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What US Health Care Needs
Medical doctor and writer Atul Gawande gave the commencement address recently at Stanford's School of Medicine. In it he lays out very precisely and in a nonpartisan way what is wrong with the institution of medical care in the US — why it is both so expensive and so ineffective at delivering quality care uniformly across the board. "Half a century ago, medicine was neither costly nor effective. Since then, however, science has... enumerated and identified... more than 13,600 diagnoses — 13,600 different ways our bodies can fail. And for each one we've discovered beneficial remedies... But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we're struggling. There is no industry in the world with 13,600 different service lines to deliver. ... And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it's the economic bailout plan. But take both away and you've made almost no difference. Our deficit problem — far and away — is the soaring and seemingly unstoppable cost of health care. ... Like politics, all medicine is local. Medicine requires the successful function of systems — of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively. ... This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do."
The thing is, that you don't actually have to go as far, politically, from the USA to see a working health care system. Before Margret Thatcher's management reforms crippled it, there used to be one in the UK and to a large extent there still is one in Scotland. The key element is to understand that money is a terrible motivator in health care.
There are always many many treatments and tests possible. For any given patient, most of those tests will either do more harm than good or be unjustifiable financially (costs 100,000, has a 1 in a million chance of helping you). The doctor has to be trustworthy to say "no, it's not worth it". That means that you have to believe that a) he has nothing to gain from not giving the treatment and b) he really has to have nothing to gain from giving the treatment c) he has to be competent and well enough trained to make that judgement.
Unfortunately, as soon as we have insurance companies, financial administrators and ignorant courts involved this breaks down. The insurance means that the doctor is doing the treatment for profit, so the more he gives, the more a non-involved third party pays. The financial administrators (e.g. in UK state care) mean the opposite. Now the patient knows the doctor is under pressure to not deliver treatment and will not leave until they get it (even if they don't need the treatment). The courts mean that the doctor can get away with killing hundreds of people with extra CAT scans, but if he misses one brain tumor by not doing one he goes bankrupt.
We need to take the direct money out of front line medicine, or at least pay it much more cleverly. For example, if you pay doctors by results (percent patients cured) they will only work on easy cases. Almost any such system I can think of can be gamed.
=~ s,(.*),<sarcasm>$1</sarcasm>,g if any_point_you_wish();
For just about everything else in life, insurance is just that: Ensuring that in the event something happens, you are covered. It is a risk transfer for certain situations. For example I carry insurance on my house. In the event it burned down, or everything was stolen or the like, I could not afford to replace it all. My cash reserves are insufficient and, indeed, I have to have a mortgage to own the place. So, in an emergency, the insurance company will cover my loss. However, it is only in an emergency. They do not cover regular maintenance and upkeep of the house. Even in terms of qualifying emergencies, like theft, there's a $500 deductible. So if someone breaks in and steals a couple speakers, I'm paying for that myself, but if they steal everything the insurance company will pay.
It is all about transferring risk. I take care of the high risk, low cost stuff, they assume the low risk, high cost stuff. It is a certainty I'll have to repair things, the risk of something breaking down is as high as it can be, more or less. But the cost is low, I can afford it. The risk of my place burning down is quite low, but the cost is high, too high, so I transfer that risk. Doesn't cost a lot, since it is low risk. Likewise, my insurance company does the same thing. They cover individual incidents. However for large things, like disasters, they have their own reinsurer. That company only deals with extremely rare stuff, the risk of it happening is minimal, but the costs are astronomical.
But for health insurance, that's all turned around. It covers EVERYTHING. I pay, at most, $10 for anything. Insurance pays the rest. Doctors visits, tests, hospital, etc. I only bear the cost if it is extremely cheap, like a generic drug. Otherwise they pick it up. However they also pick up high cost stuff. If I have a major accident and require intensive care, they pick all that up. They are liable for ALL risks to my health.
Is it then any wonder that it costs more per month than my home insurance does per year?
I really thing a medical savings account kind of plan is the right idea. You save money to pay for normal things. In the event of something catastrophic, no problem, your insurance is there to pay any and all costs.
However finding that is hard. They started offering one at work... And it wasn't worth it. My premiums stayed the same, my employer had to put in just as much money, and my personal financial risk increases. How he hell is that useful? It should cost my employer much less, but it doesn't.
Sure, keep true insurance around for catastrophic events, but otherwise let each person decide how to spend their own money on their own regular health care.
