Michael Moore’s “Sicko” does two things very well.
First, the film makes it clear that in the U.S., even if you have health insurance, this does not mean that you are “covered.” Everyone knows that many Americans are uninsured. But now, millions of middle-class Americans are beginning to realize that they are UNDERinsured, and Moore drives that point home.
For-profit-insurers spend a great deal of time designing policies that will limit their “losses”—i.e. limit the amount that they have to pay out. These “Swiss cheese” policies are filled with holes: for example, a policy may pay for surgery, but not rehabilitation after surgery. And this omission is deliberate. As a former claims adjuster tells Moore, when an insurer denies payment, “You’re not slipping through the cracks. They made the crack and are sweeping you toward it.”
Secondly, “Sicko” underlines the signal difference between healthcare in the U.S. and healthcare in other countries: the citizens of other countries take a collective view of the problem. Or as Moore puts it, they realize that when it comes to sickness and dying, all of us are vulnerable. “In the end, we truly are all in the same boat . . . they live in a world of ‘we’ not ‘me.’”
Of course people in the U.K. Canada and France know that healthcare is not free. (And contrary to what some of Moore’s critics say, he does not pretend that it is.) But since they think of healthcare as a right—something we all deserve simply because we are human—it seems to them fair that, “You pay according to your means [through taxes] and receive according to your needs.” In this, national health programs that are funded by taxes resemble Medicare: the higher your salary, the more you pay into Medicare. The sicker you are, the more you will take out in benefits. If you’re lucky, you put in more than you take out.
What “Sicko” doesn’t do is focus on the waste in our system. As Jonathan Weiner observes below, we can’t afford to pay for everything that someone might possibly want. We need to be sure that we are getting value for our healthcare dollars. In one case, Moore tells the story of a man dying of kidney cancer. Desperate to save him, his wife valiantly tries to persuade insurers to pay for new treatments –including a bone-marrow transplant that the insurance company calls “experimental.” But the insurer refuses, and a few weeks later her husband dies. This is one of the saddest moments in the film—both husband and wife are very appealing.
Yet it is not clear that the insurer was wrong to refuse the cover the bone-marrow transplant. It is very difficult to tell from the few details given in the film whether it might have helped—but advanced kidney cancer is not curable. Even the newest drugs give the patient, at most, a few more weeks of life. At the same time, it is understandable that both the husband and the wife (and apparently Moore) assume that the insurer was merely trying to save money.
After all, when it comes to making coverage decisions based on medical evidence, for-profit insurers have a pretty spotty record. In the 1990s, when insurers said they were trying to “manage care,” many were simply “managing costs.” For example, some decided which drugs to include in their formularies based simply on whether the manufacturer would give them a deep discount. In return for the discount, the insurance company would assure the drug-maker that it would not cover a competing product.. This had nothing to do with which drug was more effective.
As I suggest below (see my most recent post on MedPac ) the public will always be suspicious of decisions made by for-profit insurers—even when their decisions are based on sound medical evidence. For-profit insurers just don’t have the political or moral standing to make these judgments. (By contrast, most patients are much more comfortable with Medicare’s coverage decisions—which is why we need a federal agency testing and comparing the effectiveness of new treatments. )
But if Moore skips over the problems of overt treatment it may be because he knows that this at this point more Americans are worried about undertreatment. And to be fair, no one could examine all of the problems in our dysfunctional healthcare system in a single film. What is important is that Moore says what he says loudly and clearly. He tells a vivid, memorable story—and in the process, he has managed to spur the national conversation about healthcare reform.
This is what scares people like Peter Chowka. If people begin talking about health care, they may begin to think about it. It may even occur to them that perhaps it wouldn’t be so terrible to borrow a few ideas from other countries. As Moore points out, “If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what’s our problem? “
"It’s conceivable, Moore suggests, that we might even learn something from Cuba, a country that spends 1/27 of what we do on care. Of course the film’s Cuban adventure is controversial—and purposefully so. I’ve written about it here on TPM café where I recount a very funny story Moore tells about his experience with Standards & Practices at NBC– a tale which shows that he knew exactly what he was doing when he took part of “Sicko’s” cast to Cuba.)
Looking back on “Sicko” Moore says, “I could have played it safe, I know. I could have gone to Ireland. . . . Everyone loves the Irish …. But you know you have to get people’s attention.”
And, as usual, Michael Moore has succeeded in doing just that.
UPDATE: A couple Moore on Sicko. A balanced enough review in the NY Times from Philip Boffey, and an interesting one (sadly firewalled) by Timothy Egan about whether Americans live better than Italians (My take has always been that rich Americans live better than rich Italians) — Matthew
Barry;
Well, you almost had me persuaded that there remains a role for profit-making in health care. Indeed, in our capitalist democracy, it seems there is no stronger method for achieving real advances than the profit incentive.
That was until I woke up this morning and read an article in the Washington Post citing two oncologists who are in physical danger after advising the FDA there was not enough evidence to approve an advanced prostate cancer treatment – not just from desperate patients, which may be understandable – but from INVESTORS in the biotech company making the drug. ( See washingtonpost.com, front page.) This is a dramatic, but predictable, escalation in the medicine-by-intimidation world brought to us by the profit-makers.
This behavior is completely unacceptable.
Bev m.d., Julia, , Barry
First Bev, thank you for calling my attention to the Wshington Post story. Everyone should read it–here’s the link:http://www.washingtonpost.com/wp-dyn/content/article/2007/07/05/AR2007070502149.html.
As it happens I have done quite a bit of research on this drug (an ooncologist alerted me to the problem.) Keep in mind that no one claims that this cancer drug would “save lives” (not even the company). At the very best it will give patients a few extra months of life. At the FDA advisory panel hearing someone asked about the quality of those extra months of life, and the company replied “we didn’t study that.”
Of course they didin’t. This is a drug for patients suffering from late-stage prostate cancer and the fact is that any extra months of life are likely to be very painful. (In the late stage the cancer often spreads to the bone.)
I read the minutes of the FDA panel hearing and what was shocking is 1) there were only two postate cancer specialists on the panel (they both voted against hte drug 2) when others on the panel began to vote against the drug the FDA’s representative on the panel re-worded the question–to get positive responses.
I plan to write about Provenge on tpmcafe.com in the next day or two.
This drug is an example of the cruel waste that Julia talks about. And when she says “at what cost?”–she is right; getting Medicare and private insurers to pay for drugs like these is not just a waste of money. Such drugs also raise false hopes and expose patients to needless suffering.
Thank you, Julia for your comment–it illustrates the problems perfectly. I too wish Moore had focued on waste, but he was trying to make a film for a large audience that knows very very little about healthcare. It’s easier to explain to them first that, even if they have insurance, they may not get the care they need because their insurance doesn’t cover a lot of things.
Then, someone should make a second film showing how if you have very good insurance, there is a real likelihood that you will be overtreated. This is a harder idea for people to grasp. For decades we have been brainwashed into believing that more care is better care, that newer is better, that any so-called “advance” in medical technology is a miracle . .
So it’s going to take some re-educatoin to get people to realize that we have two huge problems: while some people (who are uninsured and UNDERinsured)don’t get the care they need, other people (who are well-insured or are on Medicare) often are over-treated.
Barry–Many of your questions come down to cost: how much would universal care cost and who is going to pay for it?
Here’s my short answer: if you look at the waste in our system, and if you look at the fact that we spend roughly twice as much as other developed countries who provide as good and often better care to all of their citizens, it seems pretty clear that we don’t have to spend More to cover everyone. We need to spend what we are now spending MORE WISELY.
If we refuse to spend twice as much for drugs and every device if we refuse to cover drugs, devices and treatments until there is solid medical evidence that they are better than what we already have; if we use some of those savings to invest in the electronic medical records that would eliminate many medication errors and many redundant tests, if we took an unbiased look at the fees Medicare now pays the highest-paid specialists and took some of that money to raise fees for family docs and internists who provide preventive care (something that Medicare is already planning on doing) . . . the savings would allow us to give everyone the care they need. We could provide care equivalent to what both Medicare and what Medigap policies cover.
Keep in mind we are spending twice as much as other countries who cover everyone. If they can do it on a shoestring, why can’t we do it while spending twice as much?
How would we finance the system? Big employers have already made it clear that the majority would rather spend what they are spending today on employee health insurance and pay it in the form of a tax that goes into a federal healthcare fund. Individuals could be taxed,on a progressive basis,so that the average middle-class American spent roughly what he spends today in health care premiums and deductibles. (I’d suggest taxing both earned income plus a small tax on capital gains.)
Hospitals that say they couldn’t afford to take Medicare rates from everyone are lying. Most private insurers don’t pay that much more than Medicare–as you know, private insurers negotiate as hard as they can for disounts. Medicaid, on the other hand, does pay significantly less than Medicare and insurers, but udner national health insurance, most reformers want to fold Medicaid into Medicare and pay the same rates.
The biggest fiancialproblem that hospitals have is uncompensated care. Under national health insurance, there would be no unpaid bills would have insurance to cover everything that is medically necessary. . The only hospitals that would be “losers” are those that now provide very little charity care.
Would we stifle innovation? No. First, drug-makers spend about twice as much advertising, PR, focus groups , lobbying, etc. as they do on research. Much of the most innovative reserach today is done by the govt-(and by small companies) -not by big Pharma. (See Dr. Jerry Avorn’s excellent book “Powerful Medicines” on all of this.)
