Overtreatment

This looks at one way to control health costs, reducing the amount of unnecessary medical care:

No. 1 Book, and It Offers Solutions, by Dvid Leonhardt, NY Times:  In 1967, ... Dr. [Jack] Wennberg had been chosen to run a new center based at the University of Vermont that would examine medical care in the state. With a colleague, he traveled around Vermont, visiting its 16 hospitals and collecting data on how often they did various procedures.

The results turned out to be quite odd. Vermont has one of the most homogenous populations in the country... Yet medical practice across the state varied enormously, for all kinds of care. In Middlebury, for instance, only 7 percent of children had their tonsils removed. In Morrisville, 70 percent did. ...

The children of Morrisville weren’t suffering from an epidemic of tonsillitis. Instead, they happened to live in a place where a small group of doctors — just five of them — had decided to be aggressive about removing tonsils.

But here was the stunner: Vermonters who lived in towns with more aggressive care weren’t healthier. They were just getting more health care.

Dr. Wennberg ... has done versions of his Vermont study for the entire country. Again and again, he has come up with the same broad result. And that result holds the key to health care reform — how to spend less on health care while not making the population any less healthy. ...

It’s not hard to find examples. Scientific studies have shown that many treatments, including spinal fusion, routine episiotomies and neonatal intensive care, are overdone. These procedures often help specific subsets of patients. But for a lot of people ... the treatments are a modern-day version of bloodletting.

“We spend between one fifth and one third of our health care dollars,” writes [Shannon] Brownlee, [author of Overtreatment] ... “on care that does nothing to improve our health.” Worst of all, overtreatment often causes harm, because even the safest procedures bring some risk. ...

Why is this happening, then? Above all, it’s the natural outgrowth of our fee-for-service health care system. It turns doctors into pieceworkers, as Ms. Brownlee puts it, “paid for how much they do, not how well they care for their patients.” Doctors and hospitals typically depend on the volume of work for their income, and they are the gatekeepers who decide when work needs to be done. They also worry about being sued if they do too little. So they err on the side of overtreatment. Patients play a role, too. We’re entranced by the wonders of modern medicine...

In plain English, Ms. Brownlee lays out an agenda for reform... It includes some steps that should be widely popular, like giving doctors incentives to explain the risks and benefits of procedures more clearly than they do now. Research has shown that patients frequently decide against marginal care when they know the true risks and benefits. Malpractice laws would also need to be changed so doctors were not sued by patients who later changed their minds.

Other solutions would be more difficult — because medical evidence is often murky, because hospitals and insurers would fight to keep their revenues and because most Americans think it’s the other guy who’s getting unnecessary treatment. These are the reasons that presidential candidates don’t focus on wasteful treatment.

But models for reform are out there. Hospitals that don’t use the fee-for-service model, like those run by the Veterans Health Administration, are already getting better results for less money. ...

Essentially, the argument is that profit maximization by health care providers does not coincide exactly with maximizing health outcomes. As Shannon Brownlee says here:

Is this happening because doctors ... are rubbing their hands together, thinking up ways to pad their incomes...? Of course not. They are doing the best job they know how. Nonetheless, they are delivering a lot of unnecessary care — much of which is driven by the way different hospitals are organized and how the medical cultures within them evolve.

The solution, then, is to change the incentives so that the incentives faced by health care providers are consistent with achieving the best health outcomes. Mathew Yglesias describes this solution:

Brownlee's alternative is to turn doctors into salaried employees charged with doing the job of keeping people healthy, rather than into fee-for-service professionals whose level of compensation depends on how much treatment they prescribe.

There are other aspects to the problem of over-treatment that this particular solution does not fix, there are other possible solutions, and eliminating unnecessary care is not the only way to reduce the growth of medical costs, but if this helps to free up resources that can be used to provide care to those who are currently under-served, as it appears it would, then that would certainly help.

Comments

[spencer]

It is very much standard thinking among economists to say government interference is the cause of the healthcare problem.

