Healthcare...and Your Doctor’s Dirty, Little Secret
Cross posted from The Progressive Pulse.
Ever since the ascendancy of conservatism and the election of Ronald Reagan we have been told that government is the problem and the free-market is the solution. If nothing else, the Bush Administration has turned that paradigm on it’s head. Bush campaigned for small government, but what he delivered was bad governance. I suppose it was inevitable that if you hold the idea of governing in contempt, you will govern poorly.
This “government bad, free-market good” mindset must change if we are to make any progress regarding the woeful state of healthcare. Two stories in the news last week perfectly illustrated the perils inherent in our free-market healthcare system.
The first one is straightforward. The Medicare plans administered by private insurance companies are performing both poorly and expensively. Courtesy of the New York Times, the details are here. On average, these private plans cost taxpayers 19% more than the traditional Medicare plan. Medicare recipients of the private plans were worse off, too, with higher out-of-pocket expenses and fewer doctors to choose from. All in all, a disaster. And not an insignificant one either, since almost one fifth of the 43 million Medicare beneficiaries are in a private plan. Here is real world evidence that the government system (with 2%administrative expenses) outperforms the free-market (with for-profit private insurance administrative expenses 20- 30%).
The second story has to do with the perverse financial incentives which are inevitable in our system. Read the story here. Cancer and kidney doctors received, legally, millions of dollars from the two pharmaceutical companies which make injectable medications to treat anemia. The perversion is that the more medication the doctors prescribed, the more money they received. Nowhere in this financial equation are healthy outcomes even measured, much less rewarded. Inevitably, it appears that in some practices the medications were overprescribed and may have actually adversely affected the patient’s health. As always, the pharmaceutical companies laugh all the way to the bank.
Herein lies one of the dirty, little secrets of medicine. In every medical specialty (including my own, Internal Medicine) with every patient encounter your doctor is faced with a series of questionable financial incentives. There are many temptations to provide more care; few incentives to provide better care. Mostly, my colleagues behave in a professional manner and these two positions are not mutually exclusive (i.e. often, more care is better care). Not uncommonly, however, the doctor succumbs to temptation. Like an unscrupulous stockbroker churning accounts in his portfolio, doctors will order tests, procedures, or treatments which provide financial gain but may not advance health outcomes.
Believe me when I tell you that it is a slippery slope to provide thorough care that is cost efficient, all the while practicing “defensively” so as to reduce your risk from lawsuits. These are the calculations going on inside your doctor’s head while you describe your symptoms. Not a pretty picture, is it?
So what we have is a very costly, inefficient healthcare system; with perverse financial incentives that do not always improve health outcomes. We need to make fundamental changes. I believe a national government health insurance is the best vehicle to trigger the necessary changes. We need a system that promotes and rewards healthier outcomes, especially those based on the best available medical evidence.
Addendum: This won’t be popular on these pages, but a simple “Medicare-for-all” approach may not be financially viable given the poor reimbursement to physicians and hospitals. I’ll post soon on Medical Economics 101 and you will realize why healthcare reform is such a many-headed monster.
Addendum 2: I would be remiss if I did not mention that the longer I look at the Edwards healthcare plan, the more I like it. It’s most clever feature is that it allows a government program to compete against the private insurance programs. For those who believe we must ease incrementally into a universal government insurance, Edwards’ plan has a mechanism whereby this can be done.
- S Turner's blog
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I'm not a student of the different methods for providing
healthcare for all but won't let my ignorance keep me from speaking out. (Why should I let it stop me at this point in my life?)
I don't care how we do it, but I believe everyone deserves to have the same quality care without regard to their ability to pay. I don't care what their income level, their country of origin or their skin color happens to be. To use your wording - If rich people want to be able to pay for more care, that's fine, but they shouldn't be able to pay for better care.
All this being said, I also believe that doctors and other medical personnel should not suffer financially in our effort to provide excellent care to everyone. I have no problem with doctors being very highly compensated as long as they earn it.
Thanks for providing a doctor's perspective
It seems to me that doctors are put in a solid no-win situation, trying to balance enormous patient loads, through-the-roof liability insurance, a blizzard of drug ads, a revolving door of drug company reps -- and still render meaningful care. Hats off, indeed.
My first experience with Medicare and Medicaid came when my dad was diagnosed with lung cancer. This was before the recent "overhaul". It took months and numerous tries, hoop-jumping, phone tag, endless trips to the SSA office and firm resolve to get any assistance whatsoever.