Secondly, much resarch shows that when it comes to “bleeding edge” innovation by drugmakers and device-makers, we’ve reached a point of diminishing returns. We made great strides from the fifties up to the mid-nineties; since then we’ve had very, very few real “break-throughs.” See for example: “Is Technological Change In Medicine Always Worth It? The Case Of Acute Myocardial Infarction by
Jonathan S. Skinner, et. al. in Health Affairs. Here’s the abstract
” We examine Medicare costs and survival gains for acute myocardial infarction(AMI) [heart attack victims] during 1986–2002. As David Cutler and Mark McClellan did in earlier work, we find that overall gains in post-AMI survival more than justified the increases in costs during this period. Since 1996, however, survival gains have stagnated, while spending has continued to increase. We also consider changes in spending and outcomes at the regional level. Regions experiencing the largest spending gains were not those realizing the greatest improvements in survival. Factors yielding the greatest benefits to health were not the factors that drove up costs, and vice versa.
________________________________________
Finally, would some people decide not to become doctors (or retire early)if they thought they wouldn’t make as much money as in the past? Most likely. And we’d be lucky to lose them. We don’t need more physicians who go into medicine for the money. These are the folks who are driving up costs with their overtreatment Let them become lawyers.
When managed care became popular, people realized that doctors salaries would flatten out–and medical schools say that they saw a change in who goes into medicine (more women, for one) and by and large they see it as a positive change.
P.S.– It occurs to me that I should make one thing clear: I don’t expect that we can realize the savings from cutting waste in our healthcare system immediately.
So healthcare reform definitely will need a large amount of “seed money”–but I think that rolling back the Bush tax cuts for wealthier citizens,combined with re-writing the Medicare Advantage law so that we’re no longer paying private insurers a premium to take Medicare patients would do the trick.
This Blog has been an excellent read.
It never ceases to amaze me, the amount of energy that can go into a project just to avoid doing the right thing. The best, simplest, least costly, most effective thing we could do is expand what has been working so well for years, Medicare. You get sick, you get care, and the caregiver gets paid. Nothing could be simpler. I’ve been on it for four years and it works beautifully.
But that’s probably its problem. Politicians don’t like “simple” when it affects a major source of campaign cash. Which should tell us that we are getting screwed over in many ways by our corrupt political system.
To paraphrase a famous quote, “America will always do the right thing, but only after failing at everything else.”
Good thoughts Maggie.
> Keep in mind we are spending twice
> as much as other countries who cover everyone.
The trouble when you say “we spend”, is that there is no “we”. Well, there is, but people don’t recognize it.
For most people here, there is only “I” as in “I get health insurance at work” and “I paid FICA taxes all my life” and “I can’t stand freeloaders.” This is the fundamental difference between the (Calvinist) USA and (whether they like it these days or not, Catholic) Europe. Here everything is about personal liberty in the negative sense of freedom from coersion and a presumption of just deserts in life. There, some things are about solidarity.
Most everything else you have considered is 1980′s style managed care all over again, and that didn’t go so well last time.
Jack is right, from his point of view Medicare is simplicity itself. But its not sustainable.
t
dMaggie,
Good analysis and summary.
With respect to the so-called waste in the system, I think one of the most doable strategies would be if Medicare takes a more rigorous stance with respect to which new drugs and devices it will cover. For those it deems not sufficiently cost-effective, private insurers probably won’t cover them either. While manufacturers of the drugs and devices, along with some patients who are seriously ill and out of options will protest, somebody has to say no sometimes. The experience you alluded to in an earlier comment regarding the wrath that fell upon the AHRQ when it suggested we were doing too much back surgery some years back suggests that nothing will be easy when it comes to cost control. I’ve said many times that our whole approach to end of life care needs serious reevaluation. A thorough study of other countries’ approach to this issue would probably be instructive.
I think electronic records is an area where taxpayer funding (or at least subsidies) would be extremely helpful. It might be easiest to start with the hospitals since there are only about 6,000 or so of them, and that is where much of the duplicate testing and medication errors occur because multiple doctors treating the same patient don’t know what each other is doing.
I’m more skeptical of our ability to reduce specialist compensation except to the extent that we can do it as a by-product of reduced utilization through practice pattern convergence and evidence based medicine backed up with financial rewards for best practices and penalties for over treatment.
On changing the way medical education is financed, if doctors emerged from medical school debt free, I wonder how much less income they would be willing to accept. If I had the opportunity to not incur $300,000 of debt that would otherwise have to be repaid out of after tax income, I might be willing to accept $30,000 less per year in beginning of career dollars. This would give society a 10% return on the capital that it relieved me from having to invest in myself. This is looking at the issue from an investor’s perspective. I would be curious about how others view it. Doctors’ income more generally will always be strongly influenced by what they can earn in other fields like business and law. That opportunity cost is considerably higher here than in Europe and Canada which helps to account for their considerably higher incomes here than in those other countries.
As for lower brand name drug prices, the government would have to back up its negotiating with a willingness to employ a restrictive formulary like the VA does. Seniors in particular might balk at that.
Regarding healthcare system financing, I was actually glad to hear you say that employers would prefer to redirect their current health insurance spending into a healthcare tax. An employer payroll tax is my favorite approach because it is closest to the current system and has the virtue of transparency. I think it is important for people to understand how much they are paying for healthcare, and the more visible the payment, the better. Employer provided health insurance is part of compensation, but many people don’t understand that. The employee could pay a much smaller payroll tax that, as you say, approximates the current employee share of the premium.
For the seed money to cover the currently uninsured, I support higher taxes on dividends and capital gains. My preference would be to make both qualified dividends and capital gains part of the income base for the purpose of figuring the Alternative Minimum Tax (AMT). For very high income people, the effect would be to raise the current tax rate from 15% to 28%. I think the current top ordinary income rate of 35% is high enough. I note that even under the Clinton tax increase of 1993, it was sold as a top rate of 36% and a temporary surcharge of 10% bringing the actual top rate to 39.6%. The surcharge was to be removed when the deficit was brought under control. The budget went into surplus in the late 1990′s, but, in typical fashion, there was never any effort to repeal the surcharge, which gives rise to the saying “There’s nothing more permanent than a temporary tax.”
Having said all that, I still would prefer a voucher system to Medicare for All even if it were a bit more expensive. Choice is a good thing and is consistent with our culture.
This is a letter that I have been sending to various public officials and media outlets. It was published in the Northeast Times, recently in Philadelphia, PA.
Candidates proposing universal health care are inspiring. However, we need
to fix the health care system as well.
As a patient and a former employee (I used to work at a famous hospital on
Long Island) of the health care system – I have first-hand knowledge on how
the care system works in America.
Close to 100,000 people die each year in hospitals due to medical errors.
The hospital I worked at had too much administrative waste. There was
endless paperwork in processing patient information.
Many of the positions, especially in the non-medical areas, were filled
through nepotism. Many of the supervisors and mid-level managers at this
hospital were concerned about how they looked to top administrators, rather
then perform thier jobs effectively. (CYA was the major activity).
A question I would like to ask the general public, particularly doctors -
How come doctors never challenge other doctors?
Right after I graduated college I was “confused,” doing drugs, and getting into trouble; so my parents sent me to psychiatrist. The psychiatrist said was I “mentally ill” and he sent me to neurologist for my tests. (Our family doctor stated at first I did not need any tests, and then he changed his mind.) The neurologist examined my brain and said I was fine. I just needed to “grow up.”
Jack, Tom and Barry–
Jack– I agree. I sometimes think that if we want healthcare reform, first we need campaign finance reform.
The problem is that campaign finance reform would be
even harder to pass–for obvious reasons. But I do think that if we (mainstream media, bloggers, etc.) make it clear to the American public just how much power health care lobbyists have–and how they use it (not to promote our health)–more Americans might begin to realize Medicare for everyone really is the simplest answer.
Tom–
I agree that Europeans take a collective view of problems while we tend to emphasize the individual. And you’re probably right this is, in part, due to our Calvinist heritage–but also, I think, because historically, “we” in the U.S. have never been under the kind of pressure that, say, the U.K, France and many other European countries faced during World War II.
Under such circmstances, people learn to pull together.
But I think that now,the U.S. is facing pressures that we have never had to face before–both economically and politically. This could mean that, at last, we will learn to say “we” instead of “I’ve got mine, Jack.”
Barry–
I greatly appreciate the amount of time and thought that you have put into this debate. And you have persuaded me that we are not as far apart as I once thought. This suggests that if more people talked, in depth and detail, about healthcare reform, more of us could come together to find a common solution.
I agree that the most “doable” solution, at the outset, if for Medicare to take a more rigorous stance about what drugs and devices it will cover. And private insurers would definitely be happy to follow Medicare’s lead.
You’re right that we need to re-think our approach to end-of-life care. We could learn a lot from other countries about palliative care (which, as you know, does not mean giving up on the patient, or ceasing to treat, but it does mean a) keeping him/her out of pain and b) letting the patient choose whether they want to continue treatment. ) Research shows that, today, in the U.S,. too many patients continue treaments they don’t want becuause they don’t want to disapoint their doctors or “let down” their families.
On medical student debt–I think that we could make major improvements in our health care system if we fully funded the type of scholarships which we had in the 1970s–scholarships that gave students full tuition in return for agreeing to practice in parts of the country where they were most needed for a certain number of years. (Think of the TV show “Northern Exposure.”) My sister-in-law did this, and wound up staying in the rural area where she first practiced.
In terms of “opportunity cost”–I tend to disagree in this sense: While you are right, many pre-meds make their decision by comparing how much they could make as a doctor, lawyer, CEO or Indian chief, I really don’t think these are the people we want in the medical profession. It is a profession–not a career you choose based on how much you will make– but something that you “profess to”–i.e., something that you believe in.
To me, this means that you want to attract future doctors with professional values–people who realize that there is an enormous difference between being a doctor and being a divorce lawyer. You want people who like the work for its own sake–people who would be happy to do it as long as they can live comfortably.
This really does seem to be the case in counttries like France, and I have a hard time believing that intelligent, hard-working Americans are that much more greedy/materialistic than Europeans.
Re: paying lower prices for brand-name drugs. The VA formulary really is not restrictive. As you know, the VA has won rave reviews for the quality and efficiency of its care in recent years–despite the fact that its funding has not begun to keep up with the number of paitents the VA is treating.