But this analysis says that the problem is that individual doctors are set up exactly like the perfect competition model says they should be -- individual firms where no one firm impacts the overall supply or demand curves. So the great variety of healthcare being provided around the country is caused by the system being set up exactly like economic theory says firms should be under the perfectly competitive model with each individual firm -- doctor or hospital -- acting to maximize their profits.

The standard solutions offered by those saying the problem is government is to work on the demand side of the equation. But this analysis says the problem is the supply side of the equation.

Many like to claim the system is wasteful because of government. But this analysis says the system is wasteful because it is too much like the perfectly competitive model.

[Richard A.]

Not only is over treatment a costly problem but so is the overuse of costly Rx drugs at the expense of cheaper otc treatments. Prevention with the proper diet and nutrient supplements (like the use of fish oil caps) would go a long way to avoid being hospitalized in the first place.

Here is an interesting medical blog for those who do not want to have a heart attack --
http://heartscanblog.blogspot.com/

[hari]

Mark -

US healthcare industry is not working for the benefit of the patient - it's working as a profit making centre!

There's no short-cut to the incipient nature of the problem, so how does one tackle it, as a consultant?

My suggestion is to forget the federal perspective and concentrate on how to tackle State healthcare system, first.

Once the state heaalth insurance and other problems of infrastucture are more or less solved, it may be possible to focus the problem at the Centre!

For the moment, the system is NOT working for the one who needs it.

[barry payne - economist]

spencer

I'd say it's more complicated than that. This is not perfect competition, far from it, where the consumer is sovereign. If it were, "overtreatment" would not be possible any more than overconsumption of drinking water from the glass.

That particular medical procedures are routinely overprescribed is an old supply-push problem not offset by demand due to submissive, uneducated customers, guaranteed payment and conflict of interest.

In certain cases where the ailment is well diagnosed and a routine procedure is available, such as the production line surgery for cataracts in Cuba, the (successful) results start to look like the outcome of perfect competition - even though fully nationalized in this case.

In most cases, a holistic exam of the patient is considered essential before undertaking specific treatment to narrow the window between Type I and Type II errors (false positives and negatives), which has become a serious problem in the U.S. and caused even many deaths.

Most doctors and patients have a strong "gateway" complex based on the holistic notion that one must have the full (expensive) exam before going on to a routine procedure, which has become increasingly suspect as worthwhile for even the most routine of procedures or available drugs (but not without a recommendation or prescription).

In my opinion, there should be walk-in retail outlets with primary physicians, nurses and assistants who do nothing but diagnosis with second opinions available and have no connection to the treatment. They should be reimbursed in a way that encourages the most accurate diagnosis, regardless of payment source.

[James Kroeger]

The solution, then, is to change the incentives so that the incentives faced by health care providers are consistent with achieving the best health outcomes>I can't say how pleased I am to hear of Shannon Brownlee's book Overtreated and the interest it has generated. I have also written on the need to fix the incentives of the health care industry, focusing primarily on why it would be a good idea to put all doctors on a salary:If a physician gets paid a generous salary for just being a doctor, for "doing what a doctor does" [a certain number of hours per day] then she will not receive any extra revenue if she prescribes extra tests & procedures. Nor will she be rewarded financially for under-prescribing care. When physicians are on salary, they are freed from their concerns about financial matters and are able to fully invest themselves in the most idealistic inspirations of their calling. They can simply focus on healing people and not worry about all of the administrative headaches.The incentives problem we are facing goes beyond the incentive that physicians currently have to over-prescribe care [thanks to (A) private insurance and (B) private practices]. At the same time, the managed care approach to controlling costs ultimately gives doctors a financial incentive to under-prescribe care at a certain point. Putting doctors on a salary (and eliminating private health insurers) would eliminate both of these perverse incentives.

