December 11, 2004
The state of medicine
There's another essay at Policy Review about the current state of the practice of medicine in this country. It's really long, but very informative. Some things you probably didn't know:
"[B]ased on federal law, a Medicare patient who requests an assistant surgeon during a cataract operation is participating in an illegal act, even if he is willing to pay out of pocket for the service. Medicare has a blanket prohibition against payments to assistant cataract surgeons (Section 1842(k)), and the patient who desires the extra security of another person in attendance is simply out of luck. The request would be perfectly legal one day before age 65, but once one is on Medicare that right is lost — unless, that is, the patient is willing to give up all other Medicare benefits..."
"[If a physician has] voluntarily excluded himself [from Medicare], neither he nor his patients can submit bills to Medicare for his services, even if only to partially reimburse the patient. In addition, the doctor is not allowed to work for anyone who does any business with Medicare. Thus, he cannot legally help out in the emergency room of the nearby hospital to relieve a severe shortage of er doctors, as he would like, even though he has earned board certification in internal medicine and emergency medicine. Opting out makes a doctor virtually unemployable."
"Traditionally, when an emergency room in the hospital, for example, was losing money, that loss might be made up in the laboratory. Something similar occurred with physicians. Extra time for complicated patients, time in the library and for other continuing education, care given at inconvenient times as well as to non-paying patients — all were subsidized by more lucrative activities such as comprehensive examinations (annual physicals) and diagnostic tests... Currently, insurers and government seek the lowest price for every service. There have been drastic cuts of two-thirds or more for electrocardiograms, breathing and hearing tests, and blood and urine analysis. This is the supermarket equivalent of putting every item on sale at the same time — highly unusual and probably unsustainable. Moreover, hmos and some ppos restrict physicians from performing any lab work (and sometimes other diagnostic testing) on patients they cover."
"After 1991, Medicare actually reduced physician fees four times, causing them to fall 14 percent below practice cost inflation. Commercial insurers found it advantageous to follow suit and, with both the private and governmental insurance sectors cutting back to arbitrary take-it-or-leave-it fee schedules, American medicine fell under the sway of third-party payers."
"The wrangling over the $400 billion Medicare outpatient drug benefit of 2003 is illustrative. Intense lobbying by drug manufacturers has won a Medicare payment increase for more than 100 drugs used in hospital outpatient procedures while Medicare physician fees were scheduled to decrease by 4.2 percent in 2004. A failure to keep up with rising practice expenses, now subject to political horse-trading, will disproportionately affect primary care. That is because its many low-dollar services still require expensive administration and are provided at the physician’s own expense in the office rather than at the hospital."
Do you think its possible that medical technique has outpaced our ability to afford it? That's what I think has happened. Our society has developed medical techniques to fix so many things that we can't possibly afford to fix all of them.
Posted by: rob at December 11, 2004 01:28 PMPerhaps. I also think it has something to do with the fact that the fact that medical science can keep people alive who would normally have died requiring that, well, we pay for medical science to keep said people alive. Diabetes is a completely managable disease most of the time, but it costs money. Many previously lethal conditions are now simply expensive inconveniences. This is a very good thing, but it's also a very costly thing.
Take something like appendectomies. Not a particularly expensive operation, with the average cost being a mere $10k. It's a simple, complete cure for a disease that no longer needs to be either fatal or even permenant. But that means that we've got a lot more people surviving into adulthood to die of something more expensive later on. Same goes for immunization. It's a fantastic thing that we've eradicated smallpox and polio, but this means that the people who would normally have been killed by said diseases, people with weak immune systems, are now going on to bigger and better diseases.
I'm not sure there's an answer for this at the moment. It's just a problem. But I'm absolutely convinced that a single-payer system is the worst way of fixing it.
Posted by: ryan at December 11, 2004 01:48 PMI tend to think that one component of an answer is a view of life and death that allows us to simply refrain from some medical treatments. We need to get rid of this idea that it's our right to be able to partake in the latest and greatest procedures.