Re: financing. I”m delighted that we are in agreement about tax-financing. And surprised that you agree with me about taxing investment income.
Though I would preferto tax capital gains rather than dividends because I would like to encourage investors to look for dividends–and encourage companies to pay out dividends. Dividends leadsto more stable returns–which is good for retirement savings. And too often, when corporate managment “invests” the money it could have paid out in dividends, it makes very stupid mistakes (mergers based on so-called “synergy,” etc.)
Finally, I agree that, in many areas “choice is a good thing and consistent with our culture.” But when it comes to healthcare it strikes me that the average layman is not in a good position to exercise that choice. Healthcare is just too copmlicated (not to mention the fact that when you need really expensive healthcare, you are sick, and in many cases, elderly.)
I think of the Wall Street Journal article that I read a few years ago that extolled the virtues of “consumer-driven healthcare” saying “consumers will be able to pick their hospitals the same way they pick their mutual funds.” Did we learn nothing from the nineties?
Just as most of us are not in a good position to be our own money managers, most of us are not in a good position to judge whether the healthcare we are being offered is, indeed, based on solid medical evidence.
Tom, Medicare may “currently” be unsustainable, but it could easily be dealt with. First by raising the taxation caps on $90K and allow the cap to swing as high as nessecary to pay a good share of the costs. Then by demanding that Medicare negotiate the same 50% discount the VA gets on drugs. Then by demanding that high-tech testing be done in the hospitals and not in clinics where the physicians have ownership in the equipment. And lastly, by not allowing hospitals to be opened and closed willy-nilly and impose caps on the number of, say, MRIs or CT scanners are purchased in an area.
And Maggie, campaign reform is indeed possible in a way that does not violate the 1st Amendment, and that’s with public funding of campaigns (but on a voluntary basis) as they have in Arizona and Maine. I won’t spend time here but take a look at http://www.wicleanelections.org
Maggie,
I agree that we are not all that far apart. Just as an aside, my view about taxing investment income is clearly a minority position in the industry I work in. I do believe, however, that the mega wealthy, who derive much of their income from investments, should pay at least a similar percentage of their income in taxes as their secretaries do. Their tax burden is considerably lower currently because the tax rate on qualified dividends and long term capital gains is so low compared to rates on ordinary income, and the payroll tax does not apply to investment income either.
On doctor compensation, I hear you, but I think the key is the definition of how much it takes to “live comfortably.” Whatever that is, it’s clearly a lot more in Manhattan than in Atlanta or Houston. Moreover, if specialists need to spend several years (or more) acquiring the training necessary to become Board Certified in their specialty, their incomes should at least reflect the opportunity cost of the income forgone during that time. Personally, I think family docs in a city with living costs in line with the national average should make at least $150K and probably closer to $200K. Double that might be reasonable for specialists, though billing rates for some might be much higher to reflect very high malpractice insurance premiums.
My comment about choice referred to choice among insurance plans, not making decisions about healthcare choices. I would like to see plenty of insurance companies trying to differentiate themselves based on customer service, deductibles, copays and scope of coverage with some minimum set of benefits defined legislatively. I also think robust price and quality transparency, along with objective, unbiased infomediaries to help consumers evaluate their treatment options would be helpful as well.
Regarding physicians and income, from my experience there are very few people who go into medicine just for the money. It’s just too damn hard. People forget there are long hours, night call, difficult patients, having to deal directly with death, threat of lawsuits no matter whether you actually made an error or not, worrying about making a mistake and killing somebody, on and on. Income expectation probably does, however, have some effect on chosen specialties, about 50/50 with the medical student’s personality. ( One can practically look at a class and predict the future surgeons vs. internist types by the 3rd year of med school.)
It’s making an income and then retrospectively having it, or your entire career, threatened that makes us defensive – just like anyone about to lose their job, or take a big pay cut. Doctors are no different than anybody on that score. We are human too.
If the income expectations were known to be lower before the student entered medical school, I do not think it would be an issue. It’s the transitional generation feeling the pain, and that’s happening right now, despite the popular perception of still-rich physicians all over the place. That may be part of what’s leading to the current perception of doctors treating “just for the money.” I’m not defending it, just observing it.
Maggie;
I forgot one thing; regarding the FDA’s deliberation process and evidence-based medicine. Below is an abstract from “Health Affairs”; on making the crucial distinction between EVIDENCE and JUDGEMENT. I was able to read the entire interview under a “access free for 2 weeks” deal, but the full text is no longer available. For anyone who can get it, it is very educational regarding the process of judging evidence in medicine.
Reflections On Science, Judgment, And Value In Evidence-Based Decision Making: A Conversation With David Eddy
Sean R. Tunis 1*
1 David Eddy is founder and medical director of Archimedes Inc. in Aspen, Colorado. Archimedes was founded to improve the quality and efficiency of health care by using advanced mathematics and computing methods to build realistic simulation models of physiology, diseases, and health care systems. Sean Tunis is founder and director of the Center for Medical Technology Policy (http://www.cmtpnet.org) in San Francisco.
*Corresponding author.
Abstract
Evidence-based medicine (EBM) has increasingly influenced decision making in health policy and patient care. Appropriate use of EBM in decision making requires a clear understanding of the distinct “anatomical” components of all decisions: (1) scientific evidence and (2) judgments applied to that evidence by individuals or organizations. In this interview, Sean Tunis discusses these principles with David Eddy. Tunis has provided leadership at the national level in applying EBM principles to health policy decision making at the Office of Technology Assessment, the Centers for Medicare and Medicaid Services, and now the Center for Medical Technology Policy. Eddy is cofounder and medical director of Archimedes; he is widely recognized as a seminal contributor to evidence-based medicine, helping shape the initial ideas and applying them to guidelines, coverage policies, and performance measures. [Health Affairs 26, no. 4 (2007): w500-w515 (published online 19 June 2007; 10.1377/hlthaff.26.4.w500)]
I have read the original essay and the subsequent commentary and I do not believe that the commentators are on the right track. In my view, there is no doubt that the American health care system is in dire need of drastic change. I believe the best way to approach that change is to go back to the basic question of “What is health care?” I believe that health care is simply the doctor—patient relationship. On an individual basis, it is the individual relationship that a patient forms with his/her doctor and through which medical care is delivered. On a nation-wide basis health care is the sum of all these relationships, nothing more and nothing less. I think that you become mired in controversy, greed, politics, profits, annual income, and deal making when you view health care as a business. I believe our health care system needs to be changed to a structure that contains businesses which exist solely for the support of the doctor—patient relationship for every patient in America and not for their own dollar profit. Certainly any business needs good, acceptable profit margins to thrive but, in health care, when the dollar bill becomes the primary focus as opposed to actual health care,i.e., the doctor—patient relationship, we get into the difficulties that we are now experiencing. My new book, EQUAL HEALTH CARE FOR ALL (ISBN13: 978-0-9796994-0-5) available through my web site describes the kind of health care system that I am talking about. It is a system that I believe will achieve the following:
1. clear and equal access to vital, comprehensive health care for everyone living in America in an affordable manner.
2. a system which supports good, acceptable profit margins for businesses which operate within our health care system while at the same time removing greed from their modus operandi.
3. centralized electronic medical record storage.
4. major advances in handling medical malpractice.
5. major advances in medical education.
6. elimination of health insurance companies by a single payer which controls prices of services and products through tough, fair negotiation but maintains good, acceptable profit margins for the businesses involved.
7. alleviation of employers having to provide a health care benefit.
8. zero interference from the single payer with the workings of the doctor—patient relationship. This relationship, with zero financial conflict of interest on the doctor’s part, becomes the driver of health care expenditure.
9. Clear, straight-forward mechanisms of funding that reveal to everyone that health care is not free. Everyone pays. However, no one has to go bankrupt in doing so or to make a choice between groceries and medicines.
10. other forward thinking concepts and ideas.
I hope that all the commentators will visit my web site and read my book. I welcome your critiques. I do not have all the answers.
One final thought: there are several “smoke and mirrors” concepts out there by which various players maintain their very profitable status quo. Some of these are as follows:
a. Socialized medicine.- a term which has been given a pejorative connotation for over the last century. It is quite possible to have a single payer system that does not ration health care. Also remember my definition of medicine. It is the doctor—patient relationship. We do not have “socialized doctor—patient relationships.”
b. Cost-effectiveness.- For anyone who wishes to use this term, I want to know what are the units of measurement, how is cost effectiveness determined, and of what clinical usefulness is it within individual doctor—patient relationships?
c. Market-mediated.- this means maintain the unbridled capitalism,a.k.a., greed that currently exists within our health care economic market place.
d. Competition drives prices lower.- In my view in health care, competition drives supply that then needs to be filled with increased demand. In health care, for a truly successful system, demand needs to be driven by the doctor—patient relationship. That is simply because health care is not and can not be a business. The last century of trying to make it a business has led to our current system.
e. and other business jargon buzz words and phrases.
Doctor K.
Bev,
Those are very good and very fair comments about doctors’ income.
The profession, however, has a somewhat arrogant image among a good portion of the public which is attributable, I think, to the following factors:
1. A general dislike of having their decisions and recommendations challenged. While doctors drive virtually all healthcare spending through hospital admissions, referrals to specialists, writing prescriptions for drugs, labs, imaging, physical therapy, etc., consulting with patients and doing procedures themselves, they generally oppose P4P and resist embracing price and quality transparency.
2. Through the AMA, they attempt to thwart competition. The latest example: opposition to retail clinics staffed by NP’s and PA’s. These can offer timely access and lower prices for simple, minor problems, but the AMA’s first instinct is to protect what they see as their turf.
3. A small number of less competent doctors account for a disproportionate share of malpractice. Yet, the profession is reluctant to admit mistakes and often does everything it can to protect its own behind a white wall of silence.
