I felt compelled to watch Obama's "Prescriptions for America" meeting the other night (transcript available here), where he talked about America's health care system and what he wants to change about it. I was curious about what he was going to say, especially after his speech to the AMA, where he said he would not put caps on malpractice rewards. For this post, I think I'll focus on the things that I didn't agree with during his meeting, and I'll leave the things that I agreed with for another time.
One of the first things mentioned during the introduction to the program was that Obama supports a health care system that resembles today's medicare, where the government handles the financing but patients still have the freedom to choose their doctors and hospitals. Now, don't get me wrong, I like the idea of universal health care. I don't mind government involvement at all, especially if it can get care for those millions of Americans that can't afford medical treatment. Like it or not, however, there is some benefit that insurance companies provide: they spread out patients to various providers, and they make people stick with their choices. People have a few doctors to choose from on their plan, and because of this they have to stick with their doctor. You might be thinking that this is horrible--what if you have a doctor you absolutely hate? Well, the good news is that you can usually switch a couple times until you find one you like. When we eventually get universal healthcare, there are going to be 50 million or so people looking for a primary care provider to call their own. The health care system will be much more stressed, and I feel that we need at least a few ways to organize the people entering the system, rather than allowing for a blind clusterfuck to occur. I already thought that primary care physicians would be specializing in the future, to where there would be divisions in primary care based on age, disease type, or even gender. This may provide the necessary stabilization to the program. Who knows. There is also something to be said about establishing a relationship with your patients, something that frequent doctor-shopping does not allow. We have to consider if too much of a good thing (freedom to choose a health care provider) is a bad thing in this situation, especially with such a large population entering the system.
There was also some discussion on private vs. public health insurance, but I think that a lot of people are missing the point. A lot of people believe that public health insurance will, in itself, lower costs for everyone. It's the simple fact that we have insurance for health care which is driving up costs. Looking strictly at costs, it won't matter what kind we have. A simple car insurance analogy illustrates this pretty well.
A while back, I was in a small car accident with an emo teenage girl bitch, probably talking to her friends on the phone about how her parents hate her, her boyfriend dumped her again, or someone left a nasty message on her myspace (I might be bitter). Anyway, she hit my stationary car in a parking lot while talking on her phone, causing a surprisingly significant amount of damage to my back bumper. I went to the repair shop, where the first words out of their mouths were "is her insurance paying for it?" When I said yes, they instantly put on a big smile, and we walked out to the car to see what the damage was. You would be amazed what these guys said needed to be fixed, all because her insurance was paying for it. They pretty much wanted to replace (or order the parts to replace) the entire back end of the car, when they obviously didn't have to. The mechanic even said that, if I was paying for the repair myself, I would be paying only $700. But the bill to her insurance company was $3400. In turn, this girl's rates are going to go up (ha! fuck her...sorry, I'm still bitter), and she'll be paying a lot more for any other accidents she inevitably gets into. Guess what? The same thing happens with health insurance. *Gasp*
Though it isn't as obvious in health care, and there are many more checks to make sure this doesn't happen...it does. In some instances, it is even encouraged. A skilled doc can tell when his patients have pneumonia when they walk through the door. They have an unmistakable cough, and their histories and physical exams confirm the diagnosis. Docs really don't need x-rays to diagnose it, but they have to. They're required to. By the insurance companies, no less. Otherwise, they won't pay the doc for the patient's treatment. Because they weren't there to examine the patient, the insurance companies need visual confirmation of the disease. So the docs get paid for the x-rays and the treatment, fucking over the patient in the process (because their rates may or may not go up, but they can still get points on their record for that x-ray) and wasting money. That's why health care costs so much. Will public health insurance fix the problem? Maybe, but why would it? Docs will still have to answer to the insurance companies, so "covering their asses" with needless procedures will still be the norm. Insurance is insurance...and it sucks.
So why do docs have to "cover their asses?" Well, Mr. Obama, it's because the pointy stick of malpractice is always about to ram them in the ass. It's why docs pay over $100,000/year in malpractice insurance (which, based on the previous paragraph, also sucks). High malpractice claims do cost the healthcare system money, and they cost patients money. Malpractice is one of the main reasons why costs are so high (and why docs are often grumpy). Fuckin' a, Obama, fuckin' a.
One of the last things I wanted to talk about was Obama's statement that more people need to be encouraged to enter medicine, especially family medicine, through loan forgiveness etc., etc. I hope Obama gets to the realization that the problem isn't that people don't want to go into medicine. The problem is that there are not enough medical schools and thus not enough people graduating from medical school. If all of these students went into primary care, we would probably still not have enough docs for the millions of people about to enter the system. I have dozens of friends who didn't get into medical school for one reason or another, but I know they'll be excellent doctors, just by knowing their study habits and their desire to help people. More than likely, they'll just apply and get in to medical school next year or the following year. It's not like we weed out everyone who doesn't get into medical school...we just delay their entering if they don't get in (40,000 people every year don't get into medical school--20,000 do. In the next year, over half of those who do not get in will apply again, and the cycle continues). It's been proven that students only need a 20 on the MCAT (out of 45) and a GPA of 3.0 to do well in med school. There aren't many people applying who don't get above these scores. Let's reconsider how we educate our physicians, and maybe a few pieces of the puzzle will naturally fall into place.