This leads to people avoiding preventive care, which drives up costs in the long run. There are already dozens of health care models around the world that deliver better outcomes for a fraction of the cost that the U.S. pays. There is no need to reinvent the wheel.
even though the overhead of dealing with 'insurance' companies can easily equal 50% of the bill.
And yet you advocate sticking with a system that involves private insurance.
I don't always use unix-like operating systems; but when I do, I prefer FreeBSD.
Dr. Gawande suggests the "13,600 different service lines [doctors] deliver" is an issue in health care costs. I put forth these comments:
* How many services are listed in the manual which guides the number of hours an auto mechanic is allowed to charge for a repair, e.g., replace spark plugs: 0.75 hours. How many items are in this book?
* How many different services does a software engineer deliver over a year's time?
I suggest the problem is related to control over charges. Car mechanics have a job with similar complexity to what doctors face. Software engineers often face a problem much more complex. (How many "surgeries" require several weeks to solve a single-line bug?)
The control of health care "service" in the US is in the hands of the AMA and the bureaucracies created around hospitals and other facilities. If they were willing to reduce their profit margins (assuming we can eliminate the defaults they see because of uninsured/under-insured patients), we could see significant reductions in general health-care costs.
This is just a thought...
-Todd
Omne ignotum pro magnifico.
I'm haemophilic - where am I supposed to get the cash for my treatment?
The free market is survival-of-the-fittest, healthcare is preservation-of-the-weakest; I don't find it that suprising that they don't get on.
The best solution is a publically owned industry like here in the UK, with much, much smaller private insurers who can stay light on their feet and plug gaps in the service when they appear.
This system is way cheaper, higher quality *and* it's fairer.
If there is a profit motive, doctors will ignore people who are really ill as it won't be worth curing them.
In the UK we are committed to provide healthcare for everyone until they are healthy, hence it is massively in the doctors and the governments interest to keep people healthy and out of the hospital; so they don't have to pay for their care.
If everyone suddenly got healthy in the UK, we would save a tonne of money - if they suddenly got healthy in the US your economy would collapse. You need people regularly paying the deductibles.
Um...hate to burst your bubble there but fact is that all the other G7 countries(which all have public health care btw) spend about HALF(in terms of % of GDP) of what the US does in healthcare and yet people in those countries live longer(there are lifestyle factors involved, but they aren't the only ones).
I have yet to hear a single empirically sound argument against public health care. No amount of ideology can contradict two very basic, and very important, statistics: percentage of GDP spent on health care and life expectancy. If the government was really driving up the cost of health care then you would expect to see the former be much higher than the US, but in fact it is the opposite. Also, if the health care was really as bad as a lot of people on the right make it out to be, you would see average life expectancy to be lower than that of the United States but it is in fact higher.
Monstar L
It seems to me that you have chosen to misinterpret my words. You'll note that I didn't ask or demand that ANYONE work for free. All I ask is that the profit motive not be the determining factor in health care considerations.
As for myself - I can't work for free, anymore than any other man or woman in the world. I MUST feed myself and my family, and all the rest of the stuff that goes with being a responsible adult.
But, personally, my career, my day to day decisions are NOT all profit driven. I COULD HAVE had any number of careers. Instead, I have chosen to work where I enjoy working, all of my life. When the job starts to suck, I go find another job. I walked away from the best paying job that I've ever had, because the boss thought that he "owned" me, and started becoming abusive. He simply could not imaging that anyone in this part of the world could walk away from more than 20 dollars an hour, a company vehicle, paid insurance, along with some other perks. I walked. Unlike so many Americans, I don't worship that Almight Dollar, to the exclusion of all other considerations.
Again - I don't ask that anyone work for free. All I ask is that people recognize that sometimes that dollar isn't the most important thing.
While I was in business, I put a roof on a house for an old lady, only charging her for the materials. I took a loss on that job, because I knew that she couldn't afford the work. I spent two days working on her house, and paid a helper out of my own pocket, because no one should have to put pots and kettles around the house to catch water from a leaking roof. Most especially, an aging woman in poor health. I did a few other jobs at discounts for people who needed a helping hand, but that one particular job, I actually took a loss.
If I can do such a thing, I expect that a doctor can do as much, now and then.
Profit. How much profit do you take with you when you leave this world, anyway?
