Nice post, Shodan.
I don’t have anything more to share at the moment, but I wanted to let you know that was interesting, informative, and really articulate. Thanks.
I think this is the rationale to explore.
It’s not that I’m unmoved by even sven’s passionate, “It just seems right.” But frankly, that’s the sort of argument that doesn’t lend itself to rigorous proof. In other words, someone else may as lief say, “Well, it seems right to me.”
I agree with even sven that, as a matter of morality, we should all want to help our fellow man in this regard. But I am equally cognizant of the fact that this argument doesn’t sway people that don’t share that view of morality. So I feel it’s important to couch the debate in terms of the practical, measure effects to society when not all of its members have basic health care.
- Rick
Sho – poor example to use the drive-thru deliveries. There are good medical reasons to keep new mothers & babies more than 24 hours, and a lot of doctors have testified about that. What makes people nuts (and makes them into HMO-bashers) is when they perceive that some 19-year-old clerk in an insurance office is making that decision and not their doctor.
It’s also a lot easier to objectively suggest that other people in a certain category should be denied life or health or better functioning. It’s a lot harder for yourself or a loved one.
As I said before, there is a “slippery slope” problem in that there are certain situations – and you’ve mentioned a couple – where almost any rational person would agree. Where that category ends and another begins is another problem altogether.
And then there is the issue of marginal vs. improved functionality. How about the person who won’t necessarily die because of a health problem, but whose quality of life will be marginal? Where does one draw the line?
As an intern, and thus someone who provides a lot of medical care without making the ultimate decisions about it, I’d estimate that at least half of what gets done to my patients, dollar for dollar, confers no marginal benefit at all. Of course, you can’t eliminate all of that, since you don’t know exactly what falls into which half in advance, but I’d say that I could eliminate a third of the costs incurred by my patients if we were willing to take even the most remote of chances.
No one wants to be the one responsible if something goes wrong, so there’s a strong drive to overdo it, “just to be safe”. We’ll use Zosyn at $15/dose rather than Ancef at $2/dose, on the off chance that this might be Pseudomonas. We could get this patient back on her beta blocker and an aspirin and send her home, but instead we call a cardiology consult, and cardiology overreacts similarly and does a cath.
Speaking of cardiology, one of my pet peeves with our local heart docs is their tendencytoward the expensive heart failure/blood pressure drugs like Altace and Coreg. While I accept that these drugs are marginally better than other ACE inhibitors/beta-blockers, they cannot accept that the marginal benefit might not be worth five times the cost, especially when my patients can’t even afford the cheap versions.
However, if the patient is a Medicaid patient (who thus has prescriptions covered), it costs about the same to them to get Coreg as, say, metoprolol, which is probably 90% as good and costs $20/month rather than $100/month. (These are all guesses.) I’m supposed to be an advocate for the patient, so you could argue that I’m obligated to provide the best treatment their money can buy–or the best treatment their provider is willing to pay for.
So I think the best way to improve access to health care is to become comfortable with the idea of uncertainty and risk, and lower our threshhold for what constitutes acceptible marginal benefit. It doesn’t even have to be as clear-cut as withholding expensive care for extremely premature infants and terminally ill elderly patients.
In many cases, it’s just the opposite of what Weil is asserting–it requires the doctor to accept that his judgement is probably right, and it isn’t worth it to spend thousands of dollars on tests and treatments just because he might be wrong.
Dr. J
MLS:
I find it hard to believe they aren’t. When you’re not the one paying for your health care, why should you make even a token attempt to use judgement when deciding when you should or shouldn’t see a doctor? If you want to see a good example of peoples’ “restraint” when they’re getting their goods for free, visit a buffet. Notice the huge piles of food that get thrown away, because people can get as much as they want for free, even if they have no intention of eating it.
Kempis:
Ack! Horrible, horrible idea. A couple years ago, I had no medical insurance. If I’d really wanted it, I could’ve had it, but I felt I had better things to spend my money on. Please explain to me why I should’ve been forced to pay for something I saw no need for. The car insurance bit is different - you’re required to have insurance so that you can pay for the damage to the other car, not your own - liability insurance. Your idea would be akin to requiring comprehensive auto insurance, which would be an equally horrible idea.
