You are already paying for it. Who do you think is paying for the uninsured to go to their edmergency rooms at 10 times the cost of a visit to a clinic, the Canadians?

First a few words about the malpractice/tort reform/defensive medicine argument for increased costs. Most large groups like the Mayo Clinic or Kaiser Permanente require patients to sign an arbitration agreement, which limits exposure to jury trials and thus reduces the need for “defensive medicine”, so you really can’t compare private practice with these large groups. However, the author of the article, Dr. Gawande, dismisses the defensive medicine canard early in the article by pointing out that the cap on noneconomic damages in malpractice awards has reduced the number of malpractice suits dramatically, experience that has been seen in other states where similar legislation has been passed. There have been more studies regarding the cost of defensive medicine since the 1996 article that President Bush quoted when he was pitching national tort reform, and while the subject is still controversial, it looks like about 5% of savings could be realized if defensive medicine in all specialties was stopped. This includes unnecessary CT scans, hospital admissions, C-sections, etc. Anyway, even the doctors in McAllen admit that this is not the reason medical care is so expensive there.

When I was in medical school (1970s), someone had the bright idea that increasing the supply of specialists would, through competitive market forces, necessarily decrease the price of the services provided by specialists. What they found was exactly the situation seen in McAllen: that is, the price remained the same, but the amount of care provided to the patients increased, resulting in an explosion in overall health care costs. Administrators are happy, because they want their assets to produce revenue so they can demonstrate a return on invested capital. Surgeons don’t want to let a paying patient get away, especially one who they can operate on and have a pathologist look at the specimen and report that there was, in fact, pathology. Patients are happy because they get the care they want when they want it, and don’t have to worry about having trouble on Christmas Eve or when they’re in Timbuktu on vacation. When a patient shows up in the Emergency Room with abdominal pain and gets a CT scan, it’s a win-win: the assets generate revenue, the patient gets a test that rules in or rules out disease that may require emergency treatment, the ER doctor can call the surgeon with a definitive diagnosis or has evidence admissible in court to justify his decision to send the patient home. The only folks who are losers with this system are those who have to pay for it….us.

I couldn’t agree more with Dr. Gawande when he says that spending time talking with patients and collaborating with colleagues would reduce the amount of testing and thereby reduce costs. Unfortunately, that’s not possible in private practice managed care, where reduced insurance payments for office consultations have forced physicians to try to see more patients per hour, therefore limiting what they can discuss. The increased administrative requirements have had a negative impact on the time physicians can see patients. So, doctors order tests, more or less using expensive technology to screen patients with whom the doctor doesn’t have time to spend.

Dr. Gawande listened to all the arguments about government’s interference in the health care sector, but he seems to dismiss those folks complaining as fat cats crying in their milk. It’s important to remember that the Federal government has been meddling in health care for over a century, resulting in the unsurprising distortion of market forces and unintended consequences. It’s jail-time and big time financial penalties if a community hospital offers a bigger discount to a patient trying to pay their bill than they offer to the Feds (Medicare); in fact, the whole pricing paradigm for hospitals is so distorted as to have no basis in financial sanity. By capping physicians’ fees and then regulating them downward, we get two major short-term consequences and one long term catastrophic consequence: short term, we see (1) the situation in McAllen, with doctors trying to maintain their incomes by churning, increasing their volume within a stable patient population and (2) as the opportunity cost of taking care of patients increases, fewer physicians are willing to take call in the off-hours and see patients in emergency situations. Low remuneration is also why we have underserved areas and over-served areas in the US healthcare market. Long term, we are seeing young people who don’t want to be surgeons or primary care physicians; the manpower shortage has been a major talking point for the American College of Surgeons for more than two decades, but no one is listening. By the time we notice and decide to take any kind of action, it takes 10 years plus to train a surgeon.

As I said in the beginning of this post, it’s hard to beat a practice paradigm like the one I work in, or Kaiser or Mayo, in terms of offering cost-effective, evidence-based care. However, no matter how you analyze the features, it all comes down to rationing care: waiting in line to see someone who knows the evidence-based Best-Practice algorithms, tells you what you need and what you don’t need, and then puts you in the queue. More and more, it seems, those who want more than the algorithm suggests or who want to bypass the queue get on a plane to India or China and pay cash—much less cash than they would pay here. Doesn’t that bother anyone? Behold the globalization of the two-tiered system of health care.

In the province where I live (British Columbia) acupuncture and TCM Traditional Chinese Medicine is covered. Seeing a naturopathic doctor is also covered. In other words, some forms of “alternative” medicine are recognized by our universal health care system.

Now if you wanted to see a shaman for cancer treatment you would be on your own. Both in America and the United states !

“Take the mortgage broker who steered his client into a subprime mortgage when the client could have qualified for a prime mortgage (because the subprime mortgage paid a higher commission), thereby saddling him with interest payments the broker knew he couldnt’ afford; or the bankers who sold small towns in Wisconsin synthetic CDOs without making sure the customers knew what they were buying (but covered themselves by shipping hundreds of pages of unreadable disclosures).” — James Kwak

What we’re really discussing here are people in professions that require them to give advice to a client who has limited knowledge and often limited resources but will bear the full financial and in this discussion health related consequences of the advice given. Whether doctor or broker, I don’t begrudge their opportunities to enhance themselves. Of grave concern however is that they don’t have to reveal the nature of the advice they are giving and the conflict of interest that I perceive this to be.

