the broader goal of fostering a more CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY efficient and provider-friendly healthcare system, ultimately improving patient care outcomes.10,11 In conclusion, this research offers a nuanced understanding of the challenges embedded within the American healthcare system and proposes actionable recommendations for reform. The call for a single-payer system, coupled with modifications to patient-centered care models, represents a comprehensive approach to address the root causes of provider burnout and medical errors.3,10 By embracing these recommendations, policymakers and healthcare stakeholders can embark on a transformative journey towards a more equitable, efficient, and patient-focused healthcare system. 98 CORPORATE GREED OF U.S. HEALTHCARE SYSTEM: A CASE STUDY 99 References 1. Obama B. United States Health Care Reform: Progress to Date and Next Steps. JAMA. 2016;316(5):525-532. doi:10.1001/jama.2016.9797 2. McClellan M. Reforming Payments to Healthcare Providers: The Key to Slowing Healthcare Cost Growth While Improving Quality? J Econ Perspect. 2011;25(2):69-92. doi:10.1257/jep.25.2.69 3. Bechel DL, Myers WA, Smith DG. Does Patient-Centered Care Pay Off? Jt Comm J Qual Improv. 2000;26(7):400-409. doi:10.1016/S1070-3241(00)26033-1 4. Tseng EK, Hicks LK. 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