"Windows is like the faint smell of piss in a subway: it's there, and there's nothing you can do about it." - Charlie Br
In US 50 years ago a family of 4 could have actual health insurance (covering of up to $50,000 of expenses, which was enough for everything) for a year for $25 dollars (payment for an entire year!) with a $500 deductible.
Basic problem is the government giving out public funding for any sort of endeavor. This leads to very rapid price increases. Before Nixon, a day in a hospital could cost $100, today it could cost up to 100 times that much. Obviously this has nothing to do with inflation. Costs to treat cancer could go as high as up to 20,000 dollars before then, now it could easily reach between 500,000 to a cool million.
Another ranting Rand-ite with no actual understanding of the problem.
Look, idiot, 50 years ago, virtually every hospital was run on a not-for-profit basis. Because there were no shareholders to have to provide quarter-over-quarter profits to - and essentially no MBAs to pander to them - nearly every dollar spent on hospitalization went to actual medical care. Likewise, medical insurance was MUCH less paperwork-intensive, which meant that overhead costs for medical billing were a whole lot lower than they are today. And finally (and utterly crucially), medical technology was barely getting started in 1960: no MRIs, no monoclonal antibodies, no gamma knives, no transplants. In fact, the only real high-tech devices were "iron lungs", developed to keep polio victims alive. If you got cancer then, surgery and whole-body radiation were pretty much the only options. Cisplatin-based chemotherapy didn't become commonplace until the 70's. So, no high-tech drugs and devices meant that treatment costs were quite modest by today's standards - and so were survival rates. It's a pretty straightforward tradeoff.
Free-market fanatics like you want to make government spending the culprit for all financial ills, because that makes understanding the world so much simpler for you. The problem is that your underlying assumptions are simply wrong, so your worldview is full of shit. The fact is that medical costs are out of control in this country not because of Medicare/Medicaid spending, but because of proliferating treatment costs and the rise of the for-profit medical insurance economy (whose overhead costs run ~30% - as opposed to Medicare/Medicaid, whose overhead is ~1.5%).
Oh, and Medicare/Medicaid wouldn't be facing the deficit problem that's looming, if Congress had had the sack to increase Medicare premiums and payroll taxes by a relatively tiny percent 25 years ago, when the impending problem first became apparent. Or, to put it in terms your tiny mind will reject: the problem isn't government spending, it's the government's cowardly unwillingness to raise taxes to levels sufficient to fund its spending mandates that's the problem.
I'm not surprised I have to explain this to you, because you're obviously too blinded by your free-market dogma to grasp the actual causes of the medical economic bubble we're experiencing in this country.
Check out my novel.
Thank you for essentially proving my point, instead of combatting my argument with empirical evidence on the efficacy of privately run healthcare you just responded with a lot of ideology with no statistics to back you up. Guess what, the problems in Greece is NOT the fault of healthcare, it stems from the government giving lavish gifts to it's own employees with 0 oversight all while trying to hide what they were doing. That happens elsewhere, including the US, all the time(both Repubs and democrats do it).
To add further empirical fuel to my argument, look at which economies in the G7 are recovering the fastest, Japan, Canada, and Australia. What do those three have in common that other countries do not? They all have public healthcare systems WITHOUT a lot of the other bullshit that comes attached with hiring and firing workers that the Europeans have. Despite their surging currencies(the loonie, ozzie dollar and yen are all really strong right now) it is STILL cheaper to hire workers(esp. for small businesses) in these countries than it is in the US. The healthcare system in the US is hurting international competitiveness and thus costing a massive # of jobs.
If you want to refute me please actually use real, verifiable evidence and don't repeat your last rebuttal where you think you win an argument just by using the word "socialism".
Monstar L
You pay hundreds of times more for your healthcare which is only marginally better, at best, than that which is available to anyone in Cuba. I think that's the point. Are you really happy having this discussion? Doesn't the fact that you are having to defend US healthcare against Cuba's indicate that maybe not everything is OK in the US healthcare system? Oh, and if you lose your job or your insurer stops covering you, you'd beg to be treated in Cuba.
Please define " Obscene corporate profits ".
Any revenue by any middlemen whom add no medical value, or exist solely to subtract medical value, from patient care?
If they're not profitable they'll either raise costs or go out of business, so he really means "obscene corporations"
Maybe he means obscene as in culturally unacceptable, obscene like kiddie pr0n or eating household pets for dinner or working in the medical insurance racket, not obscene as in "they make more money than I think they should".
"Science flies us to the moon. Religion flies us into buildings." - Victor Stenger