Doctors routinely discuss the effects and potential consequences of a treatment with patients as this is a doctor being a doctor. Intermingled with the doctor being a doctor is the doctor functioning as pitchmen and agent for financial concerns in the medical industry; first up him/herself. The idea of “Disclosure” and “Conflict of Interest” have really taken a back seat in recent memory and it is unfortunate. When you see such erosion in the White House, the Supreme Court, Congress and the Pentagon, its not surprising that its a reflection of the community that is the United States.

“But while the pursuit of profit in the free market is supposed to benefit the public – and probably does in most areas – here it has led to an explosion of costs with no measurable improvement in health care outcomes.” — James Kwak

In free markets buyers and sellers supposedly don’t coerce each other. When doctors have concerns and relationships convened solely for the purpose of enhancing their financial position AND there is no improvement to the health outcome of the patient they aren’t behaving like a businessmen, they ARE a businessmen. After all, there being no medically relevant advantage realized from the concern or relationship vs. other courses of action, the only upside is financial. Thus, the doctor is the seller and the patient is the buyer only the patient doesn’t know they are a buyer. Most patients I think find it reasonable that their physician is compensated, many however don’t realize their being taken to the cleaners.

Brokers being allowed to lie as they have is damaging and definitely not in keeping with free market principles. Free market “principles” NOT!!!!, have found their way into the examination and operating rooms of the country and its unfortunate that the very worst and corrupted of these so called “principles” take priority over the health and well being of trusting patients.

This is a devastating micsonception. The pursuit of improvement and value benefits the public – and the successful pursuit of these qualitites results, in a functional society, in a profit that is sufficient sustains the effort.

The pursuit of profit is, at best, Zen-like context free utilitarianism, and at worst a sociopathic quest to fill an empty middleman’s life with some kind of “score” accomplishment. Profit is the result, not the objective. It is a means – to allow us to continue to do what is valuable, and ideally, what we are good – if not best – at.

The idea that the pursuit of profit – an idea that is ultimately nothing more but the grudging acknowledgement that, as a species, we are shortsighted, greedy, and stupid, and that the only way to put the lot of us to productive use is to redress juvenile egotism as enlightened self-interest – the idea that this is a net positive in any frame of reference is the life lie of the productivity extortion machine called “free market” capitalism. It makes a profound misrepresentation the foundation of what is proving to be a dysfunctional, unsustainable, and quite possibly lethal approach to organizing our lives, and that of our descendants.

“Ancestors” will be a common curse.

If we, as patients and laymen, question a test or procedure, and it is well grounded in medical science, the doctor will tell us so (or be guilty of mal-practice). When I was young and uninsured, I made it a practice to raise questions. :) I continue to do so, even if I forego something that my insurance would pay for. If an expensive test or treatment is not well-grounded, there is no reason for us, our insurance companies, or our government to pay for it.

Now, in the article there was a counter example of a little old lady facing heart surgery. Them metaphor was one of the prey arguing with the predator. That is an extreme example, and it is curious to me why it was included in the artcle.

It is unwise to argue with our doctors. But a few questions, especially if we live where medical costs are high, could save us all a lot of money. :)

But health care is hardly a free market. For a host of reasons, asymmetrical information and tax subsidies being perhaps the two biggest, it’s not a desirably-functioning free market. Like housing, market demand is suboptimally warped by tax subsidies and prices are inflated as a result. Like housing, it has grown out of control for the past 2 decades. Unfortunately we seem unwilling in either case to recognize the problem and decrease the entitlement.

The problem is the incentives for the doctors are wrong (time + materials billing), the incentives for insurance is really wrong (profits are best if you can nave only healthy people pay premiums and then not pay any claims), and the incentives for business is all wrong (by effectively requiring employers to offer health coverage to get quality employees).

It is really, really easy to find a market solution for the rising cost of health insurance: let multiple insurers compete to drive down costs by denying more and more care. Oh wait- that’s what we have now. Its nothing more than a race to the bottom.

The free market in the case of health insurance doesn’t work, since the best way to make a profit is to have everyone pay in and then not cover anything. As competition increases, less gets covered.

This is slavery. After all, you pay for public schools, fire and police departments, and libraries whether or not you choose to use them. Should we opt out of them too, since socialism like that is un-American?

So, whats the difference: comparative medicine and behavioral medicine. Here are just a few of the hundreds of projects that the NIH wanted to fund through the stimulus program:
01-CA-103 The role of health behaviors in cancer prevention.
01-DK-103 Improved understanding of behavioral and social factors related to non-Adherence in people with diabetes.
04-CA-111 Quality of Cancer Surgery and Outcomes.
04-CA-112 Appropriate Use of Colony Stimulating Factors.
The first two are asking the medical research community to look for behavioral, rather than medical, ways to treat and prevent expensive diseases. The next is essentially asking researchers to look at surgery outcomes to see if some surgeries are more effective than other protocols. And the last is asking researchers to look at whether CSF drugs are being used effectively.

It would be very interesting to look at the history of the RFA programs to see whether this is really a shift or not. But what this seems to indicate is that the Obama administration will be adding comparative and preventative medical science to the mix.

The reason this is so important is that currently the bulk of the pharmaceutical and device science is funded by and controlled by the industry. The drug/device manufacturers have no incentive to fund studies that compare patented to unpatented therapies. This research has the potential to be detrimental to shareholders, but may reveal that new patented therapies are no better than the old therapies. This leads to a perverse incentive to publish only data that describes new uses of patented pharmaceuticals. It is difficult to get funding to do studies to compared the effectiveness of therapies. An active sales force for patented therapies with little or no incentive to use old therapies, patients are given the latest most expensive therapies as a matter of course.

Adding the NIH as a funding source to find best therapies and preventative interventions suggests that the Obama administration is aware of the weird incentives that exist in the medical marketplace. And is seeking ways to remedy these systemic errors.