Shodan:
Interesting idea, and excellent post (as usual), though you’re correct in that it’ll never happen, for political reasons. May I assume, though, that under your plan, if I’m wealthy and can afford either the procedure, or the insurance that covers the procedure, I can choose to save my ailing premie, or 80-yr-old dying grandpa?
Jeff
Let’s remember who lives, and dies, in America. America has far a much larger percentage of immigrants and illegal than any other country.
There are a few ways you can look at the numbers and see a similar or slightly longer life expectancy in Canada or Japan or some northern European country, yet if you try to adjust for the number of people who spent their formative years in a third-world country and then died in another country, all of a sudden the US seems to have a spike.
If you want to spend hours and hours looking at populations and outcomes, the picture for America seems better than anywhere else.
Unfortunately, I don’t think it’s possible to be absolutely sure when comparing healthcare in industrialized nations.
For my money, the biggest healthcare cost for uninsured Americans is time.
Great post, Dr. J.
I grew up poor, and am still poor. I have seen the poor scam for a lot of things. I’ve seen tax fraud. I’ve seen rent fraud. I’ve seen outright theft. But never in my life did I see the poor scamming for extra visits to the doctors.
Why? Because the poor are busy scamming to get stuff they need, not stuff they don’t need. An extra visit to the doctor isn’t going to buy the kid a new pair of shoes or some formula for the baby. It’s riduculous to argue that the poor are so dishonest that they’d just use resources for the hell of it.
Define Basic. I admit when it comes to long term treatment for serious illnesses or acute emergencies, people are going to face troubles if they can’t afford treatment. But we do have purified water, sanitation, antibiotic, vaccines, discount plans and an endless variety of generic medications that can be had for a low price. I consider that to be basic healthcare.
Gee, where to begin.
Off the top of my head, I’ll address even sven’s comment since this was one of the last topics revisted when I decided to post:
Actually, people will go to the doctor for any little thing if they know they will suffer no consequences for it. Just work a few hours in a medicaid clinic and see how many of those patients are in the waiting room with “sniffles” or a cut that requires nothing more than a bandaid. Many people think this is what’s wrong with Canada’s system, although I can’t really speak to that since I have no personal knowledge of it. This is also why many people think even medicaid patients should be required to pay at least a nominal fee, which could be waived at the provider’s discretion. And it’s not that they’re “scamming”, it’s just that they think they are entitled to go see a physician when they have a mild, self-limiting disease. People who have no insurance are not usually able to fritter away their limited health care dollars on something that medical treatment will have no effect on the outcome, and the insured folks are too often tied up at work to visit their physician for a trivial matter.
One of the things that have driven up the costs of health insurance is this sense of entitlement. People as a rule either forgot or never knew what “insurance” was designed for - a catastrophic and/or unforseen event. Having an uncomplicated pregnancy, a medical screening, or imminuzations are neither catastrophic or unforseen, but people started demanding that their health insurance policies cover these items too. Next they started demanding their insurance company pay for their birth control, which now means insurance is paying for items that are not even medical, much less catastrophic or unforseen. A couple in Dallas was successful in litigating their carrier into paying for their child’s car seat, simply becuase the child needed a special seat due to a medical condition! Sheesh! I have to consume a special diet due to a metabolic disease - soon, I guess, Aetna will be buying my groceries!
And let’s expand on DoctorJ’s good points. Not only are the physicians often ordering tests that are only marginally necessary, but since the patient is only going to pay a small portion of this (even less with an HMO) they aren’t going to say “hey, wait a minute, is this really necessary?”. When you shift responsibility to a third party, there is no longer any accountability. In an attempt to curb these expenditures the insurers began requiring authorizations and precertifications. The uproar has been so loud in the years since this has started that it is beginning to go away. My insurance company, although an HMO, no longer requires a referral to see a specialist.