Bottom line: Doctors do extremely important work and spend a lot of time acquiring the knowledge and training necessary to perform the job. They deserve to make an income adequate to sustain a comfortable living. On the other hand, they could help their own cause considerably if they would (1) embrace price and quality transparency and, through their specialist societies, work to develop P4P metrics that they can live with, (2) embrace competition where appropriate, and (3) admit mistakes and do a better job of weeding the less competent doctors, who account for a disproportionate share of malpractice, out of medicine.
Doctors should be paid very well; even on par with(honest) CEOs. But not on the basis of how many expensive tests they order or surgeries they perform. I’d like to see some controls on both.
But we should also reward the best docs, those in the top 10% of their class, with 100% rebates on their educational costs.
Barry, Bev, Dr. K. and Jack,
Barry– I think we really only disagree about the role of private insurers. When people talk about giving patients “choices” I become uncomfortable because too often they are talkig about “each according to his pocketbook.” So a poor family winds up with a policy that has a high deductible and co-pays –and as a result, puts off getting needed care. (As you probably know, studies show that people with high deductibles are just as likely to defer needed care as they are to cut back on non-essential care.)
So assuming that private insurers stay in the game (and I assume the best will, at least for the foreseeable future) I’d like to see guidelines that outline what policies must cover (essentially everything you and I would want for our famlies –something equivalent to Medicare plus Medigap.)
And I’d also like to see very low (or no) co-pays and deductibles for preventive care and generic prescriptions, and uniform (fairly low) co-pays and deductibles for other procedures.
Basically, I don’t want to end up with a two-tier health care system. I’m afraid that the lower tier would turn out to be another version of Medicaid–generally low quality, in part because providers are paid poorly.
If insurers all had to offer both comprhensive coverage and uniform co-pays and deductibles, how could they compete? On customer service and by providing suppport for the doctors and hospitals in their network that would lead to higher quality and efficiency (which go hand in hand.)
.
This might mean that insurers would pay doctors and hospitals that had the best outcomes more (measuring outcomes in terms of hospital infection rates, need for readmission, mortality rates, number of days hospitalized for a specific procedure); they might also pay providers more if they install and use electronic medical records, if they can show proof of reducing infection rates, etc. . .
Bev — I’m afraid I do know students who decided to go to medical school for the money and, to a lesser degree for the perceived prestige. Here I’m thinking of some of my son’s classmates (he went to Johns Hopkins, so knew a lot of pre-meds) as well as students I taught years ago. I remember one student analyzing law school vs. med school after he had gotten into both. On the one hand, he would have to spend more years in med school, but would probably earn ___% more, on the other hand . . Absolutely none of his analysis had anything to do with wanting to help people, finding either the science of medicine or the law interesting, etc. . . I have to say that based on my (purely anecdotal) experience, this is more likely to be true of men than of women who go into medicine. Of course,I’m prejudiced. But female doctors are also much more likely to be in favor of national health insurance, group practice, etc.
Of course, you’re right, med school and practicing medicine is very hard work–though some doctors make the practice of medicine not so hard, depending on the speciality they choose, the hours they keep, the type of patients they attract (location, location, location), how much they charge and whether or not they take insurance. . .
In terms of a “comfortable income” Barry’s $150k to $200k sounds about right as a national average. (Keep in mind that this is per person, not per family. If a doctor is married and has a family, probably her/his spouse works too)
But what is most important, I think, is to reduce the cost of medical education by providing many, many more full scholarships for students willing to work in areas where they are needed for three or four years after med school. I think the benefit–in terms of public health, and the savings (providing preventive care before people become really sick) would justify the cost.
Jaack– I’d rather do this than reward the top 10% of med students. (Students are already so competitive; I can only imagine what would happen if that kind of reward were hanging over their heads.)
Doctor K– I agree with many of your proposals–except the emphasis on the individual doctor-patient relationship and the suggestion that the individual doctor should have complete autonomy. This sound a lot like the solo-practioner/ Lone Ranger model of medicine that we have in many part of the country today.
The problem is that doctors, like electricians and writers, live on a Bell Curve. A few are excellent; the majority are in the middle–i.e. mediocre–and, at the other end of the curve,some are, at best, barely competent.
This is why we need practice guidelines and why patients are better off when doctors work in group practices where they are looking over each other’s shoulder. (See Atul Gawande’s New Yorker article titled “The Bell Curve”–you can get access by googling it. )
Finally, Bev, the Health Affairs article sounds very interesring. I’ll look it up.
There are a lot of factors that go into choosing a profession…and to think that the “smartest” or “best” students simply follow the money is not correct.
There are some pretty smart and capable physicists, researchers, philosophers, journalists, etc, etc. who have huge investments in education without the expectation of being paid like a CEO. And there are plenty of CEO’s who have little education. Why are the Service Academies some of the most selective colleges in the nation? It can’t be the $24K per year 2LT salary…or lifestyle “benefits”…
A big appeal (to many) physicians is the autonomy…and the entrpreneurial opportunities (as small businessmen and women) to make a lot of money…which is more part of the problem than part of the solution.
There are many incentives in the current system to do exactly what the system doesn’t need: work alone (vs. in a multi-specialty group practive) in a super-specialty (vs. primary care)…and do more complicated procedures (vs. prevent the need for procedures with wellness, etc.
Maggie;
Funny you should mention Hopkins; I spent 2 yrs there as a resident and assisted with teaching labs in the medical school in the early 80′s. I found their medical students to be among the most obnoxious and cut-throat competitive medical students I had ever been around. (I attended med school elsewhere, obviously.) That’s all I’m going to say about that.
Barry;
Here’s my theory: the current health care system’s financial and other incentives select, in Darwinian fashion, for the most entreprenurial, business-oriented and (often) therefore less patient-oriented physicians.
Both my husband and I left practice early because we were not those types of physicians, without going into extraneous detail.
As far as your numbered points:
1. See Darwin above.
2. Ditto; plus many docs do not think the AMA speaks for them. They do us more damage than good, in my opinion.
3. This really puzzles me. I have been on medical executive committees charged with disciplining doctors so I have some experience. Although most of the committee members correctly recognized when the doctor was at fault, their reluctance to “throw the book” at them seemed to stem from; a) there but for the Grace of God go I and therefore give the guy a break once; b) if we really discipline this person we are causing him/her to lose his livelihood and he has a wife and kids (the latter statement I have heard verbatim), and/or c) he will sue and win so it’s hopeless anyway. It’s not an active effort to protect bad practitioners, but a lack of gazongas (figuratively speaking) to make an active effort to get rid of them. I agree with you that this should change, and fast.
Maggie,
I appreciate your arguments up to a point, but I have some concerns. The primary concern is overuse of the healthcare system if patients have complete or near complete insulation from out-of-pocket costs. I have moved somewhat toward your viewpoint on preventive care after sitting next to the Chief Medical Director for one of the large insurers at lunch earlier this year. I was surprised to learn that a large percentage of heart patients, for example, stop taking statin and hypertension drugs within six months of starting. Eliminating the co-pay significantly reduced that percentage. On the other hand, not all preventive care saves money. PSA tests, for example, are controversial in this context because they often result in false positives that lead to biopsies and, sometimes, complications. Or, they identify low grade cancers that probably would have never caused any harm in the patient’s lifetime. I also wouldn’t want my tax money paying for full body scans or routine screening of millions of healthy people with no symptoms if the data shows that it’s not cost-effective. I think the AHRQ has some good data on which procedures are cost-effective for which populations and which are not.
At the same time, I do not think the upper half of the income distribution needs or should have near complete insulation from healthcare costs. Some out-of-pocket exposure is appropriate for them, in my opinion. If we designed a basic benefits package like, say, the FEHBP standard option, the cost should be unbundled into what a call an insurance piece which I define as all costs above $5,000 per year per person, plus the cost-effective preventive care and the insulation piece which would cover the first $5,000 of expenses less, perhaps, a small deductible and/or very modest copays ($10-$15 for office visits and drugs). Everyone could receive vouchers entitling them to buy the insurance piece from the insurer or their choice. We could give means tested, sliding scale subsidies to those up to 300% or even 400% of the federal poverty level (FPL) to help them buy the insulation piece. The rest of the population could buy it out-of-pocket if they wanted it or choose to self-insure.
In my own case, I incur several thousand dollars of cost each year for prescription drugs and periodic stress tests and other monitoring. On the other hand, since I can afford it and have some appetite for risk, I would be willing to absorb up to a $10,000 per person deductible if such a policy were enough cheaper than the comprehensive plan to make it a worthwhile (to me) risk/reward tradeoff. That also assumes that I would be entitled to contract rates for services within the deductible.
I’m reminded of a story that Matthew Holt wrote about in response to one of my posts a number of months ago. I had commented that if I were uninsured and suddenly received a voucher sufficient to buy the equivalent of coverage from Kaiser (HMO, closed network, etc.), I would consider myself hugely better off than I was previously even if I knew that wealthy people probably stayed in a private room when they needed to go into the hospital. Matthew related the story of a janitor he knew back in the UK who commented that if a rich guy has a Roller and all I have is an old banger (jalopy in Brit speak), that’s OK. However, if he has a Roller and all I have is a push bike, that’s not OK. I guess at bottom, I’m willing to accept considerably more inequality than you are, though I think everyone should have the healthcare basics including good catastrophic coverage if they suffer a truly serious medical event or have an expensive to treat chronic condition.
Finally, I’m with you on insurers competing on customer service and trying to find ways to reward the best providers, including paying them higher reimbursement rates. I also would not have any problem with differential copays to help induce patients to use the most cost-effective providers. Moreover, there should be mechanisms that make it considerably easier than it is now to remove sub-standard or persistently high cost providers from the network which, today, is much easier said than done.
Hello. I would like to respond to some of the above comments since my last posting. First, thank you for the kind, courteous reception that you have given to my earlier commentary. I have not been received quite so well on other blogs and web sites.