The incentives problem goes beyond the rewards that physicians face. Private insurance companies currently have a financial incentive to mislead potential customers as the the extent of the coverage they will be receiving while encouraging them at the same time to deny customer claims when those customers most desperately need insurance coverage. (Of course, insurance companies are not going to want to provide 'generous' coverage of those medical problems that their customers are most likely to face; they only want to provide generous coverage of problems that their customers are least likely to face.)

Our private pharaceutical companies currently have a financial incentive to set their prices---through the help of government-ensured monopoly power---at levels that poor people cannot afford. The outrageous markups are justified as necessary to provide researchers with the incentive to find new cures, but this is utter BS. Most researchers work for a salary and would receive one if they worked for the governemnt. Governments can provide their employees with the same kind generous financial incentives that private sector employers may currently offer to those reseachers who make a big discovery. It is a non-issue.

When I first started contemplating the state of America's health care system in graduate school, I didn't think I'd find Britain's National Health Service to be the model we should emulate, but I now believe that pure socialized medicine is the way to go, because it is the only way to get the incentives right that will provide the American people with the kind of quality health care they desire at an affordable price.

You want to talk about cost controls? If there is anything the British model of Socialized Medicine has taught us is that the very last thing we need to worry about is runaway costs (they pay less than half the amount of money Americans pay for equal/superior health outcomes). Their biggest problem is underfunding, not excessive costs.

[robertdfeinman]

Journalist Maggie Mahar has recently started a blog devoted to health issues:
http://www.healthbeatblog.org/

She also belongs to the camp which thinks unnecessary treatment is a major factor in keeping costs high.

I see several factors, call it the three blind men and the elephant problem. Each critic seems to focus on only one aspect.
1. Drug prices are too high.
2. For profit firms are extracting about 30% out of every health dollar in overhead and profits.
3. Feedback on optimum treatment is inadequate.
4. Defensive medicine is practiced because of fear of suits.
5. Useless end-of-life treatments are too common and too expensive.
6. Inadequate attention is given to preventive medicine and altering lifestyle choices.
7. High costs and inadequate coverage are a barrier to those without adequate financial resources from getting treatment when it is most cost effective.
8. R&D is hampered by profit motive, lack of federal support and theological interference with science.

On the other hand the benefits of advanced medical care are not being factored into the equation. Two examples:

1. Heart bypass operations now allow people to return to work and a full, active, lifestyle where before they would have been invalids and had a shortened life expectancy. How much have Dave Letterman and Bill Clinton earned since their operations? How does this compare with the cost of treatment?

2. My wife had cataract operations 10 years ago. Without them she would have become blind and had to stop working. How much is the economic benefit gained worth and how much is the quality of life worth? If she had stopped working not only would she have stopped earning money and paying taxes, but she would have gone on disability and cost the government money.

Where in the heath cost equation does this quality of life enhancement show up? If people earn more in the US then it is still a net benefit if they pay more for health care than in, say, the UK. Everything in the US works similarly. I don't see any national debate about the hourly rate charged by plumbers or lawyers. Why pick on doctors?

As for putting doctors on a salary, many already are. This model doesn't seem to have any connection with costs. When HMO's tried cost containment techniques by pressuring doctors on what treatments to offer there was a national revolt. If the pundits want to see treatment choices optimized they'll have to change public perceptions, not pressure doctors.

Where is the discussion on the $20 billion in bonuses that Lehman is going to pay out this year? Tell me exactly what part of the economy they improved by shifting this amount of money from productive firms into the pockets of financial speculators? Just the bonuses from the top half dozen financial firms alone would pay for all the health care of the uninsured in this country. Where is the outrage about that?