Hopefully I've shown a bit of my stance on national health care in this post--I think it's important to consider all of these things in the establishment of a new system. I'll probably end up doing more about this in the future, especially as more ideas get tossed around in D.C. about the topic.
Jim
Good post on a hugely important (and timely) issue, Jim. I take issue with some of your thinking, though. That's not to say I think that you're wrong about the facts, I'm just not sure I agree with your interpretation or your conclusions. I'll acknowledge right off the bat, though, that I'm far from being an expert on health care policy or the medical industry/ profession.
ReplyDeleteThe view of health insurance you put forth is, in many ways, identical to the one advanced by Milton Friedman: namely, that the idea of health "insurance" is nonsensical and mucks up the whole system. The simplest rebuttal is that paying out of pocket for medical procedures--while it would discourage overuse and abuse--is not feasible in many circumstances. Some things are just so expensive that pooling the resources of a group of people is the only way (or maybe just the only way I can think of right now) to allow someone to access it.
I like your analogy of car insurance but I think you miss the moral of it. Or at least you're not very explicit about it. The person bilking the system and driving up costs is the mechanic--the analog of the doctor. As far as I know, this is a pretty good indictment of the current medical system. A fee-for-service system in which doctors or hospitals profit from unnecessary additional procedures--bumping up the "car bill" from $700 to $3400 for personal gain while immune from punishment because a faceless insurance company is footing the bill--encourages inflated medical costs. If we're feeling very charitable and refrain from condemning rational actors for responding to the incentives of the system in which they find themselves, it's still hard to say the doctors are the victims of the present set-up.
You point to malpractice laws to make doctors less culpable for our current woes but I'm not sure how fair that is. As far as I know, a good deal of tort reform has been done at the state-level (in at least a majority of states), limiting doctors' liability and reducing malpractice insurance costs. On its face, the question of tort reform is a sticky one. Certainly, patients should have some legal recourse if they are harmed by a negligent doctor. But all systems are subject to abuse. Regardless, I'm not convinced that concerns about malpractice are among the leading (or the single largest!) contributors to exploding health care costs.
There are plenty of things that contribute to the rising cost of health care and some of them--possibly the biggest ones, I don't know--have serious moral ramifications attached to them. A significant chunk of expensive medical procedures come at the beginning and at the end of life. Our impressive abilities to sustain life--be it that of a severely premature baby or a chronically ill octogenarian--seem to have outpaced our ethical sense of when nature should be allowed to take its course. The fact that we can keep someone alive should not be taken to mean that we should. Sure, this is a potentially horrifying or disgusting notion to accept when one realizes that a significant motivator is the fact that it is very expensive to keep alive those patients who would otherwise die. It isn't helpful when someone produces one of those miracle tales of a premature child who "doctors said would not live" who pulls through due to persistent parents who refuse to let go. But the vast majority of us do not live in a world of miracles. We live in a world with multitudes of people and limited resources. A world where people fret over the simple notion that allowing more people access to a doctor might increase their wait time for a non-urgent medical excursion. But I digress.
One more comment (I swear) that I'm sticking in separately due to the character limit.
ReplyDeleteI agree with Obama that we need more doctors and I agree with you that any shortage isn't for lack of eager candidates. And yet it isn't mysterious why such a situation should arise. Limiting the number of doctors increases the prestige and the economic value associated with the occupation. Thus doctors themselves have an incentive to limit their numbers. This is related to something called credentialism, though certainly a great deal of specialized training goes into becoming a doctor. The issue is that there are gatekeepers who block entry to medical schools (or even the accreditation of new schools) or the granting of medical licenses. Milton Friedman famously argued against licensure for medical doctors altogether. While that's certainly a debatable idea, it does get at your point that someone needs to reduce the power of the profession's gatekeepers. Doctors will have to accept that this means reducing their salaries, which are already often inflated relative to their counterparts in other countries.
Thanks for the reply, Mike. I want to go through your points, and hopefully clear a few things up that you posted about. Perhaps I should have made a post about what I think should be done to (possibly) mitigate the problem as well, as that would cover a lot of what I'm about to talk about.
ReplyDeleteFirst, I realize that paying out of pocket is definitely not an ideal situation, and this would only further the problem we have in the U.S. I'm not advocating this at all. From my original post, I don't make it clear that I am only referring to the public health insurance that Obama is in support of (not the other systems in place around the world). It seems that he wants to keep the private insurance companies in place, while placing an "eye in the sky" with government regulations (this is what I gathered from his "prescriptions for America" meeting, not what he's said in previous pre-election speeches). I think that we would have to switch to a completely national health insurance system to eliminate as much of the corruption as possible. I would argue for a system that resembles the National Health Service (NHS) in the UK, or the health systems of many other European countries, for that matter. In the battle between their public systems and private insurance, I think a lot of people would agree that public systems ultimately provide the cheapest quality care for the most people. This isn't to say that private insurance hasn't found a niche in Europe. It most definitely has. Wealthy individuals often use private insurance as their means of receiving care, and, like everything, it has its advantages and disadvantages in a system dominated by the NHS. If you want me to explain this more, I would be happy to, but for the sake of space (and some kind of hidden character limit?) I'll move on to the next point.
