Monday, April 9, 2012

Paying for medical care

While we anxiously await the decision of the Supreme Court on the Affordable Care Act, let me offer you three thoughts.

1. Health care for all is only possible if those of us who have money and jobs pay for those who do not.

I love it when people say, “Let the federal government pay for it.” Who do they think funds the federal government? Ditto for “Let the states pay for it.”

What about “cost shifting”? Put a surcharge on health insurance so that the extra money can go to those who cannot afford to buy health insurance. Don’t look now, but that means that those who have the money to buy health insurance will be paying for those who do not.

How about mandating that corporations contribute a percentage of their profits to a fund that supports health insurance for the needy? That will make the price of everything that corporations sell rise, shifting the burden back to those who have money to buy those things.

2. An old axiom in business is appropriate for health care too. It goes like this, “You can have affordable health care, access for all and high quality, but you can only have two of the three.” There is no way that everyone can have every test for every disease.

For example, many guidelines suggest that everyone over the age of 50 should have a colonoscopy. According to the last census, there are 40 million people in the US over the age of 65. Can Medicare pay for 40 million colonoscopies? Even if it could, there are not nearly enough qualified colonoscopists to do the job.

3. According to Supreme Court Justice Elena Kagan, “You are entitled to health care when you go to an emergency room, when you go to a doctor, even if you can't pay for it.” [See page 74.] If you want to have a little fun, mention this in a roomful of physicians.

Maybe Justice Kagan can tell us how we are supposed to pay our rent, malpractice insurance, office staff, workers’ comp, other benefits etc, if we see patients who can’t pay? Oh, universal health insurance? See #1 above.

What do you think of my three thoughts?


SkeptVet said...

1. Absolutely. So the question becomes what does society as a whole want? It's a values issue. I happen to believe that those of us who can afford healthcare have a moral responsibility to those who can't, but since values discussions are all about feelings, there is no rational basis on which to decide this.

2. I'm not convinced. There will always be better care for those who have more money, but that doesn't mean that high-quality care shouldn't be possible for everyone. I think "every test for every disease" is not a good marker for quality of care, and overdiagnosis and overtreatment are both huge cost burdens an significant causes of morbidity in our current healthcare system. Some of the money to pay for access to good primary care might come from reducing costs through following USPSTF guidelines, Choosing recommendations, and so on. Of course, that requires changing fundamental curlutral beliefs such as More is Better, Statistics Don't Matter, and so on. Seems pretty unlikley.

3. As a vet, I undoubtedly give away a lot more care than the average physician. The tension between high quality care and the economic limitations imposed by the client is especially great when there is (almost) no health insurance and economic euthanasia is an option. It is definately an ongoing and imperfect process negotiating the balance between running a successful business and making a good living while meeting my ethical obligations to my patients and society and working with the real and contrived restrictions placed on my work by clients. Some of the resources to pay for healthcare would, again, possibly be freed up by reducing unecessary costs, such as the costs of litigation and malpractice insurance born by doctors. Of course, the question of whether doctors are worth what they get paid and whether it is appropriate to let the market settle this in an area with such inelastic demand, is one that will make nobody happy. I routinely perform the duties of a GP, perform soft-tissue surgery (from routine procedures to advanced oncologic or reconstructive surgery), endoscopy, bronchoscopy, cardiac and abdominal ultrasound, chemotherapy, and many other duties for at least 6 very different species, yet I make less than the average dentist. Naturally, I'm a bit skeptical about the wisdom of the Invisible Hand in setting compensation for healthcare professionals. :-)

Sara said...

"Health care for all is only possible if those of us who have money and jobs pay for those who do not."

Yes...and...? I pay for public schools even though I don't have children. I pay for roads even though I don't own a car. I pay for wars I disagree with. I pay for food stamps even though I make enough money that I don't need them. And I certainly benefit from things that others pay for but may not use - like a job at a public university, a solid public transit system, public libraries, etc. This society works? No one has ever or will ever make it 100% on their own with no assistance from other members of society.

plumtree said...

Yes, Sara. But the problem is that many people don't understand or agree with the idea that health care for all means a hefty tax hike. Most people understand about paying for public schools even if they don't have children. It's a large sum of money, but it increases the value of your house (in most states primary funding is from property taxes) and you have the payoff of good neighbors who are savvy enough to seek the good schools and the benefit of good future citizens who are educated in those schools. We haven't sold that at the health care end.

Skeptical Scalpel said...

Thanks for the provocative comments. I think changing fundamental cultural beliefs will be very hard if not impossible. Some degree of rationing, which apparently is unacceptable to many, is inevitable.

Per the NY Times ( "[Patients] must discipline themselves not to request care of little or no value" I tweeted, "Good luck."

RobertL39 said...

This is an old red herring, and smells about as bad. There is enough money in the system to provide care to all those who need it. The easiest way to convince yourself of this is probably to look at Dr. Gawande's article on Texas []. Imagine how much money would be saved if all the over-utilizers stopped, or, in his terms, if all the McAllen's were more like El Paso County, which has Medicare costs which are HALF of McAllen's. Now, add to that the 20% parasite charge that insurance companies make on the system. Got enough savings yet? Yeah, I think so. Excellent, low-cost care is provided by several groups across the country. It CAN be done, and the ACA allows experimentation with variations on how to do it. The pie doesn't need to be larger from taxes. It needs to be given to the slender and not the over-eaters. To paraphrase Dr. Gawande, 'what we need is for efficient providers to be considered an asset rather than the burden they currently are.' It's NOT the amount of money; it's the way it's being spent.