Bev: I do not know what P4P means. Regarding resisting price and quality transparency: It would be right in my view if a single payer set standardized fees across the entire country for each type of procedure and for each type of visit. They do not have to be punitive, just controlled and known. I cover this in Chapter 7 of my book. The biggest problem with a veil of secrecy over pricing comes from our hospitals which is another discussion altogether.
I have no difficulty with NP’s as long as they operate under professional supervision by an employer physician who ultimately bears responibilty for the quality of their work.( Chapter 5) Unless of course the NP takes regular, ongoing night call, pays hefty malpractice premiums, and assumes complete responsibility for a “minor” case that turns out to be not so minor. Their degree of training does not allow them to do this. How do you define “minor?”
Regarding malpractice, I agree with your comments. See chapter 9 of my book.
Jack: All financial conflict of interest for example, making money by ordering a certain test needs to be removed from doctors’ practices. I cover this in chapter 7. Regarding surgeries and other procedures performed by physicians, the issue becomes much more difficult. I guess there are some doctors who perform unnecessary operations and non-surgical procedures such as colonoscopy, cardiac catheterizations, bronchoscopy, etc; however, I have never met one. The decision to perform an invasive, risky procedure is not based on financial return for the work in my experience. Maybe others have had different experiences. But remember, that coupled with the risk for the patient from an invasive procedure is the stress for the doctor of avoiding complications and the work of managing the complication if it does occur, not even considering the malpractice litigation stress that often follows. I just haven’t met any doctors who ignore all of this and then perform non-indicated surgeries and procedures solely for financial return. In fact, I think the opposite is often true; doctors avoid doing invasive risky procedures just for those reasons.
Maggie: The individual doctor—patient relationship is medicine. There is no other way. I do not at all insist on complete autonomy for the doctor. I insist on complete autonomy for the doctor—patient relationship. I am not playing word games here. The decisions made within the context of that relationship require input from two people. No outside agency has the right to interfere with that. I develop this concept in chapter 2. There has to be a standard. In my view the standard is a sound, ongoing doctor—patient relationship for every patient in America. If you have a better one, let me know.
Regarding your comment about the Bell Curve, I expect you are accurate. Doctors are humans and will fall into the same categories of performance as other groups of humans. Did you expect it to be different? Practice guidelines are okay I guess, but they are made up by people who don’t practice. I would prefer a much higher standard of medical education prior to allowing doctors to enter into practice and then a system of strict, verifiable ongoing education, once they do enter practice. I develop these ideas in chapter 6.
Regarding your comment about group practices, I again think you are off the mark. First, I do not know if you mean group practices where all the doctors are the same specialty or whether it is a multi-specialty practice. For the former, five of the same type of doctor trying to manage one patient will result in confusion for the patient and loss of continuity for the doctors. There is a whole lot more to continuity than reading over someone else’s progress note.
For multi-specialty practices, doctors hide within the confines of their specialty, do their consultations, and leave “management” of the case to the primary care doctor who referred them. If the primary care doctor were capable of managing the case, I don’t believe he/she would have made the referral in the first place. I can think of two other reasons for making a referral within a multi-specialty practice: 1. to increase practice revenue. Obviously, I am totally opposed to this. 2. Academic interest. Even though the doctor responsible for managing a patient is doing a good job, if there is a good subspecialist available, a referral might be entertained for a more informed look at the nuances of the disease process. I quite agree with this 2nd reason because it greatly enhances the doctor—patient relationship from both ends. And I think it applies whether the doctor is in a multi-specialty group practice or not.
Doctor K.
>>> “The primary concern is overuse of the healthcare system if patients have complete or near complete insulation from out-of-pocket costs.”
Barry, we’ve talked about this before, and I think we have to quit blaming the patient for overuse (though they may be responsible for 20% of it). When physicians invest $150K in an echocardiograph, they damned well better make good use of it, and they do that because (a) they can refer their own patients to it and (b) the tests are profitable as hell when they do so. You recall a while back you referred me to the McKinsey study that showed that physicians who have a financial interest in the testing equipment are eight times more likely to order tests than physicians that have no such conflict. When a doctor tells a patient they should have an echo, it matters not whether there is a co-pay or not. Most are going to do it.
And I would argue that the smaller the co-pay the (a) less effective they are (if you believe they are effective at all, which I don’t), and (b) the more costly they are to administer (as a percentage collected). If we are concerned about utilization I’d must rather see a no co-pays for the first dozen doctor visits per year, and then a patient facilitator (independent nurse) getting involved to determine if one side or the other are abusing the system, and if so, a co-pay instituted at that time.
Doctor K, P4P means Pay-for-performance, a concept promoted here and currently being introduced in the UK. However, before we get to that point I believe we need a national database to track outcomes.
And on unnecessary surgeries, I agree this is less of a problem, though others can probably enlighten that subject with the Redmond CA case (of which I am not fully informed).
And for those who haven’t seen it, you must. I am not a Michael Moore fan, but in Sicko the message he presents is right on target. Every politician should be required to see it.
See the link below for a physician’s opinion of “Sicko” – and why he wants to live in France…….
http://homepage.mac.com/dtoub/blog/C1162157567/E20070707004823/index.html
….if you want to know why patients are unhappy and docs are leaving medicine in the U.S.
Jack,
First, the McKinsey study found that doctors who have a financial interest in imaging equipment are two to eight times more likely to order tests that make use of the equipment, not eight times. However, setting that aside, consider the following situations, both under the current system where the patient has some financial exposure (deductible and/or co-pay) and under a potential single payer system where the patient is completely insulated from out-of-pocket exposure.
1. You’re a family doctor. You want to do what you think is best for your patients and you want to be thorough. You have no financial interest in any expensive equipment, and you may even be working for a salary. You think your patient may benefit from an MRI, other expensive tests or a brand name drug where a generic exists but the branded drug offers the convenience of a once a day dose vs two or three times a day for the generic.
Under single payer with no copays, you don’t hesitate to do everything that you think might benefit your patient. If you know the patient has some meaningful out-of-pocket exposure, you may opt for the generic drug instead and hold off on the expensive tests to see if the matter resolves itself or can be dealt with in a less expensive way.
2. You’re an ER doctor. An insured patient comes in complaining of chest discomfort. Under the current system, you run the blood tests to check the cardiac enzymes. They come back normal. You conclude that the problem is probably indigestion or acid reflux and prescribe appropriate medication. Under single payer with complete insulation and assuming a bed is available, you admit the patient for overnight observation and additional testing.
3. You’re the patient. You have a cold, sore throat, mild cough, low grade fever, or occasional headache. Under the current system, you decide to see if drinking fluids, getting a lot of rest, or just taking it easy will allow the problem to resolve itself. Under single payer with insulation, you decide to go visit your doctor or, perhaps, a retail clinic for reassurance. After all, it’s free.
For doctors who genuinely want to be thorough and do what they think is best for their patients, they will drive more spending on behalf of their patients if they know the patient has no out-of-pocket cost exposure than they will if they need to be at least somewhat sensitive to deductibles and copays. Also, our litigation culture and defensive medicine mentality will, at the margin, drive more spending rather than less, again, even if the doctor is on salary and does not financially benefit from the added testing.
Medicare has done an absolutely miserable job of controlling utilization of healthcare services, and there are meaningful copays and deductibles, including about $1,000 for each hospitalization. When healthcare is perceived by patients as free, demand can approach infinity as doctors will be biased toward additional tests out of a desire to be thorough, not to make money for themselves while patients will demand and expect more.
Without a robust mechanism to track utilization by providers and relate it to health outcomes, combined with a system of rewards and penalties for cost-effectiveness and overuse, costs will explode to an even greater extent than they already have.
I don’t think, Barry, even under the best of circumstances, only ordering twice the tests because you have a financial incentive is acceptable. But in my 35 years in the industry I have seen the numbers well above quadruple. But admittedly, even while this greed persists, it is not the major problem in health care. It is an insurance bureaucracy that consumes 31% of healthcare costs without ever laying a hand on the patient. I would rather see that 31% spent on patient care, and a single-payer system will accomplish that.
Under your scenario #1, there is a much greater issue than can reasonably be discussed here. Is the brand name s new innovation or another me-too drug (where the formula has been just slightly changed to justify a new patent)? Assuming no financial incentive, I’d opt for the MRI over experimenting with any drug.
Under your scenario #2, if the beds are available remember that the costs are there anyway. Admitting a patient does not substantially increase costs for the hospital, but having lived through chest pain before I’d give the doctor latitude (and a complete family and personal medical history). I think you are too hung up on the value of co-pays, which I think are counter-productive.
Under your scenario #3, my wife just did all of the above, and she stayed away from the doctor even though she had no co-pay. As a result she is now undergoing treatment for pneumonia.
I am not sold on your hypothetical scenarios. I prefer to leave these decisions to physicians that have no financial incentive for ordering unnecessary tests, which, incidentally, could be detrimental to a patient’s health.
Medicare is not perfect, given that politicians have taken millions of dollars in campaign contributions to eliminate the sound rules that Pete Stark pushed through congress in the 1989 Omnibus Reconciliation Act. But nonetheless, it is better than anything we have in the private sector. As I said above, “You get sick, you get care, and the caregiver gets paid. Nothing could be simpler.”
We agree that MedMal should be replaced with a medical court system, and that we need a robust system for tracking outcomes and utilization. But neither are justification to ignore the massive waste caused by systemic flaws.
You can continue to claim that “when healthcare is perceived to be free, demand will go out of sight.” But that has not happened inappropriately in any other country, and if it does here there are safeguards that can be implemented later. But let’s not ignore the successes in other countries and shove free-market medicine down the throats of Americans that want a single-payer system.
