Missing the Forest
I attended a Santa Clara County Medical Association meeting tonight, and I couldn’t help but feel that the doctors were missing the forest for the trees. Jack Lewin, the CEO of the California Medical Association, gave a great talk about issues facing California physicians–ridiculously low levels of reimbursements from Medicare, MediCal, and the private insurance system, taking care of at-risk populations, suing the HMOs to force them to pay reasonable and fair amounts. I initially asked him a question about single-payer (surprise), but every other question that was asked had to do with administration. Business. Billing. “What can I do about Blue Shield sending a check to my patient?” “Who should I talk to about HealthNet losing my documentation?” On the subject of one health insurance billing system, three-quarters of the physicians knew the difference between billing as a “non-contractual” versus “contractual” patients for Blue Shield. They smiled at our medical student ignorance. “How silly of you to think you’re going into medical practice to help people! Don’t worry, you’ll end up sucked into this horrific system too!” I don’t want to work like that. Neither do my classmates. One leaned over and whispered, “Man, they know as much about billing and administration as we do about anatomy.” Imagine all the time they spent navigating the insurance system that could’ve been used seeing patients. Or reading more about the latest best-practices research. Or hell, spent with their families. The health care system is one that makes absolutely no sense. No one wants to be a part of it. And why should we have to?
After every question, I just wanted to shake them and scream “Single-payer!” (Yes, I have a slight flair for the dramatic.) And I’m not trying to be idealistic. I realize it’s not a golden bullet. I realize health care reform is politically difficult. I acknowledge it. Fully. But how can doctors continue to work on some sort of patchwork system–like suing the insurance companies, like the CMA did with the RICO lawsuit–but not fight for a long-term change? People seem like they’re willing to fight their own fights–but not fight for medicine as a whole, as well as their patients. It almost seemed as if the doctors were more willing to deal with the hassles of HMOs (which they cited as “the reason you never get to see your kids”), but aren’t willing to try another solution, even when it was staring them in the face.
Dr. Lewin made a great analogy of why doctors have to stick together. He gave an example of speaking to neurosurgeons last week, who didn’t care about struggling pediatricians or internists: once internists and general practitioners are replaced with nurses and techs, all physicians risk becoming obsolete.
But honestly, how much of this “doctors are barely getting by” mantra am I supposed to believe? I’m a medical student, and at the same time, still a member of the public. A lot of the questions discussed “How do we get patients to realize that doctors are hurting,” and “Universal health care does nothing to address low incomes for specialists.” The malpractice issue aside, who’s struggling out there? And I mean struggling. When you’re “struggling” to make car payments on the BMW or the 5-bedroom house, you don’t count. You can live a perfectly happy and satisfactory existence with a measly Honda and cheaper mortgage, can’t you? Isn’t it more the expectation of a certain level of income that’s the problem? Not the absolute income, but the level relative to one’s societal expectations as an all-important doctor? (Sidenote: would specialists and/or general practitioners not be willing to take a pay cut to have reduced administrative workload, increase the time they’re actually practicing medicine, and possibly increase the time with their families?) Maybe it’s my societal naivete of what it’s like to have children and mortgages and responsibilities greater than oneself?
“Political feasibility” and “tax increases” were cited as the reasons that single-payer wouldn’t fly. “The public would never support it.” “No one would be willing to pay for the tax increases.” I don’t buy either of them. The economics aren’t as bad as they seem–otherwise, how could any other nation be insuring everyone, have higher general health outcomes, and spend less? I’ll admit the political argument is a more worthy foe, but people also thought Women’s Suffrage was silly (“Women? Voting? HA!”), and even though Nixon opposed the Environmental Protection Act. The politically unfeasible can become common sense over the course of a decade. And I don’t buy the “marketplace freedom” argument, either. Your Holy Market would’ve had no problem if slavery still continued today.
Why do you think that single-payer will work any better than the current mess?
I picture a (realistic) single-payer system working about as well as the IRS, not nearly as good as the post office.
As long as people who are not involved in the success or failure of a system (government, or monopoly) they won’t have any motivation (altruism aside) to do a good job or give a damn, and as long as the consumer (patient) has no interest in the cost, the health care system will continue to deteriorate.
And, as long as a third-party (single payer or current insurance industries / medicare industry) has an interest in keeping their jobs, their share of the health-care dollar will increase, the quality and quantity of health care PROVIDED will decline, the reimbursement to the health care providers will decline, and the overall cost will increase.
Factor into all of this the added effect of the cost of malpractice insurance, and it bodes ill for health care in the US.
I spent the holidays in Canada, visiting with a very close friend – a former health care professional who is know in academia. She can’t get a doctor in Kingston (where she moved from Ottawa), apparently there are NO physicians, dentists or OD’s in Kingston (a city of 125K) who are accepting new patients. So, she goes to Ottawa once every couple of months for her routine medical care.
The reason that new docs don’t want new patients is that they’re all maxing out on what the provincial health care will pay them, so they dont bother with more patients. BTW, Canada has a single-payer system. Each provience runs their own, and it DOESNT cover people who move from one provience to another. BTW, Kingston and Ottawa are both in Ontario, so that isn’t my friends problem.
Then, they have trouble with drugs too – if the Prov. formulary doesn’t have what you need, you’re on your own. And, generics are a LOT more expensive than name brands.
Single-payer is NOT t he answer. Fee for service is.