Ryan, I think your observations in your comment are precisely correct. But isn't it possible that this means that the cost of healthcare ISN'T necessarily a problem - at least, not as big a one as people make it out to be? If I live to face an expensive disease 50 years from now because of the repeated times I _haven't_ died from things that used to kill people, then I don't see a problem with not going all-out in treating that more expensive disease. Why assume that such procedures should be affordable by the average American in the first place?
People complain about the cost of procedures that didn't even EXIST 15 years ago. That strikes me as plain silly.
Or, put differently: the fantastic-ness of the eradication of smallpox and polio means that we ought to be very humble when it comes to claiming a "right" to medical procedures that will fix the next problem that comes along. To put it crassly, we should've been dead a long time ago!
Easier said than done, but I really do think that one's view of life, death, and suffering has a huge impact on how we interpret the situation. Is suffering an absolute evil? I don't think we can say "yes."
Posted by: nick at December 11, 2004 04:06 PMYes, Nick, but the American people aren't used to not getting what they want when they want it. Dying of preventable disease is something that happens to other people in poor countries, not to us. Americans just aren't stricken by diseases that we might be able to cure, but just can't afford to. No, that's strictly a Third World phenomena. Right?
Posted by: ryan at December 11, 2004 05:42 PMI agree totally with Nick's opinions here. Ryan, your "Perhaps. I also think it has something to do with the fact that the fact that medical science can keep people alive who would normally have died requiring that, well, we pay for medical science to keep said people alive..." is exactly what I meant, though I said it perhaps too shortly to make that clear.
I'm not convinced yet that single payer is a bad way to rectify the problem. Why are you (I ask this not because I can't think of any reasons single payer might be bad, but because I'd like to hear a persuasive case from someone whose opinion I respect)?
Posted by: rob at December 11, 2004 09:17 PMDamn straight!
Posted by: john q. at December 11, 2004 09:18 PMLook, I understand the economic realities of the situation, believe me. I think people deserve the health care they can personally afford, no more, no less. But part of me still wants to say that we should be trying to provide as much health coverage to as many people as possible, especially as so many diseases are easy and relatively cheap to manage. Diabetes is an expense, but not a huge one. We can produce insulin by the tank, and testing blood sugar costs pennies.
The problem is one of perception, and you can't change what 300 million people perceive to be their right by saying that they can't afford it. The facts of the issue may be economic, but like it or not, the discussion has become a moral one. It shouldn't be that way, but it is, and we need to figure out how to respond without leaving the conversation.
Oh, and the reason that single-payer systems are bad is that you'd take the current problems and magnify them: utter, dictatoral control of health care by semi-professional bean-counters with no medical training or interest in patient care. These are not the people you want determining whether or not you need that bypass operation. They aren't qualified. And they certainly aren't qualified to tell the physician what it costs. When you tell a carpenter to make you a table, and he does, you either give him the money he asks for or he keeps the table and doesn't do business with you anymore. But, when you go to the doctor, the government tells the doctor what he's allowed to charge - completely ignoring the actual costs involved - and if he dares to resist, he's cut out of the Mediplans and unemployable. A single-payer system would exacerbate that problem a thousand-fold.
The old name for the study of medicine is scienta misericordia, the science of compassion. We're curing the sick, for crying out loud. Making that a Fortune 500 issue distracts from that. Physicians are not in the business of treating disease, but healing people. People may be economic beings, but they're people first.
It is completely within the capabilites of this country to provide some basic level of medical care to everyone in it - I'm not talking about full health insurance here - and we're doing that right now, more or less. There's a reason that the Third World still has polio but we don't: government mandated immunizations. There are plenty of people who through lack of either money or education, would opt out of immunizations if given half a chance. But the government says that you have to be immunized - and this is a good thing. It's cheap, and it actually saves us a lot of money by cutting out several major and potentially lethal/debilitating diseases.
Look, my positions on the provision of basic human services are changing now that I live in an actual urban area. I'm still working through this. I recognize that the costs of health care are a growing problem, but I'm not sure what the solution should look like, much less how it should work.
Posted by: ryan at December 11, 2004 10:29 PM