As far as studies like Gadarene’s, I wonder - if you are figuring all healthcare dollars, I wonder. I have more than one life-threatening disease. But I also have allergies and migraines. These are certainly neither life-threatening nor even health-threatening issues - I take medications only to improve the quality of my life and make myself more comfortable. So, unless those dollars are omitted from these type studies, they are bogus, in my opinion.
Ditto to most of what RickJay and Shodan say, too.
Then you still have a lot of difficulty with the Canada example. In fact, Canada has a HIGHER percentage of foreign-born residents than the U.S. One sixth of everyone livi9ng here was born elsewhere. Canada’s per capita immigration rate is very high.
I can hear the hammers of the state’s democrats hammering another nail into the coffin of California’s small businesses, and eventually the coffin of California as we know it today…
The Cal-Dems already shoved through the a paid-leave bill which taxes the employees and starts another bureaucratic system for any employee on medical leave (even after they work one day at a new job).
Another 25+% hike in worker’s comp premiums coming this year without any consideration of reforms and a democrat governor who is not able to balance a budget because of weak revenue.
More people come here every day, but businesses relocate out of the state (or country) to avoid the dem’s approach of “taxing the businesses to cover for all the shortfalls”. Each year, I re-evaluate my viability of doing business here, and I’m beginning to feel that I should sell or relocate within 5-10 years if this non-friendly attitude towards businesses in California keeps its current heading. I currently pay 50-60% of an employees health coverage, but cannot afford to cover dependents. If I was forced into this system, guess what - I’m going to cut my losses and leave (like other small businesses before us). Some of my employees are savvy enough to know that the writing is on the wall, but they won’t leave our company because they cannot find a job that pays better (w/benefits).
California claims to be a progressive state, but we’re progressively getting worse and eventually heading for ruin. Health care coverage would be great and should be available for everyone, but if it means jobs and businesses lost in the process, then nobody except millionaires will be paying for their own healthcare.
OF course, the US does have much higher obesiety rates than any other First World country. If people in the US would just eat less and exersise more, that alone would reduce health care cost.
Referring to required health insurance …
Because if you don’t I have to.
So let us say that you got sick and showed up in an ER. Possible heart attack. You would be seen. You would be admitted if you needed to be. You would be charged full retail, not the discounted PPO rate or the smaller amount the HMO pays. You would never pay it off. The hospital, the docs eat it, and pass it along.
Uninsureds cost the system, cost you and me, lots of money. They get sicker because they don’t get preventative care as they should. They get cared for in the most expensive way possible … in ERs where every test gets ordered, rather than in a private MDs office where a relationship allows for better and more cost effective care.
We currently ration healthcare … irrationally.
Mandatory basic healthcare insurance.* Same fee for the same product all comers, whether you are part of mega-corp or Joe Blow, pre-existing condition or not, only out is for risk factors under conscious choice, eg smoking. Cut out the administration costs of all that cherry-picking. Companies compete on product package and cost and service. Buy the deluxe package if you want.
(Yeah, “open minded” is believing what Weil has closed his mind about. I’ll stick to my skepticism of all points of view.)
*Yes, debating what is basic is an open question.
The only problem I see with mandatory health insurance is the truely truely poor. I don’t drive because I can’t afford car insurance. But I don’t have a choice about the whole living thing.
The more you legislate, the less choice you give to everyone else.
If you make health insurance mandatory, you are enforcing the disconnect between health care and its perceived costs. It is the old problem of the commons. If I am forced to pay premiums on health care, that is a sunk cost. It is therefore in my own best interest to get as much for that sunk cost as I can manage, therefore I go to the doctor for every little thing, self-limiting or not. This is why even HMOs have co-pays, to combat this tendency.
We seem to have set up in America a health care system that actively works to eliminate cost-benefit analysis. I agree very strongly with DoctorJ and lorinada on the nature of the problems facing us, and disagree with MLS (sorry). I never saw a cost-benefit analysis of “drive-thru delivery” that offered a justification of a longer average ospital stay - indeed, the analyses I saw found no statistical differences in outcomes. But it is traditional to keep mothers longer, the patients like it(and perceive it as free), and maternity dollars pay for a lot of the rest of the hospital’s expenses - and we get laws passed to mandate a policy that drives health-care costs up with no medical benefit.
