Map of life expectancy at birth from Global Education Project.

Monday, July 20, 2009

Doctor Pecuniary

I have been active in health care politics for something like 25 years now (ever since I was in kindergarten?) and my single greatest frustration is that it simply is impossible to make the issues simple. Actually, they are reasonably simple, but our culture is so profoundly indoctrinated with Ptolemaic economics -- the nonsense that is taught to college students by professors who call themselves social scientists but who are actually theologians -- that we have to spend all our time shoveling out the stable before we can get on the horse.

To be sure, even if the economics turns out, in the end, to be reasonably accessible to the de-programmed, medicine itself is still pretty complicated and somebody, somehow, has to make decisions about how to allocate the resources that we do assign to health care. A common argument against meaningful reform boils down to, "We can't trust anybody to do that, so let's not do it at all," in other words let irrational and unjust forces prevail rather than even try to do what's right. (There's probably a Latin term for that, but I don't know what it is.)

But I digress, somewhat. The question is, what is the physician's financial stake in reform of health care finance and why would some physicians oppose universal coverage, as the AMA has notoriously done in the past? And why have they apparently suddenly changed course and endorsed the current Democratic proposal in the House? More specifically, some readers want to know why, since more people insured presumably means more money to pay doctors with, doesn't that make up for whatever doctors might lose?

The bottom line is that it will likely be good for some doctors but make it harder for some others to afford their boat payments and horse fodder. Suppose Congress were to wave its magic wand and, by any means necessary, cause everybody to have good, comprehensive health insurance like the good comprehensive health insurance that some people have now, without changing anything else. That would indeed mean more money going to doctors and hospitals and drug companies and the only losers would be whoever had to pay for it, which you will notice I have not specified. Alas, even if we paid for it with a tax on puppy abusers and Rush Limbaugh,* that well would go dry very quickly, and they'd have to start taxing puppy rescuers and Rachel Maddow, and it would just get worse from there.

The fact is that we have an inextricably entwined double crisis, at the heart of which is not the failure to provide universal coverage, but rather inexorable growth of medical spending. It is the latter which causes the former, or at least makes it very difficult to solve. Closely related is the shortage of primary care doctors and the oversupply, overconsumption, and overpayment of many specialty medical services. Barack Obama, Barney Frank and Ted Kennedy all know that. Primary care physicians who understand what's going on ought to support radical reform that not only gets everybody covered, but also redirects resources to what they do and restricts elaborate, expensive, high technology procedures that aren't worth the cost or even do more harm than good. And many of them do.

The American Medical Association, however, is dominated by specialists who stand to lose if we do what we must. The reason they have decided to support the House bill is because it doesn't -- it just waves that magic wand and causes everybody to have insurance. As I wrote the other day, it can't end there, and it won't. But this is a problem of political tactics. Can we get there by doing one piece at a time? Or will we just mire ourselves deeper in the doo doo? I am not sure.

*Al Franken is now a United States Senator, and Rush Limbaugh is still a big fat idiot. That's got to hurt.


kathy a. said...

that is an excellent point, that physician stakes vary. also, that there is a shortage of primary care physicians, many of whom do not have yachts. or horses.

something has to happen, and the only thing that *can* happen immediately [besides nothing] is incremental change. once everyone is covered, the pressure will be on to avoid unnecessary procedures and more costly meds that don't work better.

i think it might be helpful to talk more about reasonable allocations of care, and unnecessary procedures. there are a lot of variables, naturally, with individual situations; someone with high risk and/or symptoms has specific reasons for some procedures, whereas simply reaching a certain age may or may not be a good reason to undergo a procedure. a good many of us have needed to fight arbitrary denials by insurance companies for medically necessary things, so that is a reason for folks to be wary of arbitrary guidelines.

i also think there are some cultural changes that could help. direct-to-consumer ads for prescription medications and specific medical interventions, for example, seem to me insane. we could be more rational around end-of-life care, also; relatives never want to feel like they are killing off an elder, but i suspect that heroic interventions in hopeless cases rack up a lot of bills plus family angst.

Cervantes said...

All true K. What we need is some form of "fuzzy" rationing -- a way to effectively and enforceably define what is reasonable to do in a given situation, but allow for a fudge factor that is protected from abuse. Most people who think about this seriously try to accomplish this (in their imaginations anyway) by realigning incentives rather than writing rules, that is to say based on principles rather than deontology. Cultural change is certainly part of the requirement.

roger said...

it looks like the fight is about how much of an incremental change can be made. responsible docs want a decent start, the ama wants a false start which essentially changes nothing.

while i e-mail and call my representatives, and even call senators from other states, i am not at all confident that any meaningful change will be made. my senator feinstein seems to be an active enemy of change and senator boxer is too timid to declare anything.

kathy a. said...

letting more people see primary care physicians is a good start. well-kid care and care for that which comes up -- outside the ER setting, and instead of needless suffering and complications -- is just basic. surely we can do that much for everyone.

i badly labeled banning direct-to-consumer ads as a cultural change. that needs to happen legislatively.

not sure what to do about all the "one rule for burning belly fat, lose 10 lbs in a week" ads that are ubiquitous, but i wouldn't be opposed to heavy fines and public stocking. i realize this is a side-issue to public health, but they must be bringing in a lot to do such heavy advertising, and i can't imagine the method has much better medical credibility than any of a million miracle diets.

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