And I imagine the single-payer system working as well as the NIH, the public library system, and having the efficiency and administrative costs of Medicare. I can’t buy your “IRS/Post Office” argument.
I can’t address your friend’s program in Kingston, but it’s a health care access issue, not a financing one. We have people with the same problems in the US–it’s not due to single-payer, it’s due to economy, city life, and other factors.
You’re absolutely wrong on both of your last points, however. The Canadian Health Act specifically requires portability from province to province. Go take a look.
Your statement about drugs is incorrect as well–generics are about 28% cheaper in Canada.
Well, if you cherry pick – here is a current story by CNN: http://www.cnn.com/2004/HEALTH/01/19/generic.drugs.ap/
As far as portability between provinces, each provence sets the rules for accepting people who move into their provence – yes technically they have to (eventually) accept them, but they have the option of fairly substantial time delays – like a year or more before you’re covered.
Finally, why do you think NIH is well run? NIMH (to take an example) spends more money on finding out how pigeons think than they do on researching cures for mental health in people. Not a good use of my tax dollars, I think. Even accepting that NIH is well run, why do you think that any federal single payer system will be as well run as it?
Can you give a single example of a federal government monopoly that is well run, excluding government only functions like defense?
An example is NASA – huge cost overruns, terrible book keeping, and poor mission accomplishment with poorly defined missions. Bureau of Indian Affairs? 150 years of incompetence. CDC? A political animal, spending far more on (say) AIDS research than (say) prostate cancer research – but which kills more people,?
And, a system run by the government will be subject to more tinkering by politicians, catering to special interests (ie getting themselves relected), not to what is objectively better for the individual, or the population as a whole.
A single-payer system will result in inqequities like we see in Canada, where my friend has to make routine appointments 12 to 14 weeks in advance, or in England where teenage girls can get breast implants at government expense while women with breast cancer have to wait 6 months for a mastectomy – the girls got on the waiting list first, and “to be fair they to in order of the list”, not in order of any rational need.
The only system of interaction that has a 100% track record (long term) of correcting abuses and taking care of the most people is a free market. Is it 100% perfect? No, especially short term – but it is far less imperfect than the government control systems.
Every governmental system that impinges on that free market, in any way, results in the inequities that we see now. What we have now is not caused by evil health care providers or greedy insurance companies, or even lazy and careless patients. It’s caused by 35 years of the federal government screwing around with the system through medicare, and people at all levels simply working the system. The classic economics argument is a varient of the “problem of the commons” – health care has no cost, hence no value, and so people try and get as much of it as possible.
Yes. Some generics are more expensive. On average, they’re cheaper, and on average, Canadians pay much less for their drugs than Americans. Are you going to deny that?
Right. And if there’s a year-long delay before one province accepts you, the other province has to continue to cover you. It says so right in the law…
Medicare. A great federal monopoly. 3.6% administrative costs. The private insurers average 11% costs. The GI Bill helped a lot of people. So did the national highway building project. And social security.
And not to be picky, Flighterdoc, but AIDS is killing 3.1 million people every year. That’s quite a bit more than prostate cancer, and while masturbation has been shown to decrease the incidence of prostate cancer, most men will get it if they live long enough. AIDS is a much more important target for a public health/epidemiological/prevention focus for the CDC.
The economic argument does not hold in health care, Flighterdoc. It is not, in many cases, a choice or a want. I can choose to buy a t-shirt for 20 dollars or a new book. But if I get cancer or an infection, it can kill me, keep me from productively contributing to society. Economic theory is based on consumers making informed choices, and that doesn’t work in health care–you don’t necessarily know if your doctor or hospital is good or bad, nor do you get to pick your doctor or hospital–your employer picks it for you.
In no other industry does the amoral corporate goal of making money conflict so greatly. The free market may take care of *most* people, but the sickest of the sick. It’s willing to do unncessary heart bypasses, defraud the system, and deny care due to “pre-existing conditions” in order to worship its bottom line.
“how could any other nation be insuring everyone, have higher general health outcomes, and spend less?”
For the FRG, it’s very simple how they manage to get more by spending less. They’re using involuntary servitude.
The health ministry has at its disposal approximately 90,000 conscientious objector draftees that it only pays peanuts for. In fact, the German military wants to end the draft but is being stymied by the health ministry because they can’t afford to run the health system by paying people to do it without a prison term hanging over their heads.
A lot of public systems advertise low costs and good service but they simply do not deliver. In former eastern bloc countries the system was that the service quality is terrible unless you bribe people. France demonstrated this summer how fragile their health system is with 15,000 excess deaths due to poor healthcare planning running into generous vacation schedules.
The list can go on and on but it all boils down to a double standard. The current system is a mixed free/state system but is labeled free market healthcare and is looked at in its reality, warts and all. Public systems, by contrast, are examined in their platonic, idealized glory and it’s relatively rare that you get to see the reality of poor service, slowed innovation, and unsustainability without external support like those poor german draftees.
You can bet dollars to donuts that the pay difference between a draftee’s salary and what a free market worker is not included in international price comparisons for health care. Fantasy comparisons like that dominate the discussion of free market v. single payer solutions.
Economic Ignorance in the Medical Field
I’m on a random blog journey and I stumble across a clueless med student: After every question, I just wanted to shake them and scream “Single-payer!” (Yes, I have a slight flair for the dramatic.) And I’m not trying to…