Rather gloatingly, Hillary has indicated that healthcare reform is back on the table. I’m familiar with the problems of the uninsured, I know about the benefits of and problems with Medicare, I know about skyrocketing drug prices, etc. I can confidently argue both sides of each issue, since each side has good and bad points. None of those, though, are the things I want to talk about. I want to talk about how doctors have learned to use the system. The following is a true story (swear to God) which happened to someone I know with premium health insurance.
My friend has a long history of ulcers. A year or so ago, he started feeling sick with the typical symptoms of an ulcer. He made an appointment to see his internal medicine doctor. Now, if I were the doctor in cost effective world, I would begin with non-invasive the blood test for H. pylori (although that’s not determinitive, since that bacteria isn’t the only thing that causes ulcers). If it was positive, that would have dictated a straightforward treatment. Even if there wasn’t any H. pylori, based on the patient’s symptoms and health history, I would have written a prescription for Prilosec (or just told my friend to buy it OTC) and said, “Let’s see what happens in a couple of weeks — and be sure to contact me immediately if you get worse, not better.” If the symptoms went away, I would be pretty comfortable believing that I had correctly diagnosed my patient. But that’s not what happened to my well-insured friend. Here’s what happened:
He was told to make an appointment with a gastroenterologist for an endoscopy. My friend met with the gastroenterologist before the endoscopy. Ka-ching. My friend went in for the endoscopy. Ka-ching. My friend, rather than receiving a phone call saying “You have an ulcer; take some Prilosec,” was required to go back to the doctor for a “hear the news” appointment. My friend went back, was told he had an ulcer, and was given a prescription for Prilosec. Ka-ching. Six weeks later, my friend was told to have another endoscopy to ensure that the ulcer was actually gone (the cessation of all symptoms apparently being inadequate to prove this point). My friend underwent another endoscopy. Ka-ching. My friend, rather than receiving a phone calling saying “You’re good to go,” was required to go back to the doctor for a “hear the news” appointment. My friend went back, and happily learned that he was “good to go.” Ka-ching.
Now, you can’t entirely blame the doctors for engaging in this kind of fantastic overreaching. Between deadbeat patients, low Medicare payments, and obscenely high insurance premiums (so let’s all give a loud Bronx cheer for the plaintiffs’ bar), it’s completely logical for them to engage in entirely legal, professionally accepted behavior that helps fund their practices. The problem for Americans, taxpayers and patients alike, is the role that little Medicare payment plays in this cycle. Medicare payments are so low, in part, because there are so many demands on Medicare. But there are so many demands on Medicare, in part, because the payments are so low that doctors have to maximize their number of Medicare contacts to make ends meet.
It would be easy enough to say that Medicare payments should be structured to reward physician efficiency. That sounds good in theory, but the dismal HMO stories of the late 1980s and early 1990s demonstrate that, when medical efficiency is the criterion for a doctor’s financial remuneration, there are some who will, or feel forced to, give substandard care. And that, of course, leads one into the whole icky, sticky question of what is adequate care, what is substandard, and what is gold standard — and who is entitled to or who should suffer from each of those standards?
My favorite model is the Kaiser model. The doctors are salaried, so they have no incentive to go overboard to ramp up their income. The expensive testing equipment is owned by the institution, so no one doctor feels compelled to give myriad unnecessary tests to pay for the cost of the equipment. It’s no surprise to me, therefore, that Kaiser consistently rates as one of the better care providers in America. It’s not perfect, of course. First of all, no human-run institution is going to be perfect, and the medical profession has lots of room for error. Second, because the physicians are salaried, some of the best and brightest may opt for the financial possibilities in private practice (and in elective and/or cosmetic surgery). Nevertheless, system-wise, I think it’s the best thing going, because it minimizes the incentive for fraud, without destroying the doctors’ and nurses’ desire to do the best they can for the patients in their care.
Filed under: Health
Hi Bookworm. You state that “I’m familiar with the problems of the uninsured, I know about the benefits of and problems with Medicare, I know about skyrocketing drug prices, etc. I can confidently argue both sides of each issue, since each side has good and bad points.” Then you go on to talk about “how doctors have learned to use the system.” Okay.
Please explain how your ability to argue both sides differs from the doctors behavior. Don’t lawyers learn to argue both sides with no regard for right and wrong, and isn’t that arging “using the system,” too?
People are dying from lack of good medical care, while you seem more concerned about whether doctors’ behaior is ethical. If we wait for everyone to become moral, I guess we’re stuck with the status quo. You point seems to beg the issue.
I don’t think I can have made myself clear, Helen. I’m sorry. What I was trying to say is that the system is set up to be gamed, and that doctors aren’t doing anything wrong with taking advantage of the system. Their logical behavior, though, creates an economic problem, which is that the system becomes vastly more expensive than it should be. If there were a way to limit the doctors’ incentives for legally permissible abuse (as opposed to fraudulent abuse) of the payment systems, Medicare bucks would stretch further. I don’t have an answer to this problem, but I do hold Kaiser up as a working model that has dealt fairly well with the problem of a system that rewards doctors for maximizing patient contacts — even when those contacts are probably unnecessary.
