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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."
Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.
Which is why in the UK, where everyone can use the health service for free and is insured automatically by the government provides better health care cheaper?
Doesn't sound like you've sorted that out right.
Doesn't that depend on what your ailment actually is? If you've got the flu, a doctor in the bottom 20% is good enough, while if you've got brain cancer, then you'll want a doctor in the top 10% or better. You could have a system, let's call it "triage", where someone qualified could decide what kind of doctor you need...
1. Uniform billing codes and realtime price-lists so that we know we're not getting ripped off. California's chargemaster publication requirement is a step in the right direction, but it needs to be updated more quickly, and rural hospital exemptions are BS. If you can run a hospital, you can update your billing DB no matter where you are.
2. No anti-trust exemptions. This is so fundamental it's mindblowing.
3. Nationwide competition.
4. No more buyer's clubs. If the doctor and/or hospital is *licensed* then the insurance must pay out. You get to keep your doctor no matter what. Any company that wants to keep having a buyer's club can do that; but you can't be compelled to purchase into a club, only real insurance.
5. Real insurance means you can't lose your life savings due to a percentage payment or a cutoff. After all, you can't actually insure health. Only genes and behavior can do that. When we talk about health insurance, we're really talking about medical bankruptcy insurance, and the current system fails to do that. In order to be considered a real insurance plan, you have to prevent medical bankruptcy. That means, for example, you can lose no more than 10% of your net worth or income in any calendar year. That way, you could be severly ill for 5 years, on chemo, and emerge with roughly 60% of your life savings intact instead of nothing.
6. Stop torturing doctors. No, really. Many people won't even consider med school because it's torture. Maybe we need to put some doctors through boot camp. Maybe it's important for brain surgeons; but I can't imagine this system is really doing much to increase the number of competent family doctors.
7. Malpractice/tort reform. Duh! If a doctor is so incompetent that we're better off taking him out of the profession then let's do that. Requiring all the other doctors to pay out as if they're that bad is insane. Multimillion $ payouts won't bring back your relative. License revokation, however, will prevent it from happening to somebody else. Note, this is tricky since it's possible for competent people to make mistakes. You actually need to make sure that the number of mistakes is statisticly significant. Otherwise, nobody will want to risk becoming a doctor (see point 6). Statistics is a bizarre thing. There's actually an expected number of botched operations; but the odds of a single doctor botching 10 operations in a row are probably low enough so you can safely conclude that doc needs to lose his license.
8. Everybody self-pays and submits claims. That's right. You run healthcare like a normal business. I know it's hard to believe, but it really is just like buying a loaf of bread. Fire the beurocrats. No biggy. They'll get free health care while they look for a real job.
9. No paper work until the patient is well. No signing anything under diress.
10. You can put a pharmacy in the hospital. Quit making sick people drive to get meds.
ACing this since you posted as AC above (where I replied as AC and refuted your infant mortality claim).
First, if you have any background in health you know the different between determinants and indicators. You can cherry pick whatever indicators you think will militate best in your favor. And when they don't militate the way you'd like (say: infant mortality) you will claim they are "cheating" by offering abortions or by using a marginally different method.
Allow us to get into the technicals of the method they use. Using your OWN LINK's info, the US method includes less than 1.3% extra babies, of whom 50% may die (less than this but we'll round up. So instead of 6.0 per 1000 for Cuba and 7.2 for the US The US actually has (.5*1.3%) better stats. So 7.1532 instead of 7.2. Wow, who cares. Furthermore, even if we ignore all of this and say that US IS BEST EVER for infant mortality, Cuba still trumps several other "first world" countries that have way more GDP/PPP and use the SAME method of measurement as Cuba. So their indicator holds.
Furthermore, this is ONE indicator. Life expectancy is another important indicator, and one you can't explain your way out of so easily, especially if Cuba has such a horrible medical system the fact that they live approximately (but not quite) as long as Estadounidenses again speaks to their health outcomes. Or their abilities at reanimating their dead.