I guess I did not explicitly say that doctors are also part of the problem (maybe due to some unconscious bias? haha), but you're right, they most definitely are. From the docs that I've shadowed, two family docs and two surgeons, I can honestly say that there were cases where an extra lab or procedure was needlessly performed at the doctor's whim, and that has to stop. BUT, you have to realize that a large portion of these procedures are required by the insurance companies. When your doc gives you a prescription, performs a procedure, or gives any other service, codes are written down that are sent to insurance companies (i.e. the CPT code for stitching an inch of skin is 12002, and the code for a flu shot is 90658). The thing is, all insurance companies have a set treatment plan for every condition, which often contains unnecessary procedures (mostly because you can't possibly say that every elbow fracture is the same, for instance). They'll get a handful of codes from the doc for, as an example, a broken arm (x-ray, cast, pain meds) and they'll determine if the right codes are present. If they're not, the insurance company may not cover the bill at all. Say you didn't get an x-ray for that broken arm--insurance may not cover your cast or pain meds. That's how your treatment is essentially dictated by insurance companies, and one reason why so much paperwork and documentation is required. Again, I'm not saying doctors are saints when it comes to this stuff...I'm just saying that people don't often realize how much of a factor their insurance companies play in their treatment, and also the implementation of unnecessary procedures.
On to the issue of malpractice. You're absolutely right--a good deal of reform has been made in tort reform. Did you know that anesthesiologists still often pay 1/3 of their salary to malpractice (as told to me during an interview with an anesthesiologist at the Cleveland Clinic)? That's $100,000/year. Surgeons pay a similar fraction, while family docs pay considerably less because they are not often performing acute procedures on patients in a life or death manner. If a surgeon leaves instruments in a patient, I agree that this is cause for a lawsuit--they should be paying attention to what they're doing. The tort reform, while limiting the kinds of cases that are brought to court, generally do not limit the amount that a patient can sue for. If you wanted, you could sue for $25 million if your doc left a 2"x2" piece of surgical towel in your abdomen. Is that right? Seems odd to me. So, malpractice continues to be very high--not because of the frequency of lawsuits, but because of the severity of the one horrible case where the patient sues for $30 million. And docs probably feel like they can make some of this malpractice insurance money back by performing unnecessary procedures, which leads to higher costs, fueling the vicious health care cost circle. Personally I think that's no reason to do this to patients, but it is what it is, and I have a feeling that malpractice contributes to it.
ReplyDeleteYou're also right about beginning/end of life treatment being a large portion of costs, but unfortunately we get into the issue of changing the laws about when someone is alive/dead, the definition of a "vegetable" and laws on DNR orders, surrogate decision making, and the such. We're getting into ethics, which I like, but I don't think these definitions and laws are going to change in the near future. Also, unless we give docs the ultimate power of attorney as the surrogate decision makers, families will continue to leave their loved ones on ventilators, keep very sick preemies alive, and cost us millions. That's the price we pay to stay in control of our own care and the care of our families We have to change a lot of ideologies to curb these two ends of the spectrum with regards to costs.
Finally, while I think that credentialism does play a part in the limited number of docs entering the system every year, I think there are also other components. Simply, the resources needed to train even a small number of physicians are enormous. We also have to have a place to obtain put these graduated med students for their residencies, something that may be hard to do with an infusion of tens of thousands of new students. As far as decreasing the salaries of physicians if a lot more docs enter the system, wouldn't the infusion of 50 million new patients (under Obama's plan) somewhat offset the increase in physicians? I feel like salaries would not decrease as much as you may think, given so many more patients (and a reduction in malpractice insurance, which would also hopefully happen).
Let me know what you think about all of these issues. I'd be happy to talk about anything, including ethics--I find it all really interesting.
Jim, have you been keeping up with the different plans that are being bandied about right now? I know there's at least two Senate plans in the works, a more liberal creation from Kennedy's HELP committee and a slightly less bold plan from Max Baucus's Finance Committee. Then the House Dems are supposed to be working on their own plan (I don't know if they've released the details yet other than Pelosi's promise that it would have a strong public option).
ReplyDeleteMaybe we could do a comparison of certain features of the different plans once they emerge in greater detail. Might be a nice companion piece to this post and would give you a chance to discuss how you think different provisions would impact the medical profession and the cost and quality of health care delivery.
Yeah, sounds good. Obama's deal with the hospital administration is also pretty interesting, and I think similar talks are in the works with drug companies. I think a comparison of all the plans would be a good idea.
ReplyDelete