[JRossi]

These comments make me think of rearranging deck chairs on the Titanic.We family physicians have run up against the limits of human ability. My number one job, my stock in trade, is my ability to make accurate diagnoses. If I can't do that I am not a competent doctor. Accurate diagnosis is a difficult to master--it takes many years to learn and constant practice to keep up the skills. And unlike an academic or a policy expert, I can't just pick a single microfield and ignore the others. Someone would get hurt. I also have to stay abreast of the details of current treatments for a huge number of diseases, no easy task. Google clinical practice guidelines or wander a bit in the health sciences library of your local university if you don't believe me. I have to keep my patients happy to avoid getting sued. Business-wise, I have to at least break even. In a nutshell, the problem is this: My fellow FPs and I are simply not intelligent enough or energetic enough to do the kind of job that people who know very little about what we actually do for a living think we should be doing. And neither are you.
It's funny to read posts about how to structure our incentives to make us do the right thing. The incentives have been well and truly structured, and primary care is dying. Look it up. Good luck to the economists and policy experts in getting the specialists to make sure the blood pressures and cholesterols get checked

[calmo]

Thank you JRossi for providing us an example of how to treat our little economic patients that Mark sends our way for "treatment". My number one job, my stock in trade, is my ability to make accurate diagnoses. If I can't do that I am not a competent doctor. Accurate diagnosis is a difficult to master--it takes many years to learn and constant practice to keep up the skills.
That, and your professional time away from your busy practice to inform us on health care issues.

[James Kroeger]

My number one job, my stock in trade, is my ability to make accurate diagnoses. If I can't do that I am not a competent doctor. Accurate diagnosis is a difficult to master--it takes many years to learn and constant practice to keep up the skills.On this subject, I have a question for Dr. Rossi. Is it not possible to program a computer with every kind of symptom known, every kind of combination of symptoms, and all of the step-by-step reasoning that the best diagnosticians use to arrive at their professional guesses?

If that can be done, then why do we need to train physicians to retain all of the factual knowledge that a computer could retain for us? Just collect the medical histories, the vital signs, the test results, etc., and then follow the accumulated knowledge of reasoning processes of the best diagnosticians around, all stored on a computer?

Isn't that the most efficient way to produce quality health care?

[billyblog]

This is anecdotal and, therefore, of limited utility in an economists' forum. But let me share anyway.

About a year ago I started experiencing, initially only on the periphery of my consciousness, what I would describe as exceedingly mild gastric distress. I am otherwise quite healthy but, nonetheless, since my years are advancing, after about 2-3 months of experiencing these symptoms, I made an appointment with my primary doctor.

He practices in a clinic with probably 30-40 other doctors. Some are "internists," like him, who operate the front lines, and then hand off to an increasing number of specialists in the clinic as necessary. The overall client community served by this clinic is probably professionally tilted with a low unemployment rate, high property values, and probably well above average in terms coverage by (still) reasonably solid corporate or institutionally sponsored health care plans. My particular insurer is BlueCross BlueShield PPO.

The clinic is a bit of a mill, and despite the fact that I have a good relationship with my internist – I took him on as my "family" doctor after he arguably saved my life one night several years ago at the ER after some complications from surgery – he had to hustle me in and out in less than 15 minutes. Taking quick stock of my reported symptoms and what he knows of my medical history – a lot – and where I am in the medical life cycle, he hastily handed me a two week course of a trial drug called Protonix (as I recall), a drug I would expect is trying to peel off some market share from Nexium and the like.

I went home, took the pills, though in a somewhat desultory fashion, and noted that they did not really seem to help the problem. But since the problem was so low key, I did not stay focused on it. I don't remember what the insurance payment for the visit was, but it was probably $150 max.

After about 3 months, though, when the symptoms continued to persist, I called back my internist and he immediately referred me to one of the two gastroenterologist specialists in the practice.

I visited this guy – for maybe another $150-$200 whack to the insurance company. (My own co-pay is (still!) $15.00.) He then scheduled a full scale endoscopy for me. This procedure was done out-patient at the clinic, complete with their in-house anesthesiologist. Total cost? About $2,000. Diagnostic outcome? Nada. The test revealed nothing. More drugs were offered, but I am on none now and have no interest in getting on any until I can no longer, well, blog comfortably. We are far from that point.