Jack,
I think we might both benefit if a couple of the doctors provide their perspective on how practice patterns might vary if they know that the patient is completely insulated from the cost of care vs the patient having a meaningful deductible and copays to cover. It does not seem like much of a stretch for there to be a difference between (a) this is what I would like to do to be absolutely thorough in treating your issue and (b) since you have a meaningful deductible and copay, there are a couple of expensive tests that I’ll skip. Even though their information would be nice to have, it’s not absolutely essential.
I really wish you would stop quoting that administrative cost figure of 31% which is just not accurate. Large, self-insured employer plans, which insure about 70 million people, have administrative costs in the 5%-7% range. Typically, such employers pay an insurer between $15-$20 PMPM for claims processing, network access and disease management. Medical costs for a typical employer’s population (and their families) whose age averages about 40 are $3,500-$4,000 per year. Private insurers’ medical cost ratio for commercial customers averages 80% while after tax profits are about 6% of premiums on average. Several percentage points of each premium dollar flows back to the government in taxes. The individual health insurance market, which insures about 17 million people, does have very high administrative costs related mainly to broker commissions and underwriting. However, people who can pass those underwriting screens wind up with comparatively low cost insurance even after paying the high administrative costs.
Others more expert than I have also shown that Medicare’s administrative costs are significantly understated. Most obviously, since spending on behalf of the elderly is 2.5-3.0 times higher per person as compared to the rest of the population, administrative costs as a percentage of total spending are not directly comparable to private insurance spending on behalf of the younger population. Dollar spending per member per month (PMPM) would be a fairer comparison. Moreover, as I understand it, what Medicare calls administrative expenses is basically what it pays its private contractors for claims processing. It does not include anything for the cost of capital to raise the money it needs to fund its program, nor does it include the cost of its own employees or office rent for the buildings they occupy. A proper and fair analysis comparing Medicare’s administrative costs with those of the private sector would show that they are surprisingly close.
Finally, the doctors might also want to weigh in on the issue of just how burdensome and time consuming are Medicare’s (and Medicaid’s) documentation requirements needed to get paid.
The 31% of insurance bureaucracy waste comes from people who have done a lot more studying of the industry than I, and it is a rather commonly accepted number when you consider that it includes all of the extra billing clerks required by hospitals and clinics to deal with the 1500 insurance companies and likely 50,000 different plans in the nation. But I can readily believe the numbers when I look at the industry’s own administrative costs which include marketing costs, sales brokerage commissions, underwriting, gatekeepers, high executive salaries and high profits enjoyed by shareholders. You can defend the industry all you want, but I don’t know many industries that can operate on 5-7% and still provide all of the above.
The comparable costs of a Medicare-care-for-all system I expect will be in the range of 9-10%, much like Canada’s, but that will cover 100% of the people for a first class system. And yes, the per-capita spending on Medicare patients is (likely) 2.5 to 3 times that of all other “policies” because they almost exclusively cover seniors that require more care (and the cherry-picking industry would not cover nonetheless), plus the very costly end-of-lifers. But fold in all of the younger crowd and those costs will average out to less than we experience today.
I’d like to hear from the doctors too, but in my 20 years of billing patients I found Medicare a hell of a lot easier to work with, and with no more paperwork or approvals than the privates. In fact, when you consider the “out-of-plan” difficulties and “gate-keepers” of the private industry, Medicare was a breeze.
Regarding practice patterns being dependent on and changing in accord with patient’s financial responsibility, my views are:
1. When you bring the dollar bill into the doctor—patient relationship, you adversely affect the relationship. Medical decision making should have as its foundation the “medicine” of medicine and not the “business” of medicine. This is why the doctor—patient relationship has to be the driver of health care expenditure. A single payer (completely funded by everyone living in the USA) will have the ability to control health care expenditure by controlling the prices that are paid for services and product. That way the doctor—patient relationship is left unencumbered by the dollar bill. And the control can be such that good, acceptable (not egregious) profit above and beyond true cost of doing the work can occur for health care businesses. Also, potential financial conflicts of interest need to be removed from doctors’ practices.
2. Regarding ordering of tests, I think the distinction between information that is “nice to have” versus “absolutely essential” is off the mark. A test result that is “normal” or “negative” may be as much help in further clinical decision making as one which is “positive” for the abnormality that the doctor is looking for. On the other hand, a “negative” result does not always mean that a particular illness is not present. A crystal ball would be nice but I haven’t heard that that piece of clinical equipment is currently available.
3. A big part of the doctor—patient relationship is Experienced Judgment Grounded in an Extensive Fund of Knowledge. Doctors having this knowledge base is expensive for any health care system because the evaluations become more thorough than they would be without it. I believe that health care business people need to accept this,i.e., deal with the fact that the doctor—patient relationship is the foundation of medical care and therefore the driver of health care expenditure. If you try to influence medical decision making by bringing the dollar bill into the relationship, then you have HMO medicine.
4. Regarding paper work, my suggestion is to link billing-payment interaction with a single payer to a central storage system for all medical records. I develop this concept in chapter 8.
Doctor K.
Matt, Bev, Barry, Jack,
Matt—I wasn’t suggesting that the “best” or “smartest” students make career choices
based on money; rather, I was suggesting that AMONG THOSE WHO CHOOSE MEDICINE, a certain percentage make the choice with an eye to how much they
will make.
I agree that the fact that many doctors are drawn to the profession because of the autonomy is part of the problem, not part of the solution. That’s what I’ve been trying to say to Doctor K. Virtually everyone who has studied the problems of poor quality in healthcare agrees doctors need to learn to be team players.
Bev—Your description of why doctors don’t do a better job of policing each other confirms what other doctors have told me. I agree that this must change. Probably the best way to do it would be to set up regional (or state-wide) committees of doctors in a particular specialty to hear cases. It’s important that they only hearing complaints s involving specialists that they do not know (do not work with or compete with). If someone on the committee knows the specialist in question he could recuse himself./herself from the hearing.. Such committees would need legal protection so that they could not be sued.
And I couldn’t agree more that competition in our healthcare system has become Darwinian—and has helped to breed the “doctor as entrepreneur.”
Thanks for the link to “I want to move to France.” His experience rings true.
We need to have guidelines (not rules) for best practice set by specialists in the area—and it shouldn’t be too difficult for a doctor to deviate from those guidelines as long as he
gets another doctor to sign off (or at least puts his reasons in writing.) This is the way things work in the VA system. For instance if a doctor wants to prescribe something that isn’t in the formulary. If someone is constantly deviating from “best practice” guidelines the VA (or the Mayo Clinic or whoever) will want to know why—patients need to be
protected from the “I know best Lone Rangers.”
Doctor K—First, yes I am talking about multi-specialty group practices and secondly, in the many interviews I have done I have not heard of doctors “hiding” in their specialty at places like Intermountain or Kaiser . . . .Doctors talk about collaborating and working with each other.
As for “one doctor and one patient” having absolute autonomy, most patients will follow their doctor’s lead (particularly if they are very sick and frightened), so in many cases we are really talking about “one doctor” having autonomy. And we can’t afford to have one doctor (or even one doctor and one patient) decide that Medicare (or a private insurer) should pay $300,000 for an unproven treatment.
Re unnecessary surgeries: I don’t know where you practice, but virtually every heart specialist I have ever talked to says that we’re doing way too many angioplasties and way to many by-passes. No one says “I’m doing way too many” but everyone knows that someone is doing too many—they see the patients. And the most recent medical research suggests that perhaps half of all angioplasties do the patients no good. The same can be said about many treatments for prostate cancer. There is very little evidence that patients who receive the treatments live longer.
Barry—I completely agree about PSA testing—and other testing .that can lead to unnecessary procedures without reducing mortality or extending life. Have you read Dr. Gilbert Welch’s “Are You Sure You Want to Be Tested For Cancer? Maybe Not And Here’s Why.” He’s up at Dartmouth and has been doing excellent work in this area. He also has published a couple of brilliant op-eds in the New York Times.
So when it comes to questionable tests, I think that high co-pays are entirely appropriate. And we need to do more to discourage unnecessary tests. (Dartmouth ‘s Center for Shared Decision Making” has some excellent videos and pamphlets outlining the pluses and risks of various elective procedures and tests. After viewing them/ reading them and talking with a doctor, many patients decide not to go ahead with the test or procedure.)
For most care, I agree that people in the top half of income distribution can afford modest co-pays of $10 to $15. -–though I’m concerned about setting up two tiers of medicine with the best doctors practicing in the top tier.
I don’t think private rooms in hospitals should be covered by insurance (except in extreme cases—for example, a dying child and her parents should be given privacy, Patients who are in a lot of pain may need their own room. . etc.)
As for the jalopy/ roller comparison, I think that the difference between driving a jalopy and driving a roller cannot be compared to the difference between having your very sick child treated by a resident or having the child treated by a specialist –depending on how much you can afford to pay. In many states, most specialists in private practice simply won’t take Medicaid patients. They are more likely to get care at an academic medical center but ,there they may only be seen only by inexperienced resident—even if they are seriously ill. .
Another example—if a child is born healthy, but deformed, should a wealthy child receive the very best plastic surgery while a poorer child receives just what is medically necessary without trying to reconstruct the face as perfectly as possible?
The fact that some people can afford better healthcare than others is very different from the fact that some people can afford a nicer car. Healthcare is a right, not a commodity. . I’m just not comfortable with “inequities” at the bottom unless we are talking about luxuries (the private room, valet parking, fully body scans for asymptomatic patients, etc.) One reason Medicare has worked as well as it has (and Medicaid has failed) is that
Medicare is equitable.
Also, Medicare has done a much better job of containing cost than many private insurers who (since 2000) have been simply passing higher costs along in the form of higher premiums. . You’re right that Medicare wound up costing much more than was anticipated in 1965 (largely because Johnson agreed to let doctors and hospitals set their prices fee-for-service in order to get the legislation passed). But over the last twenty years or so Medicare has been trying to control costs, with more emphasis on outpatient treatment, the $1000 co-pay for hospitalization, etc.
