52293-Health Care Reform

[Darth Fedora]

Mad props to Claudio and Foreman! Thanks for being the voice of reason, guys.

[Waldorf and Sauron]

Foreman's glorification of a doctor's profit motive leaves out an important flipside - one significant reasons the cost of healthcare is skyrocketing is that doctors will often order expensive — and frivolous — tests just to make a buck. Certainly doctors should be paid well (but is it really that inappropriate to draw the line at one porsche and one mansion instead of two houses, a porsche, and a ferrari?), but in the end, we'd all be better off (or rather, those who struggle with health care costs would be better off) if doctors were motivated only by the patient's best interest, and not their own. Am I naive to think that a doctor can be motivated by compassion and humanity just as well as money?

That's how it works at the Cleveland Clinic, which pays doctors a salary instead of by procedure, simultaneously bringing the quality of health care up and the cost of it down.

[Darth Fedora]

I am extremely skeptical of the idea that most doctors order unnecessary tests to make more money. The few who do that are certainly behaving unethically.
Yeah, doctors order plenty of unnecessary tests, but it's generally to prevent possible malpractice suits. Tort reform would reduce those unnecessary tests more than anything else would.

[Darth Fedora]

And let's get real--only a handful of private-practice or administrative docs can afford mansions and Porsches. Maybe in the 80s that would have been more true, but it's definitely not now.

[Waldorf and Sauron]

I guess it depends on how big of mansions we're talking about.

Take a look at the article "The Cost Conundrum" in The New Yorker, an article that has heavily influenced the Obama administration.

One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.

Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.

Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“Come on,” the general surgeon finally said. “We all know these arguments are [crap]. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.

The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”

[wired]

I guess it depends on how big of mansions we're talking about.

Take a look at the article "The Cost Conundrum" in The New Yorker, an article that has heavily influenced the Obama administration.

One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.

Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.

Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“Come on,” the general surgeon finally said. “We all know these arguments are [crap]. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.

The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”

While that article is fantastic at pointing out that there are problems with too many people receiving ancillary or unnecessary procedures, it does not address the fact the government will somehow manage to do this better than private insurers. Furthermore, this looks like a case where the author of an article took a position and then looked for evidence to support his claim rather than objectively trying to determine where issues were. For instance, his assertion that, "he would call on the heads of its hospitals, in their swanky, decorator-designed, churrigueresco offices, and... ask them," leaves me little doubt that he already views them as the problem.

Really, if the Obama administration is taking cues from what appears to be an biased, un-documented, highly anecdotal article, I'm pretty disappointed.

[Foreman]

Foreman's glorification of a doctor's profit motive leaves out an important flipside - one significant reasons the cost of healthcare is skyrocketing is that doctors will often order expensive — and frivolous — tests just to make a buck. Certainly doctors should be paid well (but is it really that inappropriate to draw the line at one porsche and one mansion instead of two houses, a porsche, and a ferrari?), but in the end, we'd all be better off (or rather, those who struggle with health care costs would be better off) if doctors were motivated only by the patient's best interest, and not their own. Am I naive to think that a doctor can be motivated by compassion and humanity just as well as money?

That's how it works at the Cleveland Clinic, which pays doctors a salary instead of by procedure, simultaneously bringing the quality of health care up and the cost of it down.

Again, false dichotomies are not our friends. Just as benevolent doctor can but need not equal best doctor, profit-motivated doctors are not necessarily unscrupulous ones. Someone can be perfectly good and legal and ethical without 100% altruism. Noble motivations are great and all, but we all have days, no matter how much we love our job/field, that we're really just there because we have to get it done and we want the paycheck.

And hey, maybe there's a medical legal suit cap in Texas, but that still leaves a lot of states out of the equation. There really are places where people will be sued for millions, and insurance for such a likelihood ain't cheap. Again, noble motivations are great, but you know just as much as I do that when the chips are down, everyone looks out for number one. Taking extra precaution is not unreasonable in this sue-happy world.

Besides, there's such a thing as caring too much. If doctors were that seriously involved with every patient's well-being, they'd quit or lose their minds within a year. People die, and you have to be able to emotionally distance yourself from that at some level. Heck, many things that could be considered (in some cases) "in the patient's best interest" will get you in trouble. For instance, a patient is suffering from a terminal illness and would prefer euthanasia. Showing compassion and respect for their wishes in this case will get you arrested.