A couple of posters have mentioned the slippery slope aspect of my recommended reforms. Entirely true. Much of the problem is that we react in the US to slippery slopes like this by treating everyone with everything no matter what - either out of fear of being sued, or because the patient is insulated from the real cost by insurance or by government programs.
ElJeffe - yes, under my proposed system, a wealthy person who wanted to could spend whatever she desired on prolonging life for the dying. The hope is that by reducing demand, the cost of such care might be reduced.
The hard part of all of this comes when you have to deny care in cases where it might make a difference. As DoctorJ mentioned, sure, maybe the drug has been shown to be 15% more effective in clinical trials - but it costs ten times as much. So you can’t have it.
And then it hits the fan.
Regards,
Shodan
Here’s a point I would like someone to address:
Where would you draw the line between public health (paid for by the community because it benefits society as a whole) and individual health care? For example, treatment for contagious ailments (I guess SARS would be the current example). Is there enough of a threat to society to justify the resources currently used for it? Or, to take another tack, society as a whole, does better with healthy and longer-lived individuals. How much of an investment should the community put into an individual’s well being?
Healthy? Probably. Longer-lived? Not necessarily.
Smoking, for instance, has been a boon to the Social Security system. This is because smokers often pay into the system all their working lives, and then die at the age of fifty without ever collecting anything. Also, two of the most common diseases of smoking, heart disease and lung cancer, are relatively cheap diseases to die from - lung cancer, because it is often asymptomatic until after the lesion becomes untreatable, and heart disease, because quite often, the first symptom of serious heart disease in a chronic smoker is death.
Or consider how much money we could save on NICUs if most premature babies died at birth.
I am not arguing that any of these outcomes are necessarily desirable. I am arguing that efficiency in health care delivery is often counter-intuitive, and the automatic assumption that a longer life = a public good is part of what drives people to drag out the process of death long after it is clear that we are only delaying the inevitable - with the thousand to one chance of a miraculous recovery.
Most of the advances in life expectancy in the Western world are due to a very few factors - sanitation, improved nutrition, vaccination of infants, and broad-spectrum antibiotics. All wonderful things, no doubt, and highly efficient in improving the health status of the US. But there are relatively few other changes that we could make that would have a comparable impact. Thus there are few other easy choices.
Most of what is left is questions like AIDS. Twenty years ago, AIDS was a death sentence within a year or so. Nowadays, with protease inhibitors and AZT, AIDS patients can live for years - at a cost of fifteen thousand dollars a year or so for their treatment. Even if we all agree that this is a good thing, the unavoidable fact is that this is fifteen thousand dollars a year that cannot be spent on anything else - and that fifteen thousand does not come out of nowhere.
Historically, we chose to avoid the question of what to spend our health care money on by choosing everything. Thus the cost spiral we are now experiencing.
Regards,
Shodan
Well I don’t really have any alternative to offer but would like to sound off on a few things I have observered in my lifetime. Background to follow:
My father was a surgeon in a small town with 3 other surgeons in the seventies. My wife is in sales related to the medical industry. I have seen what completely socialized medicine can be (military) and have been uninsured (self sustained student) been a business owner (paying full benifits for employees) and am currently an employee myself at a small (70-100) company that payes full medical benifits for employees and offers health insurance for families.
I will try to give as little comentary as possible because this could quite possibly be a very long post. Here are some of the problems that I see.