Finally, while an insurance policy with a $10,000 deductible and a lower premium might well make financial sense for you, or me, or many other upper-middle-class and upper-class people, we need your full insurance premium in the pool to help pay for everyone. . If the wealthy “self-insure” by buying cheaper, high-deductible plans that leaves poorer, generally sicker Americans in the regular insurance pool, forcing their premiums up. We need to take a collective view of health care—to understand that we’re all in the boat together.
Jack—I agree: in many cases, supply, not demand, drives excessive care
Barry—Re your hypotheticals::
First, I have never had a doctor ask me “What is your co-pay on this drug/test? etc. “
so I have a hard time believing this factors into most doctors’ treatment decisions most of the time. Very likely doctors working with very poor patients in a community clinic might ask the question—or perhaps doctors prescribing very expensive chemo where a 20% co-pay could be unaffordable.
Secondly, I don’t think insurance should agree to cover a more expensive prescription drug simply because it’s more convenient (1 dose a day instead of 2 or 3). Whether we have a single-payer system or not, this is something that a patient should have to pay for out of pocket.
Under a single payer system we need to encourage doctors to think collectively, too.
They shouldn’t order an MRI merely because it “might” benefit the patient. Unless it is an emergency and time is of the essence, they should try less expensive alternatives first (x-ray).
Under single payer, the ER doctor should be penalized for an unnecessary hospitalization—not just because he is wasting everyone’s money, but because he is exposing the patient to unnecessary risks. Hospitals are dangerous places—especially if you don’t need to be there.
As for doctors over-treating because they fear litigation, this is why we need more practice guidelines based on unbiased “comparative effectivenss” research that MedPac is calling for.
Patients who have a cold should see nurse-practitioners, not doctors. And at a certain point, if the nurse-practitioner feels the visits are unnecessary, they should be billed (or sent for counseling).
Finally, I couldn’t agree more about the need for a “robust mechanism to track utilization by providers and relate it to health outcomes, combined with a system of rewards and penalties for cost-effectiveness and overuse” This is precisely what MedPac wants to do—see its March 2007 report on moving beyond the SGR. I can’t think of a for-profit private insurer that is doing this, except perhaps Kaiser . . .
Jack and Barry—For various reasons too wonky to detail, it’s extremely difficult to get a handle on administrative costs. Clearly, Medicare has lower costs because it doesn’t have to advertise, lobby or enroll, dis-enroll and re-enroll patients. Clearly, doctors and hospitals would have much less paperwork if there was only one payer (or fewer very good insurance companies who agree on using the same forms while competing with Medicare-for- all). How much lower? I don’t know which is why I don’t tend to emphasize administrative savings when talking about reform.
But, Barry, Jack is clearly right. Most doctors greatly prefer working with Medicare’s forms. (Medicaid is a whole other kettle of fish since in varies state by state.) Moreover, Medicare pays promptly, while private insurers are notorious for “playing the float” with the money, requiring extra documentation, etc.
Maggie;
Are you aware that in the current almost unprecedented boom of hospital new construction/renovation, the vast majority of the patient rooms will be private? Although some cite infection control as a reason, most administrators just baldly state it’s because that’s what the patients want. As I commented in another(I think) blog recently, only our cockeyed healthcare system would lead hospitals to construct private rooms because of demand by patients Who Don’t Pay For The Rooms!!!!!
You wonks have overwhelmed me with the other stuff. Time to finish the weekend! (:
Oh, and Maggie, I think you are misinterpreting the term “autonomy”. Autonomy to me (and I valued it a great deal) means you are not an employee of a corporation who has to please your boss. It in no way precludes collaboration. (And ps, collaboration only works when the whole team is sued for their collaborative action, not just the doctor on the team. Teach the lawyers that before collaboration becomes a meaningful term in health care)
“Autonomy” as used by physicians today also means freedom from being second guessed by insurance companies in the practice of medicine.
Bev–
The whole hospital building boom is a scandal. In some places, we’re going to have far more beds than we need. We’re definitely going to have more waterfalls, marble lobbies and saunas than we need.
On “autonomy”– in Manhattan solo practitioners talk about autonomy when describing why they don’t want to be in group practice: “I don’t want someone looking over my shoulder” or “No one is going to tell me what to do” or “I don’t like working with other orthopods.”
I understand why doctors don’t want to be second-guessed by insurers, but to have a colleague say, “Mark I noticed you’re prescribing X for Mrs.Wilson and I wondered why not . . ” can only help everyone. Given the amount of information out there today, no one docorcan know everything that he feally needs to know . . .
When I think of collaboration, I think of Kaiser (where doctor satisfaction is pretty high and turnover is low) the Mayo Clinic, the VA and other multi-specialty group practices where doctors are on salary, are not paid fee-for-service, and most importantly, are all looking at the same electronic medical record for a given patient–so they knew what the other doctors are
prescribing, recommending, etc.
I think we will ultimately get to a system where the patient sits in front of a computer and answers a lengthy health questionnaire that would then be turned over to the physician for evaluation. But first it would instantaneously search for patients around the country with similar diseases and a list provided of physician treatments and outcomes would be provided. That would allow physicians to remain on their own with at least some feedback from other physicians.
But I see the days of the solo practitioner as being over. If I were a physician I’d be damned concerned about where healthcare is heading. He who has the gold, rules. And that’s the corporations and they are already establishing their own co-op managed care companies. They should get ready for corporate medicine, because they won’t have another choice in five years.
Unless out politicians free themselves from insurance company money and establish a Medicare-for-all plan where physicians can remain independent.
I view “autonomy” is the absence of accountability. Maggie’s description of clinicians being able to deviate from guidelines, formularies, etc…but have to document why…and get another clinician to sign off…makes a ton of sense.
A role of a health insurance administrator playing this role in a cubicle thousands of miles away is what should be (and is) objectionable to many…especially when the administrator has no clinical background.
Manhattan may have the $$ to support solo practitioners, but in my metropolitan area, they usually can’t survive on their own. Having myself practiced in a group and watched others form and split, most disputes arise not over how one practices but over taking call, vacations, how to split the money, which insurance plan to provide, employee problems, personality conflicts, etc. If you read Sermo you would be reassured about docs asking each other for advice; it also goes on in lounges, hallways, before and after Grand Rounds, phone calls, etc. I just don’t see “autonomy” as the danger or even the definition you do.
Having said that, I totally agree as I mentioned above that a Mayo or Cleveland structure is best – but mostly because it makes the doctors and hospital work together instead of against each other, and coordinates care better.
Speaking of Kaiser, here’s where more “autonomy” is needed (unless they’ve changed their ways) – Say Mrs. Jones has a hysterectomy for bleeding fibroids and I, the pathologist, unexpectedly find uterine cancer. At any doctor’s office, but NOT Kaiser, I could call and report this surprising and life-threatening finding directly to the physician who performed the surgery. At Kaiser, I was routinely told, ” (A different) Dr. So and so is taking care of hospital patients today”, or ” Dr. Smith (who performed the surgery) rotated somewhere else this week” – so I would wind up talking to a doc who didn’t know the patient from Adam and couldn’t give me any information about clinical findings and, I was worried, would not accurately relay this critical information where it needed to go. This occurred every day, not just weekends. Ugh!!
It makes a ton of sense, Matt, unless s/he is a solo practioner.
Maggie,
I’m not sure that I understand your concern about a possible two tier healthcare system under a reform model. Here is a clarification of my perspective.
First, I assume that money is a constraining resource. Second, if health insurance does nothing else, it must cover the full cost of catastrophic events beyond a reasonable out-of-pocket annual maximum amount. Third, while I don’t have good data on this and, perhaps, you do, my perception is that at least 25% and possibly as much as 30% of healthcare costs incurred by the under 65 population are attributable to the first $5,000 of costs incurred each year.
I think a reasonable approach might be to provide universal coverage for costs above $5,000 per person to be funded by a dedicated healthcare tax. Everyone would get that, rich or poor. We could fund it with a payroll tax split between employer and employee in approximately the same proportion as current health insurance premiums. Insurers could compete, along with standard Medicare, to offer this coverage and receive either more or less than a benchmark amount depending on the actual health risk of the insured population that they wind up with. They would have to take all comers.
For the first $5,000 per person of healthcare cost exposure, we could provide sliding scale subsidies to help people with incomes up to 400% of the FPL to acquire this companion coverage which I call the insulation piece. The subsidies would be financed with general federal revenue. The segment of the population with income above 400% of the FPL could buy insurance on their own to cover some or all of the first $5,000 of costs or they could self-insure.
Whether a given individual opts for standard Medicare or an offering from one of the private insurers, a given insurer’s reimbursement rate to a given provider for a specific procedure would be the same whether the insured is rich or poor or middle income. There would not be any equivalent of Medicaid with its poor reimbursement rates. If it turns out that we can provide the catastrophic insurance piece at a cost we can readily afford, we could always make it more generous later.
Barry–
400 percent of FPL for a family of 4 is $82,600–Before Taxes. If they live in a state with a state income tax, they probably take home around $58,000.
If each family member spends $5,000 on healthcare (not hard to do if, for instance the mother has a baby that year, spending $5,000 on herself and $5,000 on the baby, one child has an accident playing sports, another child has asthma and winds up in the ER in the middle of the night two or three times a year etc. . . . . they are now paying $20,000 for healthcare–on a salary of less than $60,000. This is unaffordable, even in regions where the cost of housing is not off the charts
Doing the math for a single person– 40% of federal poverty level is $40,800–figure $30.800 take home , paying $500 for healthcare . .
Perhaps some of the items listed above would come under preventive care, and in your proposal, would be covered from the first dollar? Even so, it would be very easy for a family to spend $5,000 per person–especially in areas where specialist’s fees are high. (I spend about $1200 a year just seeing my eye doctor. And that doesn’t include glasses.)