You cherry pick breast cancer survival, which is a pretty random and focused statistic. I don't think you want to get into the "focused indicator game" with me to prove which country has better health outcomes. How many people does breast cancer kill in the US? Instead of arguing if Cuba wins or loses here, I'll just let you have it. Now how may people do GUNSHOTS kill here? How many in Cuba? Drug overdoses? Car crashes? You will lose the focused indicator game. Most resident doctors in Havana's hospitals have never seen a gunshot wound. Or a drug overdose.
And when we dig deeper into indicators, and I mean overall indicators, not narrower ones that are likely to show more bias, things get interesting. US life expectancy is one thing, but the distribution of life expectancy tells us a whole lot more. Which is to say that black men who live in Harlem have a shorter life span than the average Bangladeshi. So yea, if your last name is Buffet or Rockafeller you're gonna live maybe even 10 years longer than the average Cuban (if you're really lucky), but for the million of marginalized minorities in the United States, you'll probably live 10 years less. See: Hans Rosling's work.
Lastly you are either an idiot (i don't think so) or disingenuous to characterize experts who literally write WORLD HEALTH policy as "enchanted foreigners." If you or I went to Cuba and came back with a glowing review, we might fairly be viewed as "enchanted." When the world's foremost health equity experts have glowing reviews it is ignorant and dismissive to call them "enchanted." I cited people who run the top medical schools in the world. You cited a Philip Morris funded web site. Game, set, match.
This is pretty much what happens right now in Australia.
All income taxpayers pay the Medicare levy. A large payment base means there's enough in the nation-wide pool to cover pensioners, unemployed, etc who can't afford to pay-in.
Private health insurers then come in and make a killing on gap insurance and covering things Australian Medicare doesn't - like dental.
How do you answer the point that many other developed countries have much more government involvement in healthcare, and yet pay less for better healthcare?
In France, for example, public healthcare is available to all, but they pay only only 3/5 as much as the US as a proportion of GDP and are considered to have the best healthcare system in the world by the WHO.
The British NHS, which at the time of the WHO's report cost only half as much as the French system in terms of GDP, was placed 18th; a fair few countries behind France, but still 19 places ahead of the US. To reiterate: the NHS, which is entirely Government funded, costs only just over a quarter of the US system and yet has better results.
Developed countries with socialized or partly socialized healthcare systems topped the list, while the US, coming far closer to your vision of non-Governmental healthcare, was beaten by powerhouses like Costa Rica, Columbia, Morocco, and the UAE.
More than half of ostensibly qualified applicants every year are turned away.
One of the prime reasons I didn't go into medicine was the cost. Chose the I.T. field instead.
In retrospect, I wish I went into medicine. Instead of competing with a glut of "educated" "certified" "trained" personnel in IT, I'd have a "guaranteed" job as a Dr.
What fraction of people go into C.S., learn how to design compilers, databases, OS kernels, clusters, large scale BGP networks, etc, and then get stuck on the helpdesk, or if not underemployed, unemployed due to outsourcing?
On the other hand, it seems that approximately 100% of doctors whom learn how to suture wounds, on the job, believe it or not, actually get to suture wounds?
The level of underemployment in IT is so extreme, that there is a whole comic industry of making fun of the "peter principle" folks above them in management, the humor being that IT folks are so strongly underemployed that the concept of a "peter principle" line of work is hilarious to them. On the other hand, it seems like doctors actually get to do, what they trained to do, which must be pretty nice.
"Science flies us to the moon. Religion flies us into buildings." - Victor Stenger
As a side note, addressing the GP/FP doctors in the US have a bit of a control freak nature. Not only are there not enough of them, they seem to have issue with delegation. Recent pharmacy grads are exceptionally good at prescribing and much better at diagnosis than their predecessors. Yet doctors are still slow to utilize them as specialists. This lack of respect for other disciplines in medicine is causing many issues as well. (There are states that do allow pharmacists to prescribe and are getting closer, but we are a long way from reducing the burden).
CS: It is all sink or swim...oh and did I mention there are sharks in that water?