America’s justice system doesn’t work as it was intended to work. Lawyers should already know this, because they know that advocacy systems only work when the prosecution and the defense teams are more or less equal. Great gains have been made, but not nearly enough. In fact, lawyers back when chaos reigned were better than lawyers are here today. Ramsey clark and Thomas Jefferson comes to mind.
Bookworm’s behavior differs from the doctor’s behavior, because Bookworm is Bookworm and the doctor is the doctor. Therefore to quote the conservation of mass law, one cannot be both here and there, in space-time because that requires duplicating matter and energy.
As I see it, Bookworm. Some people prefer institutions and how they look on paper, to how they actually work with real people in them. For some reason, they don’t bother looking at the behavior of humans once they are given a job to do something. They just look what the job is supposed to accomplish, and give not a care to any possible failsafes for human misbehavior.
Second, because the physicians are salaried, some of the best and brightest may opt for the financial possibilities in private practice (and in elective and/or cosmetic surgery). Nevertheless, system-wise, I think it’s the best thing going, because it minimizes the incentive for fraud, without destroying the doctors’ and nurses’ desire to do the best they can for the patients in their care.
Good institutions, and I think you recognize this Bookworm, first and foremost derive their operating principle from human nature. Minimizing incentives for fraud and human misbehavior, is necessary, it is not a “feature” that can be added cause it might look better on the outside. Increase reward for good behavior, decrease punishment for those with initiative, heart, and courage. Increase rewards for people who do the right thing, even if the punishment is de jure that they be expulsed. A good institution, a good system, does everything it can to keep its best people in, and kick out the worst.
After all, America would not be America if all the criminals and psychopaths came here, instead of all the geniuses and those yearning to be free. Might start looking like France then. If the military didn’t have a war that necessitated kicking out the political soldiers to replace them with warriors that fight, the military wouldn’t be as good an institution as you see today.
The creation of an institution or the modification of a current system, is so hard that not even the Founding Fathers got it right on the first try. They had to fail and flounder around, but at least they recognized that human nature matters, far more than any possible idealistic goal they were trying to craft.
Your “gaming the system” example is, I’m afraid, set wholly on the doorstep of the plaintiff’s bar, and if you can get to a doc who isn’t embarrassed to be honest about it, you’ll hear it from the horse’s mouth.
My brother has spent the last week in the hospital, and he’s having a fascinating time noting how it’s changed from thirty years ago. Things that nurses used to do routinely they no longer touch. Two examples: insertion of a pain medication dispensing IV; and removing a saddle block line.
He waited six hours two days ago for the doctor to come and replace the pain IV line (which he had ripped out in his sleep) because none of the nurses – any one of whom could have put a needle into a vein, which is all it really is – would do it. Because it’s a drug-carrying line, there’s a possibility (did I just say possibility? I meant, there’s an inevitability) that somebody will sue – even if it goes perfectly but he has a problem with the medication, or gets a rash from the disinfectant, etc., etc. Anything.
Then to remove the other needle from it’s placement in his lower back, which involves simply pulling it out. Again, a day-long stage wait for the doc to do it. When the doc showed up, all he did was grab the top end of the layer of tape on brother’s back that held the whole system in place, and roll it down his back. Along the way it pulled out the needle. Doctor was deeply engaged in looking out the window and not even watching what he was doing. My brother remarked: “Jesus – a trained monkey could have done that!”
Doctor cheerfully agreed, but pointed out that owing to lawsuit potential it had to be him, in person.
So it’s not at all a surprise that they order extra layers of tests to cover every possible base, (reasonable or not),and it’s not at all a surprise that they drag you in needlessly to tell you about it themselves. That’s the only way they can defend themselves against the charge of having failed to be sufficiently thorough, and doing it in person is the only way they can be sure information was accurately transmitted.
Although often enough they get sued either way: both for administering too few tests; and then for administering too many. The medical profession in this society is now in full-time CYA mode – and it is absolutely the fault of the lawyers.
Hillary 1 Bookworm 0
HelenL, if you think Hillary getting her socialized hands on medicine will change that, you’ve got another guess coming. Socialized medicine has degraded medical care for everyone in every country in which it’s been tried. Socialized medicine is okay only if you’re so jealous of the huge numberwho can get the best quality care that you’re willing to consign the whole system to Hell in a handbasket. Otherwise, it degrades the system beyond remedy.
Since JJ is right that it is the fault of the plaintiffs’ bar, the logical thing to do isn’t to rejigger and destroy the whole system, but simply to impose more reasonable risks on doctors — something that will never happen while plaintiffs’ lawyers are the backbone of the Democratic party (or has anyone forgotten who was the 2004 Democratic VP candidate).