When my father was practicing he was constantly frustrated with the other surgeons around him because of what he considered unnessary operations or operations that where performed with the slightest indication that an operation might be needed. He also fell into the timeline when and let me quote him “in order to make any money at all you had to have some kind of little pissant lab in your office in order to suppliment your bussiness”. In conversations that I have had with him since his retirement we have discussed insurance providers and his take was that private insurance was much much better than Medicare or Medicade because of the hassle that a doctor would have to go through in order to be paid. He said it was not uncommon to wait 90 or even 120 days to be paid for an office visit. Anybody in business will tell you that having accounts recievable stretched out that long is a real cost of doing business. His last complaint was that malpractice insurance was astronomical and these were the days before Mississippi was the I sue you capital of the world. He has been convinced that we are headed for socialized medicine in the US for a number of years. As an aside he went broke in his private practice and moved to California and made a ton of money doing hairtransplants of all things. His lament to this was “I spent twenty five years trying to scrape out a living trying to save peoples lives and had to move to California putting hair on bald people before I ever made a damn dollar.”
My wife on the other hand is in sales. She calls on doctors offices all day long. We live in the poorest state in the union and her territory is in the poorest part of this state. Drug companies, doctors, and everybody in between are being sued every day here and it has gotten so bad that lawyers even run ads in papers advertising for clients. The drug she sells just came out with a new indication and within five days of comming out with the indication (which really isn’t that serious and would only effect the very elderly who are already seriously ill anyway) the papers in 10 cities have run advetisement by lawyers. She says that 75% to 80% of the people she sees in the doctors offices are medicaid patients most are there for the common cold.
As for myself I provided health care insurance for my employees when I had my own business (in order to attract employees at that time you had to). We were a small business and the employee insurance package was about 1/3 of our total monthly operating cost. I personally have been to the doctor one time in the past 10 years and that was just for a checkup I had insurance at the time and I still had to pay over $250 copay. It chaps my ass that I have either personally paid or it has been paid for me probably over $15,000 over the past ten years into insurance and the one time that I go get a checkup it cost me $250 out of my own pocket.
I know this is a long narrative and I don’t have any answers but these are some of the things I see going on around me.
P.S. Excuse misspelling I don’t have time to proof.
Shodan,
I guess I was thinking of additional productive life - taking your AIDS example, if the patient experiences a fairly normal quality of living, his productivity should offset the cost of his treatment. I look at the projected increase in retirement ages, which I believe is a reflection of an increase of relatively healthy individuals in each age cohort.
Overall, I suppose I look at health care as a subset of the cost/benefit of the individual as a whole. As you mentioned earlier, most of the health care expenditure for most people is at the end of life (the majority don’t have any problems at birth) but this is a relatively recent phenomenon. I recall seeing a study researching the cost of absenteeism due to illness (I’m looking for it now). I think there is a real practical benefit to society as a whole in individuals as healthy as long as possible. Part of the problem is that in a capitalistic system (not that that’s bad; I’m a wannabe capalist myself) is that with the number of payers between patient and objective, good or restored health (the healthcare provider and all of his support; the insurer; the pharmaceutical industry, lawyers, etc.) have a vested interest in making a reasonable (or unreasonable) profit. The system doesn’t appear to be set up to save money, no one appears to get a direct benefit for costing less.
even seven,
Your point is valid; any such system would have to be coupled with tax credits on a sliding scale and continuation of a “free” system for those in true dire straits.
Shodon,
Your point is not valid. Co-pays can still exist. Deductables can still exist. But as a doctor, I can tell you that my HMO patients are thrilled as can be to talk to me over the phone and be told that they don’t need to come in. Just as thrilled as those with high out of pocket. Time is most people’s most valuable resource and they do not want to waste it. And this in an office that usually sees patients within 10 to 15 minutes of their appointment time.
Lung Ca and heart disease are cheap?!? Just plain not so. I’d ask you to provide some cites for your claims but I know that they do not exist. Maybe later I’ll do a quick PubMed to get some numbers on what these diseases cost our society.
As to doing the dollar and cents cost benefit … calcualtions have to place a dollar value on year of life saved and quality of life. Hard to do, but it is meaningless unless you do so. Make some real comparisons … how much does it cost to potentially save a year of life with universal mammography screening at 40 to 50? With colonscopy from 50 on? So on. Are we consistent with how much we spend or do those with more organized voting blocs get more approved, are some interventions more appealing because they are “sexier” technology or have people with appealing faces?