Finally, research shows that high deductibles (which is really what you are talking about) leads people to defer needed care.
Maggie,
A couple of things. First, most current employer plans that I’m familiar with have a family out-of-pocket maximum that is only two times what it is for single coverage, no matter how many children there are. Second, very few people incur $5,000 or $10,000 of healthcare costs every year. Even among the Medicare population, in any given year, 50% of the beneficiaries (21 million people) account for only 4% of the program’s costs according to CMS. If people want to supplement high deductible coverage with a companion policy that would provide complete insulation at a cost of several thousand dollars per year, they can do that. Alternatively, when they experience an occasional high medical cost year, most people in the upper half of the income distribution should have some savings to help cover the costs.
Suppose, for example, we could provide catastrophic coverage ($5,000 deductible for single coverage or $10,000 for a family) for a 10% payroll tax (split 80-20 between employer and employee) on the first $150K of salary or wage income. To provide first dollar or near first dollar coverage, the payroll tax might have to be 12.5% of wages. While I didn’t mention it previously, we would also need a funding source to cover insurance for the unemployed including retirees not yet eligible for Medicare. I also assume the current Medicare program would stay as is for the current 65 and older population. The question boils down to how much more are we prepared to ask the broad middle class to pay in taxes on top of what they are already paying to achieve universal health insurance coverage? Even the much praised French health insurance system only covers about 75% of costs according to Ezra Klein. About 86% of the population also has supplemental coverage, usually obtained through employers, but a meaningful portion of the population takes care of the other 25% of costs on their own. Moreover, the total tax burden is much higher in France than here which never seems to get much mention from single payer advocates.
Mark Steyn’s take on the NHS is pitch perfect:
http://www.nysun.com/article/58028
You see, very few Brits these days actually go to medical school. Why? No one wants to work in the NHS. So, the UK becomes dependent on foreign doctors (more than 60% of new UK doctors are from abroad), a few of which turn out to be undetected Jihadists. In fact, probably many more could actually give a hoot about their elderly British patients.
So, if you want to scare away the best and brightest from the practice of medicine here in the states, by all means go “socialized.”
It is nonsensical that one’s employer should be the main source of insurance, and also nonsensical that one should pay exorbitant rates for individual health insurance. Universal health coverage may not be perfect, but it would be many, many times better than our current system (or lack thereof).
“You see, very few Brits these days actually go to medical school. Why? No one wants to work in the NHS. So, the UK becomes dependent on foreign doctors (more than 60% of new UK doctors are from abroad), a few of which turn out to be undetected Jihadists.”
—Sonoma
Gosh… I’ve never seen foreign doctors or nurses here in the US. It must be awful over there!
And Jihadist doctors too! That could never happen here!
“Sources: 2 in plot explored U.S. jobs”
The probe of bomb attempts in Britain has reached Phila., where a certifying agency for foreign doctors has offices.
By John Shiffman and George Anastasia
Inquirer Staff Writers
Mohammed Jamil Asha , a doctor, and his wife, Marwa (right), a medical technician, were among those arrested. With them are his mother and son.
KHALIL MAZRAAWI / AFP, Getty Images
Mohammed Jamil Asha , a doctor, and his wife, Marwa (right), a medical technician, were among those arrested. With them are his mother and son.
Two of the seven doctors arrested in Britain after last week’s failed bomb attacks had explored the possibility of coming to the United States, making inquiries to a Philadelphia-based organization, sources said.
http://www.philly.com/inquirer/home_top_stories/20070706_Sources__2_in_plot_explored_U_S__jobs.html
Bad people are everywhere, and we best implement safeguards in medicine and food distribution. But I don’t see universal health care as the problem.
A nurse in the US killed 40 patients, so the entire US healthcare system is bad. Right?
http://www.cnn.com/2003/LAW/12/15/hospital.deaths/
Dear Mr. Browning,
Having visited your site I found it to be short-sighted, slanted starboard (I wouldn’t call it right), and nowhere did I find a link inviting comment or discussion. Congratulations on your appearance on Fox News–that bastion of unbiased journalistic integrity. Jolly good show!
Thanks to many of you joining the conversation–
First, on foreign doctors in the U.K. and in the U.S.
Fully 44% of physicians providing primary care in the U.S. come from medical schools outside the U.S. (This is because American doctors are reluctant to go into primary care but the pay is so much lower than in other
specialities, and U.S. med students are often saddled with debt. Thus, other countries that provide free or low-cost medical education are subsidizing primary care in the U.S.)
When you include all specialties, it turns out that 24% of U.S. physicians are from med schools outside the U.S. Fully 24% are from India; roughly 10% are from the Phillippines,etc. This is all from an AMA discussion paper http://blogs.ilw.com/gregsiskind/files/AMA-IMGworkforce2006.pdf.
As for how many Americans want to go to medical school–surprisingly, only two students apply for each place in U.S. medical schools. This is in large part because med school is so expensive, in part because it is so difficult, in part because you have to have such high grades to get in–and in part, because our health care system is so broken.
Many,many doctors are very frustrated with how hard it is to try to deliver high quality care in the U.S. Our hospitals, they know, are dangerous places (errors, infections); many of our private sector insurers do their best to delay payment and deny care (which is why doctors prefer Medicare); meanwhile, as doctors and hospitals vy with each other for scarce health care dollars, the competition in a profit-driven system can become vicious. This is why many doctors
now say that they would not advise their children to go to medical school.
If we subsidized our med schools in some way (perhaps providing generous scholarships to students willing to practice in parts of the country where they are most needed) we might have a larger and more varied pool of applicants, but if we want to make medicine an attractive profession, we also have to reform the
system.
Barry–
Thanks for continuing to find a plan we can agree on. I agree that the cap on a family’s out of pocket expenses–no matter how many children–is very important, and makes your plan much more affordable.
Let me just ask one question: Am I right in remembering that you originally said that your plan would cover preventive care from the first dollar (perhaps with a $15 co-pay)? And secondly, would regular care and prescriptions for chronic diseases like diabetes, asthma, glaucoma, etc.be considered “preventive care” that patients would receive for a very low co-pay before they paid the deductible?
If so, then I think we’re pretty close to agreeing on what good insurance means.
As for taxes in France–it is true that they are much higher, but the safety net is also much more secure in many ways, and the French are very proud of that. Basically, the French feel that nothing is too good for a fellow Frenchman. If only we had such solidarity in the U.S.–it would be much easier to agree on national health insurance.
Maggie,
I’m basically in agreement with you on the preventive care co-pays before the deductible kicks in including the drugs for diabetes, asthma, etc. My preference, though, would be to have an independent agency like the AHRQ attest to the cost-effectiveness of various treatments based on good, unbiased research and sound science. Ideally, if a particular preventive measure would cost less than, say, $5,000 or even $10,000 per QALY, it should be in the first (lowest) co-pay tier. For those that cost more than $10,000 but less than $25,000 per QALY, they could go in a second tier while a third tier could apply to services that cost up to $50,000 per QALY. Above $50,000 but below $100,000, the insured might have to pay the full cost until the deductible is reached, and above $100,000 per QALY, the treatment should be deemed not cost-effective, and doctors should be discouraged from using it unless the patient wants it and is willing to self-pay. Policymakers could decide on the real numbers that they think make the most sense from both a health and an affordability standpoint. Mine are just illustrative of how I would approach the issue conceptually.
Maggie;
I am shocked about your statement of 2 applicants for every U.S. med school position. After I had to bust my buns to get in in 1973, and I suspect it was mostly because I was a woman and they were under pressure at my med school to admit more women. Up till now I’ve
avoided answering your prediction that women will comprise the majority of physicians in the future, but
I believe your prophecy will prove true. I will avoid the wrath of physician readers by explaining why I think that’s true, but there is one caveat – women tend to work best in a collaborative and cooperative system, not an unstable and viciously competitive one. Make our system better and I think you will see more applicants, mostly female. What will happen to nursing, however, is another story…..
I am a physician who believes that a single payer health care system is an imperative for the long term viability of American health care. I believe that it is obscene that there is no true safety net for all Americans. Though I applaud “Sicko” for its impact on the psyches of Americans and its demand for some sense of fairness in health care delivery, I am disturbed by details in the film that so outrageous that they threaten the credibility of the messenger.
Foremost, the Skid Row scenes are absurd in that the premise is that these people are taken to Skid Row and unceremoniously and cruelly dropped off because “they can’t pay their hospital bills”. This is untrue. They are dropped off on Skid Row because our society has no destination in which to place these unfortunates. It is not the job of the hospital to solve all of society’s ills- the City Union Mission is often the only option for the homeless.
The “fingertip” scenes are provocative yet beg discussion. We all want all of our bodyparts for all of our lives, but sometimes that is simply not possible or reasonable. Fingertips get amputated by accident or irresponsible behavior, and they are rarely replanted in any country for the excellent reason that you can function fine without them. Is it really society’s or the busy surgeon’s responsibility to provide “free” cosmetic surgery to all who ask? This scene should not have been juxtaposed with the Canadian’s plight of amputating all of his fingers- one cannot function well without the use of his hand.
The only way a Universal Health Care System can ever be successful is if we, as a society, are willing to make some tough choices of what health care we will pay for. Cosmetic surgery-no; amputated hands-yes. The free choice of any of five osteoporosis drugs-no; the negotiated lower price for one-yes. Truly experimental treatments outside of an established research protocol-no; evidence based treatments and innovative treatments within an established research protocol-yes. Four wheeled “rascals” for every elderly patient with a limp-no; renal transplants and dialysis for the hopelessly vegetative-no; endless choices for drugs of clinically equal efficacy-no. Universal Health Care will only succeed if Americans are willing to abandon their demand for instant gratification and look beyond their own unique selfishness to what is best for our society to survive and function most effectively and efficiently.
JML:
Hear, hear.
What if health insurance companies could only be owned by their policyholders?