Skeptical Scalpel said...

Robert, thanks for the comment and the link. I read Gawande's article. The question is, how do you get the doctors and the patients to be more responsible?

RobertL39 said...

To quote George Carlin: "Ya gotta' wanna'!"

You get them to be more responsible by valuing efficient providers with your reimbursement scheme. The fact that it's been done in quite a few places says that it's not impossible. Probably the most effective way is devolution of the health care dollar to the lowest possible level. As I've mentioned before, our county saved, and continues to save, tons of money, and patients get much better care, on Medicaid because we manage the dollars locally. And, in general, groups are going to do a better job of that [see Relman's book]. In addition, I think a codification of what we know in the form of 'best practices' will help, as will ACOs, the specialization we've talked about before, and checklists. Be sure to read [] for some more detail. Lastly, Clay Christensen's book "The Innovator's Prescription" is a MUST read, as he discusses a lot of these issues.

Happy to answer or talk more as desired.

Skeptical Scalpel said...

I wish I shared your optimism.

P said...

Skeptical Surgeon is correct in that you can't have high quality and access for all. As an economist would say there are no solutions only trade-offs. High prices are only symptoms of the underlying problem. If more people were allowed to practice medicine the price would drop. Today we only have around 129 medical schools which is less than the number of medical schools we had 100 years ago. If the FDA allowed people to take drugs after Phase I testing it would cause drug prices to drop. People should be allowed to determine whether or not a drug benefit them. Also why not allow prescription drugs to be sold in stores without a prescription.

Currently, a hospital in Oklahoma City (The Surgery Center of Oklahoma) is doing surgeries for essentially cash without insurance. They actually post their prices online for various surgeries and claim to have infection rates much lower than the national average. I wouldn’t mind seeing more of these hospitals pop up.

Marc said...

As a race, the Human one that is, don't you think we should have evolved to the point where we realize that the benefits of modern medicine should be available to all who need them. Yeah yeah yeah, I know you're thinking commie, and frankly I don't give a shit. If people are sick and we can make them well we should, period. Shame on this whole race for allowing the profit motive to even be part of the clinicians thought process. And you can preach all you want about free market capitalism as the only way we could have gotten here but once again, it's just a bunch of self serving bullshit. The practice of medicine should and will eventually I am confident, be treated differently. What you do, (or did), is a calling, you should be revered and respected and compensated generously for what you do. In return you should treat patients, all patients.

Skeptical Scalpel said...

Peter and Marc, thanks for the comments.

Clarification: I am a full-time salaried surgeon. I treat anyone who shows up.

Marc, I don't know how old you are. What you said in your last two sentences is the way it was up until about 1980. Since then, MDs have been squeezed by expenses, regulations etc. (Too much to put in a comment) Also, we have to pay for college and med school. As reimbursements have fallen, margins are less for many MDs. Would that what you said in those last two sentences be possible. I don't see where that compensation will be coming from.

Old Rockin' Dave said...

The Swiss seem to manage well with a system not unlike what's going on here. Every citizen or permanent resident is required to have coverage, and those who can't afford it have it paid by the federal government on a sliding scale. Every insurance company has to offer the same package at the same price, adjusted by region; they make their money by offering extras beyond the basic plan. There are flaws and problems in their system, but no one goes uncovered and their health statistics look pretty good. And don't forget, they are probably the most capitalistic major nation in the world.

Skeptical Scalpel said...

Dear Dave,

Thanks for commenting. Switzerland is a wealthy country with a relatively homogeneous population of nearly 8 million people, which is bout 2.5% of the population of the US. It does not have the historical, social and economic issues that exist here. I doubt that docs there have an average tuition debt of $158K that we have here.

This reminds me of a blog I wrote about life expectancy in different countries, a metric that the US always comes out poorly on. Here's the link

Old Rockin' Dave said...

No question that the USA and Switzerland are very different. My point was that if such a capitalist country as Switzerland can embrace the individual mandate, it can hardly be painted as "socialism".
While we are not as homogeneous as the Swiss, they still have three official languages and a fourth that sees significant use, a reflection of the fact that they assembled a nation from very disparate parts. We did too, but they seem to have done it a little better.
I agree that the way we pay for higher education in this country needs to be reformed along the lines of other developed nations. But if you were to ask me how to reduce medical costs in this country, I would start with gun control. What other nation that does not have a war on its territory has to cope with a staggering quarter of a million gunshot deaths and injuries a year? It is a massive human and financial cost to preserve the delusion that a ragtag band of poorly trained amateurs with deer rifles can stand up to a modern professional military.

Anonymous said...

Affordable care, access to care, high quality care. We can only have two? Which ONE do we have? Much less two.

Presently we have unaffordable, high-volume/high-tech care of uncertain quality, accessible in emergencies and to the insured and subsidized.

For me, the ethically-compelled starting point is access for all. Redefine quality to include affordability and presto, you can have all three.

Skeptical Scalpel said...

Chris, good comment. I didn't think of that but you are right. We don't even have one of the three.

I think the only way to do this is single payer for everyone, but not likely to happen. The insurance lobby is very powerful. And who would run it? The federal government has not shown much ability in running anything.

Anonymous said...

Here's the rub: The US median wage in 2010 was $26K. The average health insurance premium was about $15K. That is an absurd fraction of a person's total income. Should we mandate coverage for everything, say, birth control, acupuncture, whatever, then the average health insurance premium could easily surpass the average wage. Then, disaster.


Skeptical Scalpel said...

Nick, thanks for the response. The link is very interesting. Lots of stimulating comments on it.

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