There are policies and practices in place because they protect patient and doctor. Some people (on both sides) doubtless find ways to take advantage of the system, but one problem does not vilify a whole field of people. People who are trying to keep you alive, to boot.

[Waldorf and Sauron]

Wired,

I'm having a hard time understanding your knee-jerk reaction. Is your problem the "bias"? Because everybody's biased. And it's not like this is his first time approaching the topic; in Mr. Gawande's case his "bias" —or rather, point of view— comes from his roots in his long career as an surgeon, health researcher, and health analyst. So, if it's a bias, it's an expert bias. And I think he's a little more balanced than you give him credit for: after admitting his preconceptions (those "decorator-designed, churrigueresco offices") he notes that "her office seemed less churrigueresco than Office Depot," indicating a challenge to those preconceptions.

I'm not sure why you say it doesn't address problems in the government systems; the article's first focus is wasteful medicare (government) spending in McAllen, TX.

As far as calling it anecdotal, I disagree; I think anecdotes are well balanced by interviews with experts, executives, and doctors, and scientific studies. He cites several facts, figures, and studies.[/url]

[Waldorf and Sauron]

Foreman,

I was mostly replying to your assertion that "capitalism is just as valid a motivation as anything else at the end of the day." Again I ask (in context) "Am I naive to think that a doctor can be motivated by compassion and humanity just as well as money?" I never meant to insinuate a dichotomy, only an alternative. I believe the profit motive is good overall — I doubt we'd have very many doctors if there were no paychecks — but I'm trying to say that profit is not the best motivation for everything.

No, McAllen, TX is not a microcosm of America. It's American healthcare at its most corrupt, degraded, and profit-driven. That doesn't mean all profit drive is bad. It just means we have an example of what we can turn into if we're not smart about the specifics of profit motives in health care.

I didn't mean to vilify doctors in general. I did mean to challenge the sainthood of unbridled capitalism.

[Imogen]

there's a reason my dad drove my mom to harlingen texas when i was being born instead of mcallen. it costs more and the quality of care is less.

[vorpal blade]

My take on this is … follow the money.

Why are doctors in this country paid so much, but paid no more than school teachers in other countries? It’s because the supply of doctors is limited here, and the demand is great. If the doctors were heavily competing for business they would have to lower their prices. I believe they charge as much as they do because they can, and not because they have to.

Why is the supply limited? They make it expensive and hard to get into medical school, and difficult for doctors trained outside of the country to practice medicine here.

And why is that?

I think the real problem is that the American Medical Association limits the numbers of certified doctors and medical schools so that the doctors can charge more money for their services, and the medical schools can charge higher prices for their schooling. Congressmen find it to their advantage to support the AMA in its anti-free market practices.

[Foreman]

Foreman,

I was mostly replying to your assertion that "capitalism is just as valid a motivation as anything else at the end of the day." Again I ask (in context) "Am I naive to think that a doctor can be motivated by compassion and humanity just as well as money?" I never meant to insinuate a dichotomy, only an alternative. I believe the profit motive is good overall — I doubt we'd have very many doctors if there were no paychecks — but I'm trying to say that profit is not the best motivation for everything.

No, McAllen, TX is not a microcosm of America. It's American healthcare at its most corrupt, degraded, and profit-driven. That doesn't mean all profit drive is bad. It just means we have an example of what we can turn into if we're not smart about the specifics of profit motives in health care.

I didn't mean to vilify doctors in general. I did mean to challenge the sainthood of unbridled capitalism.

I believed I'd made it clear that, yes, I believe altruism and genuine concern are the best motivations for providing health care, and I'm sure that a huge majority of doctors possess them to some degree. Still, money is most likely the lowest common denominator, and if that gets the job done right, there's nothing wrong with that. I don't like people getting ripped off any more than you; but I also apply the same right to the doctors, who have worked long and hard to get where they are.

In any case, I really feel like the issue is with insurance companies, not doctors. Doctor bills are high because if they request, say, $1000 dollars from the insurance company for the treatment of the patient/insurance customer, the insurance company offers them $500 (for instance). Doctors offices start making less, so they charge $2000 so they can get haggled down to the just $1000 they wanted in the first place. Uninsured people do lose out on this deal (sorry, Cogs), but if the doctors can't recoup their costs from insurance, what are they supposed to do? In the mean time, the companies are benefiting from paying less while collecting payments from their customers... who they apparently can and will pull the rug out from under once they really have a health problem.

