Mass left some questions in the comment section that I thought were insightful and added to the discussion about health care policy. So I’m treating them like an interview.
1) I’d like to know how Dr Whitecoat is an “Independent Voice for Emergency Physicians”? Does that mean that all or most independent ER docs are conservatives or Republicans or anti-HR 3200? It would seem so as there are plenty of references in his blog to the loaded phrase “socialized medicine” as well as (at times indirect) links to groups like CAHI (the health insurance lobby) or the NCPPR (a conservative lobby) or to other conservative blogs. Either admit you’re a proud conservative or give some left-leaning blogs and groups some links.
First, I’m not, nor have I ever asserted, the “Independent Voice for Emergency Physicians”. That phrase refers to the magazine Emergency Physicians’ Monthly, and you won’t find a better forum in emergency medicine for emergency physicians to express their views. You could even submit an article and have it published if it was germane to the practice of emergency medicine. Dis me, but don’t dis the mag.
I actually had to go look up conservative versus liberal qualities on a web site before I could respond to your challenge. I’d have to agree that if I had to choose between personal responsibility and government intervention, I’d pick the former. However, the news is replete with stories about how people and businesses, when left to their own dealings with the public, take advantage of others. Government intervention is necessary to establish and enforce rules by which everyone must abide.
2) How would WC doc define “socialized medicine”? Are patients in the VA system, or those who have Medicare or Medicaid part of such a system? Does it matter that Medicare patients have higher satisfaction than other insured patients? I would submit that if WhiteCoat Doc would term universal healthcare as “socialized medicine,” then I can call the present system, “Darwinian every-man-for-himself medicine.” Unwieldy, but accurate.
Socialized medicine = publicly funded health care. Period. I don’t think that anyone can draw a line between “socialized” medicine and “single payer” medicine (in which government pays, but does not participate in delivery of care). The “golden rule” always applies – he who has the gold makes the rules. Look at the Medicare system now. The government pays for care, but conditions payment on a plethora of byzantine rules. Fail to follow the rules – even if you provide the care – and you don’t get paid. Technically, even though the government is not “providing” the care, it is orchestrating the care – sometimes on an “ubermicromanagment” level.
Many people are content with Medicare because they get what they want at no current cost to them. Don’t forget that most people receiving Medicare have paid into the system through payroll deduction for all of their lives. I think that people in stories like this or this or this would disagree with your general assertion that Medicare patients have “higher satisfaction than other insured patients”. Being “insured” by Medicare doesn’t mean much if no providers accept it. Our Medicaid crisis right now is what Medicare will look like 10 years from now unless the system changes.
3) Is this blog written from the perspective of a professional concerned about his income, independence, status, the overall health of his patients, or some mix of these? While I too am a physician, I don’t believe that physicians’ and patients’ interests always go hand-in-hand. There is no shame in defending our incomes and status – let’s just not delude ourselves that our positions are always for the good of the patients.
This blog is written from the perspective of what a single speck in the universe of physicians happens to find interesting at the moment. I’m not going to go through a psychiatric profile to answer your question. If you like the blog, let me know. If you don’t agree with me, post a comment and challenge me. If you don’t like it, go read a blog that aligns more with your interests. I won’t be offended.
Physicians’ and patients’ interests can’t always go hand-in-hand. Physician interests should be aligned with patient interest, but at some point, paternalism must occur. We have to do what we believe is in the patient’s best interest even if the patients don’t realize it. Patients interested in multiple narcotic prescriptions from multiple physicians shouldn’t be allowed to receive them. Patients who think antibiotics cure colds shouldn’t just get antibiotics because they want them. Patients, and a lot of physicians, have to learn that sometimes doing nothing is better than doing everything.
Are there some specialists who go “scoping for dollars”? Absolutely. That practice must be stopped, but unfortunately, there is little disincentive to doing too much right now. In fact, our government has created monetary incentives for performing procedures. Guess what many physicians make their living doing.
4) If some believe that it is not our health care system’s fault — but other factors like income disparities, personal habits, etc — that we have much higher per capita healthcare costs but worse infant mortality and lower life expectancy than other countries, isn’t it incumbent on us as advocates for our patients’ health to see money directed AWAY from the medical system into areas of the economy that actually WILL improve those health statistics?
Some of the largest costs in US health care are provision of end of life care and caring for critically ill patients. The same things that make our system so unique are also crushing our system under the weight of their expenses. We have to choose what we as a society want out of health care. Do we want to provide coverage for everyone at the cost of rationing or eliminating payment for many expensive treatments? That might mean limited or no cancer treatment, curbs on who is eligible for dialysis, limits on chronic ventilator care, and governmental “quality control” oversight on who is and is not resuscitated during a code. We’re probably headed down this path anyway because the system is hemorrhaging so much money, but the government is now faced with the frog in the boiling water conundrum. Throw a frog in boiling water and it jumps out. Put a frog in a warm pot and turn up the heat until the pot boils and the frog doesn’t leave. I personally think that the government is floating a bunch of health care trial balloons to see just how fast it can turn up the heat without too many frogs jumping out.