Canadians go to the US, to pay for better care, then what they got. Oh, they like their socialized medicine all right, so long as it is supplemented by the best and brightest of new techs and procedures, in the US.
Hehe, Hillary 1, Bookworm 0. Preposterous. Lawsuits constitute a huge drain on the American economy and standard of living. America isn’t France, where the news media sues bloggers for telling the truth. No, what we have is that most of the people who use lawsuits, are doing so as a way to get back at people. Easy way, with few risks, of getting revenge.
Regardless of how good your justice system is or is not, when most of the people who use it, are out to get rich and are greedy as hell, well don’t expect any good from it, okay.
Although often enough they get sued either way: both for administering too few tests; and then for administering too many. The medical profession in this society is now in full-time CYA mode – and it is absolutely the fault of the lawyers.
Fault of lawyers and the system that lawyers are in. Lawsuits need to be reformed, punitive damages reformed, a lot of things reformed. The justice system as we see it now, iS NOT the one any sane person would want.
Same for the military. The lawyers are on them as well. Everything from GitMo, to fake Hadithas, omg. The country will destroy itself, don’t even need the jihad.
I think the basic difference in philosophy that helen holds and Bookworm holds is this. Bookworm believes that people matter, that systems and institutions must be geared with the people in mind, and that the purpose of those institutions must accomodate human desires, needs, and selfish vices. Helen believes that since humanity can’t be “perfected” with “perfect morals”, that the only thing that should matter is what the institution was constructed To Do. So if it was constructed to save people with good medical practice, then that is a Good Thing. If it was constructed to make a profit or something else that might possibly lead to the possible ending of people’s lives, well, that is the Bad. To helen, the intentions of the program is what matters, not what it actually does or how it performs. The system will solve human problems, that is what looks to me, is helen’s position and belief. Bookworm seems to believe that humans should solve problems, the system should only help.
A difference of priority and concentration, as I see it.
I think you’re absolutely correct, Book. Little in life is 100%, and it isn’t absolutely the fault of the Bar, but boy, there’s some blame there!
There needs to be a reasonable limit. What doctors have lost is the ability to have an opinion, and act on it. They don’t dare. If they can’t support everything they say with some kind of data back-up (i.e, endless ridiculous – and expensive – tests) then they just open themselves up to be screwed.
Medicine is of course a science, or at least is based on science; but it’s also fair to say that the practice of it contains a lot of elements of art. The best docs tend to have a lot of flair. Those old guys Norman Rockwell painted who could look at a kid and know at a glance what was wrong really did exist: I went to one for the first twenty years of my life.
He took a look at me one day – I swear I walked into his office, he took me by my shoulders, turned me around, and marched me right back out before I’d even sat down – and a half hour later he was taking my appendix out. He was right, too, after no previous trouble at all it wasn’t all that far away from bursting.
Forty years of experience helped, of course – but the fact is that today he wouldn’t even express, let alone act on, what he thought. He wouldn’t dare. He’d order a multiplicity of tests – while, untreated, I elided into an emergency case.
The point is, the art part of it is lost, or being lost. And that’s a big part of it.
And face it: in the long run doctors do not win: everybody dies. We have trouble with that simple truth, and when it happens we often tend to look for someone to blame.
On the other hand, if there has been a mistake or carelessness, there has to be some recourse for the victim thereof. There has to be a middle way somewhere in there, a place to draw a line.
But it isn’t going to be found by a liberal lawyer, whose models are a bunch of bankrupt systems around the world, and who is greatly supported by both the plaintiff’s and the tort bars – which the democrats are.
Bookworm is right that the state in which we find ourselves is not totally the fault of lawyers. But when a poor criminal can get a free (court appointed lewyer) and a poor, sick granny can’t get a free (hospital appointed doctor), something isn’t right.
In fact, as I think about it, Helen, Hillary should be recused from the discussion. As a lawyer, and as someone who takes donations from both the plaintiff’s and the tort bars, she’s conflicted. She ought to be enjoined from having a word to say about it.
Nor supported by the pro-abortion crowd. Judging by Laer’s story, doctors riding rough shod on other doctors is enough even to outcraze the crazies.
Mitt Romney already figured out a lot of good solutions, which when I heard his brief, agreed with it.
After practicing medicine in NJ for 19 years,I thought things could not get worse. After reading of JJ’s friend’s experience, I’m proved wrong. Institutions cannot be made safe from corruption. The only ultimate protection is an individual’s integrity.
There is no question that the entire tort system needs to be changed. Financially crushing awards for supposed negligence are corroding more than just the medical community.
As far as medical inequity goes, comparing socialized Canada with capitalistic US, how’s this?
In Canada there are support groups for parents whose children have died while waiting for life saving cardiac surgery. These families have the Canadian “health insurance”. If I diagnose a newborn with a life threatening heart defect at my local hospital,I can have the babe choppered to a world class pediatric hospital in 60 minets for immediate evaluation and surgical correction. Regardless of ability to pay. In the past 19 years, I have done so four times.
Al