In other words, I can see a need for reform, and it's even possible for medical care prices to go down without deserving doctors taking the hit. I call the foul on insurance companies, for not fulfilling their responsibilites to either doctors or patients.

[medievalman]

As far as doctors only ordering tests to make more of a profit, I'd rather they did that than the reverse. I almost died because doctors wouldn't order tests, it was the third doctor I went to that finally decided an mri would be a good idea and discovered that my appendix was about to burst. After being told by the first two that I only had a flu (without doing any real testing) I was rather grateful for the emergency appendectomy that the third doctor ordered after he saw for himself what the real problem was.

[vorpal blade]

A few random thoughts.

I have to smile when people say that doctors deserve high salaries because they have to spend so much time in school before they can start earning real money. I spent six years of full-time, maximum credit hours, class work after I had a bachelor's degree. Then I spent 10 years working on my dissertation before I could get my degree. Today, at the end of my career, I earn about half of what a doctor is guaranteed to make in his first year of practice working in our local medical clinic. And I’m still taking classes every year.

While my experience may not be typical, it is typical for a Ph.D. student to spend as much time as a medical doctor, including all the time the doctor spends in residence and internship. I have a pair of nephews who are twins. A couple of years ago one of them became a doctor and set up his own practice. His twin is still in school, working toward a Ph.D. in history. The doctor had his pick of places to live in this country, and will be earning far more than his twin will ever earn, if the twin can even find a job with his major.

I wouldn’t have a problem with that, if the free market dictated how much each earns. But when the market is manipulated to create artificial shortages I cry “foul.”

I don’t know any doctors who order additional tests to make more money. In my experience the doctors don’t earn anything from these tests. They recommend a patient have some blood tests, or an MRI, or some such, and the patient goes to that testing center and pays those doctors or technicians and the testing center. The original doctor doesn’t see a penny of that testing money. He orders the tests because he is unsure of your problem and wants to give you the best care he can, or to protect himself from being sued for malpractice. Medical technology has advanced to the point that we can do many more expensive tests, which brings with it the question of how many of these tests are really necessary. Some doctors will err on the side of caution.

Besides, those with insurance don’t really care how many tests are done, or even how much money the doctor is earning. The money doesn’t come directly out of our pockets. Indirectly this leads to paying an outrageous amount of money in insurance. In our brains we don’t always think that our free use of the health care is driving up the insurance costs. For many of us our employers pay a large portion of the insurance costs. We don’t often realize that whatever the employer pays on our behalf means less money he can pay us in salary, or the more he has to charge for the goods or services your company provides. Because nothing is free in life. And if it were just one or two of us with a careless attitude about the cost of our health care it probably wouldn’t make a difference. It is when millions of us want to get our money back from all the insurance we pay that the insurance companies have to fork out billions of dollars.

I don’t blame the insurance companies. They are just trying to make a living as well. One way they can keep their costs down, so you can [barely] afford their insurance, is to negotiate with the doctors on how much they will pay. In my experience I have to pay what the insurance company will not pay, but perhaps your experience is different. The insurance companies see themselves as a force to keep health care costs down, so that doctors don’t just charge whatever they feel like charging, and making as much money as they want. If you had to pay for health care out of your own pocket, you too would negotiate with the doctor on the price. You’d shop around for a doctor who would do it cheaper. Unless it was an emergency, and you had no choice at the moment. Then wouldn’t you be glad to have an insurance company who had already negotiated in your behalf?

[Nanti-SARRMM]

I think MidievalMan has a point. I mean look at House. He orders tests left and right and most usually the patient survives because of it. So clearly he's onto something.

[Cuddlefish]

Dr. House is perhaps not the best example of what a doctor should or should not do.

Vorpal Blade-

If you don't have health insurance and you have an emergency procedure, it's possible that you can get some or all of your debt forgiven. My husband had an emergency appendectomy last year and didn't have health insurance to cover it. The total bill for an ambulace ride, a fairly simple sugury, and less than a day in a hospital bed was over $22,000. After about a month of proving that he was, in fact, a poor college student with no real assets, the hospital just forgave the whole debt. The point is, you can still negotiate after your emergency if you don't have health insurance, and sometimes you can even get a better deal than an insurance company could have given to you.