5) Which Republican health care bill currently being proposed ought we to support as an alternative to the current “Obamacare” legislation?
I haven’t read them all and probably won’t. I posted some of my ideas on how to improve health care here, here, and here. Scalpel also had a great set of posts a couple of years ago. I just went over to his blog to link to them and he re-posted them two days ago for everyone. See here, here, here, and here. Incorporate some of these ideas into a bill and see what kind of traction it gets.
6) Given that the US spent 8.8% of GDP in 1980, up to 13.9% of GDP in 2001, and then most recently 16% of GDP for health care in 2007,
(http://www.kff.org/insurance/snapshot/chcm010307oth.cfm) — does anyone think this is sustainable and if not, what are our options? If “rationing” is out and no one (doctors, hospitals, health insurance) wants to get paid less and no one wants any restrictions of any kind on costs, should we all fly to other countries for health care?
Medical tourism is a free-market alternative for medical care. If cost is what is most important to people, then they will go to the centers that provide care at the lowest cost. However, if you fly to another country, do you know the qualifications of the doctor treating you? Do you care? If cost is all that is important to you, why not get Lucy VanPelt from the Peanuts to give you psychiatric counseling for five cents? Lower costs have to be weighed against quality. It will be difficult to legislate our way to higher quality medical care – if that is what we want. We’ll never have low cost, fast care, and quality care.
Two quick ways to drop costs and increase quality in the current system:
1. Divorce employment from health care coverage. Employers use health care benefits as a means to obtain and retain employees, but employers also try to find the least expensive ways to provide such coverage. Just let patients purchase their own insurance. Let the companies reimburse all or part of their premiums if that’s what you want. Then employees wouldn’t have to worry about COBRA coverage and insurance companies could extol their virtues to the consumers who actually seek their services – not to the employers whose bottom line is cost.
2. Create a government mandate (there’s my liberal side kicking in) that all prices for health care services must be clearly posted before a patient receives the services. Everything down to the last Kleenex box. If you don’t post a price for it, by law it is provided at no cost to the patient. Once people saw the wide disparity in pricing, they wouldn’t have to go to other countries for their care. They would just flood hospitals that provided the lowest prices in the US. Those hospitals would reap larger profits and expand. Other systems would either compete or fail. I guarantee that prices would drop significantly.
7) Since physicians seem strangely wedded to the idea of the private health insurance industry being the intermediary in our medical system, does it bother anyone that most areas of the US now have near-monopolies by private insurance companies in the markets for medical insurance? (http://www.marketwatch.com/story/study-confirms-health-monopoly-fears)
How does one reconcile the facts that “socialized medicine” in places like France, Germany and the UK are associated with frighteningly “high taxes” (used in menacing ways in posts) but that we spend at least 50% per capita more on health care than any other country? Is it possible that higher taxes are offset by…. something else lower?
Think about how the insurance industry monopolies affect care in those areas of the US.
Are you prepared for a country-wide monopoly and the restrictions that will go with it?
9) When the following post recommended by WhiteCoat doc (http://www.fundmasteryblog.com/2009/07/16/reform-healthcare-culture-and-politics-first/) explains how the free market indeed does work for the medical system, are there, um, more practical examples available than Lasik (a cash-on-the-barrel and completely elective procedure) and traveling abroad for health care? Does any ER doc discuss with a patient the pros and cons of all proposed tests (CMP vs BMP vs cardiac panel vs cardiac enzymes, etc) and radiological studies (MRI vs CT vs ultrasound) including full disclosure of the costs of these tests?
I don’t think that any time-dependent service can be entirely free-market. If people are unconscious or having a heart attack, they can’t request transfer to a less expensive facility.
Regarding non-emergency care, few, if any, emergency DEPARTMENT physicians discuss cost, risk, benefits of any procedure. I bet that 99.9% of physicians don’t even know what the tests cost. Probably the biggest reason for nondisclosure is what you alluded to – everyone wants the best health care that someone else can pay for. Patients want the latest and greatest … as long as it is covered by insurance. If everyone had to pay out of pocket for everything, you better bet there would be a lot more discussion. Patients would demand it. I’ve had patients refuse helicopter transport to tertiary care centers because of cost. They would rather accept a larger risk of dying than be saddled with any portion of a $15,000 transport bill. The discussions would result in a better-educated patient and would be a good thing.
The malpractice climate encourages low-yield testing to “prove” that disease doesn’t exist. Right now the “defensive medicine” mindset is so deeply ingrained in many physicians’ minds that it will be difficult to change. The best way to mitigate that risk is to educate the patient and let the patient make a decision. But as the Happy Hospitalist says, FREE=MORE and until patients have some skin in the game, little disclosure will happen because there is no disincentive to not providing it.