Almost twelve years ago, I partnered with a man who is now 24 years Poz. Again, from the outside, I've seen the dismantling of Medicare and Medicaid to near uselessness. The first month after the sweetheart deal for Big Pharma, one of his meds, (Norvir, a long-standing and proven part of a cocktail regime) increased in price over 400% in just one quarter. There was no other reason than piratical gouging for the increase. Since then, the number and kinds of meds he could get has steadily decreased, while the prices for the remainder have increased. Less choice for the doctor or the patient -- consequently, his health has declined in the last five years when before he was doing extremely well.
Other than wild profit-taking by the drug manufacturers, there has been no benefit to the patient that I can see. Trying to get my partner's doctors to reauthorize courses for him that have in the past given him improved health is like pulling teeth. We realize that 99% of that has to do with insane restrictions laid down by Medicare. I suppose that's what we get when politicians attempt to practice medicine :-\
We also perceive that there are a lot of disincentives for young people to become doctors. We have a failing education system that cannot produce the quality of individual who can take on the enormous learning requirements. The cost of higher education is distantly out of reach of many who could qualify. Then there's the abuse that a resident has to live through in order to practice on his or her own. Once a doctor can practice, the expenses just to have a job at all are out of sight. From where I sit, the system seems completely rigged, end-to-end, to fail. The only ones making out are the insurance companies and the drug companies. Where's the benefit in that to either the doctor or the patient? Lord help me, I just don't see it.
To have a health care system at all, it's going to take a lot more than putting the insurance and drug companies in their place -- as vendors to, not controllers of health care providers. It's going to take fixing our education system from the ground up, putting qualified people within reach of medical school and allowing them to practice healing (rather than accounting) once they're achieved their degrees and practical training. There's no other way for this to work unless the politicians practice governance and allow the healers to practice medicine.
"The most unamerican thing you can say is 'You can't say that'" - G. Keillor
Very thoughtful discussion
what you have written Dr. Turner is indeed an eye opener. From a potential patient's postion, what, if anything, can I do to make sure that I am receiving proper care? Also, as a voting citizen, what can I do to get my representatives to do the right thing? Where do we begin and what do we ask for?
No matter that patriotism is too often the refuge of scoundrels. Dissent, rebellion, and all-around hell-raising remain the true duty of patriots.
Progressive Discussions
Excellent posting
Much to think about . . .
But the one comment I want to highlight is this:
This lies at the heart of the gross incompetence of the Republican party. From Art Pope and his Puppetshow on one hand to uber-conservatives like Fred Smith on the other, we are dealing with men (mostly) who despise government - and yet they want to be in charge of it.
Entrusting the common good to these kinds of people is like putting children in a daycare center staffed by known pedophiles.
single-payer
It would absolutely have to increase the payments to health care providers. Absolutely. No doubt. But, that doesn't mean it couldn't be done. In fact, if done right, it could get the health care providers on the side of single-payer.
One man with courage makes a majority.
- Andrew Jackson
Thanks.
I'm a pharmacist, and I've heard nothing but complaints from my peers since Part D came into effect. I'm just glad we don't deal with insurance at my health department.
Part Duh is a nightmare
I've been navigating it with my chronically ill mother since its inception. The so-called "donut hole" left her without the ability to pay for critical medication for nearly 6 months. Fortunately, my brothers and I were able to mostly make up the difference, and the pharmacist at her local drugstore actually ate the rest of the cost.
Now I don't mind paying for my mother's care. I love her and I'm grateful to have her still with me. What I mind are broken promises and false hope. What good is it to say that "now Medicaid will cover your prescriptions!" -but only some of them, and only part of the time. It's beyond stupid. It's cruel.
I can see that it will take time to convert to a single payer system, which is what I beleive we should have. But I think we need to get started on that conversion now.
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The Den
My darling girl, when will you understand that 'normal' isn't necessarily a virtue. It rather denotes a lack of courage." - Alice Hoffman, Practical Magic
Your doctor should be able to answer...
...the following questions regarding your treatment:
--What is the clinical evidence for my treatment?
--What are the risks?
--How will we know if my treatment is successful? This question is not as simple as it sounds. Doctors need to be sure the patient has a realistic expectation for their treatment.
If she/he cannot answer these questions I would be wary of the treatment.
Also make sure you are up-to-date on preventive health issues (physicals, immunizations, etc)
And if you have a really open discussion, ask your doctor about the proper role of pharmaceutical companies and whether they accept any gifts from drug companies.
As to what to do as a responsible voter regarding healthcare matters: I would focus entirely on universal health coverage. This outweighs all other health issues.