[vorpal blade]

You are right, Cuddlefish. Thanks for reminding me. I don't think Cognoscente was so lucky with his medical emergency. I think those of us in the middle, too much money to not have to pay, too little money to be comfortable paying, have it worst.

[Foreman]

A few random thoughts.

I have to smile when people say that doctors deserve high salaries because they have to spend so much time in school before they can start earning real money. I spent six years of full-time, maximum credit hours, class work after I had a bachelor's degree. Then I spent 10 years working on my dissertation before I could get my degree. Today, at the end of my career, I earn about half of what a doctor is guaranteed to make in his first year of practice working in our local medical clinic. And I’m still taking classes every year.

I don't think it's (entirely) that they spend a long time in school. Obviously, time in school has to do with the amount of knowledge gained, but I think the money comes down to the usefulness and demand for said knowledge.

I could become an expert in, say, monarch butterfly migration, but I can't make myself believe there would be an incredibly high demand for such a specialized field. Health care, at some point or another, is going to impact 100% of the population. That's a lot of demand for a very useful set of skills and information. Thus, there's money in it. Just because someone is very educated in something doesn't automatically make it lucrative.

As for the supply restrictions, I don't know exactly how those operate (is there a set number, percentage of applicants, etc? Any actually real, cited, informative statistics would be good), but I for one don't mind medical schools being really selective. I'd like to visit a doctor who deserves his degree, and hopefully didn't just squeak by his licensing examination.

[Darth Fedora]

Regarding vorpal blade's comment:
I'm not saying that doctors deserve to paid well just because they spend a long time in school. I'm saying that to make up for the opportunity cost of spending so much time falling into debt instead of making a salary while they're in school, you have to offer future doctors enough of an incentive that the really smart people will want to go into medicine.
It is really important for the quality of life of all Americans that their doctors be the best and the brightest. It's only marginally important to the quality of life if historians are smart. (please, nobody read that the wrong way, I'm not trying to open up a debate about the relative merit of the humanities)

[vorpal blade]

I’m sure it is very tough to become a medical doctor, and there are many sacrifices you have to make before you finally reach your goal. However, I think Claudio somewhat overstated the sacrifices. According to several sources I looked at, the average debt after medical school is not $200,000, as claimed by Claudio, but about $100,000. The University of California at San Francisco, for example, says with the scholarships that they offer their average student debt is $66,958. High, but less than you might have thought. And you might find an even more inexpensive medical school, I wasn’t looking for that. See this site: http://medschool.ucsf.edu/admissions/tuition/

You can have your loan forgiven if you are willing to practice medicine in some areas of high need for doctors. http://www.staffordloan.com/repayment/f ... veness.php You also get loan repayment deferment while serving in a residency or internship.

Claudio says “That means that for at least four years in med school we'll be living on debt and for the remaining time we'll be living on a fairly meager salary.” He then calculates that he could have been earning for “those nine years,” apparently referring to medical school and residency, about $65,000 a year working in business. Well, what they pay you as a resident is meager compared to what they pay you after you finish your residency, but it isn’t zero. According to this site http://mdsalaries.blogspot.com/2005/10/ ... aries.html medical school residents get paid, on the average, $46,000 a year for the first year of residency, and it goes up $2,000 a year every year after that. That site says that residencies for internal medicine and family practice last three years. For neurology and pathology it is four years, general surgery for five years, and for neurosurgery it is six years.

By my calculations then the total lost earnings plus expenses is $846,000 - $161,000 - $46,000 - $48,000 - $50,000 - $52,000 - $54,000 = $435,000. That’s assuming you go five years of residency, instead of three that you could do, and that you don’t select a more economical school for medical school. It also assumes you could have actually found a job earning $65,000 a year with just a bachelor’s degree in today’s market.

There’s more. There are perks to being a medical resident, like medical and dental plans, free food while on duty, life insurance, and other benefits. Not only that, but in most residencies you can work in your spare time (what little you have, yet many doctors do it), and earn $100 - $150 per hour moonlighting, after your first year of residency.