But then about 2 months later, with the very mild symptoms persisting, and a year long sojourn in France coming up. I was concerned that I might be over in France and suddenly find that my symptoms had grown acute. At that point I would be forced either to go home for treatment or rely on the French health care system – which, from previous experience I can report is pretty good, but that is another story.

So I called back the gastroenterologist. He said come on in. I did. After a little poking around and some mild suggestion that I might just want to deal with my admittedly mild discomfort and stop bothering him, he checked and found they just happened to have an opening at their other facility where they housed their spanking new 16 slice CAT scan machine, and that if I could make it down there that afternoon they could slot me in.

With two shakes of a lambs' tail I was down at that other facility (that very evening hosting a reception for its inauguration with, I am sure, the 16 slice CAT scan slated to be the "guest" of honor), got my CAT scan, got the radiologist's read in less than a half hour (he was concerned to get to the party), and, lo and behold … nada again. I was fine, and should feel comfortable in dismissing any thoughts that I might be harboring the Big C, or something similar, somewhere in my digestive tract.

With a spring in my step I left the office and a week later I was in gay Paree looking forward to a wonderful year of deflecting anti-American sentiment (just kidding).

I still haven't seen the mail with the insurance payments for the CAT scan and the radiologist's read, but I suspect it was in the neighborhood of $2,500.

So there it was, several months, about $5,000 or so in insurance payments … and, alas, still the detectable gastric distress.

About two weeks after I came to Paris, I had occasion to get together with an old friend living as an ex-pat here. As aging folks are won't to do, while strolling through the Musée d'Orsay, we started talking about our various maladies, real and imagined. When I got to mine and began to describe the symptoms, my friend interrupted and said he had the "same" thing a few months ago and wondered if I had ever tried mint tea, which had worked for him

Mint tea? C'mon, I have a problem that even $5,000 of the most advanced medical technology in the world cannot detect – let alone solve. Mint tea? You gotta be kidding.

But I gave it a try. That was about three months ago. Guess what? Two cups of mint tea a day and I'm a new man, at least as far as my gastric distress is concerned. It's a miracle!

You can Rorschach this one any way you want as far as unnecessary medical treatment is concerned. As for me, it's time for my tea.

[Lafayette]

MT: and eliminating unnecessary care is not the only way to reduce the growth of medical costs

I have to agree with this, because though the article focuses on a probable waste of health care, I am fixated by its cost.

I can't help that, because I know costs here in France and I have compared them to the same costs (same service) in the US. The cost multiples are usually four to one.

The problem of the overuse of Health Care is also prevalent here in France, for which the French have introduced the Health Care Card (for reimbursement of the service) that contains a patient's history.

Often, it has been seen that patients make the rounds of different doctors (as if they were different restaurants) to see which they liked best. Or, they had several doctors treating the same symptoms, all being paid by the National Health Service. Supposedly the patient's medical history on-a-card will supposedly stop this abuse, since they are now obliged to nominate one principal GP who then guides them onwards to further exams or specialists for treatment.

Still, I must get back to basic costs. If my GP visit is costing me, here in France, $30 and yours in the US is costing twice or three times as much ... then you don't need a calculator to see the w-i-d-e difference in pricing.

Medicine as a public service should not cost you an arm-and-a-leg. (Pun intended.)

[anne]

Ah, I understand now what nonsense this book of the year is, as the nonsense of the story. Me, I like the idea of being able to see a doctor when I am worried about my health and I like the idea of all sorts of tests when my doctor, who I trust completely, dating does that, thinks tests are needed.

The heck with rationing my medical care, ration the hideous occupation and war in Iraq and I will visit my doctor any and every time I wish, and I may well go more often now. Ration that, and I despise green tea.

What rubbish.

[JRossi]

James Kroeger, Time is of the essence in my job.Differential diagnostic computer programs simply take too long for practical use. Maybe someday they'll be better, but as for now, I fart around with the computer in my office for too much time already. Also, patients want a human practitioner. It is a reality of human psychology, so you can't get rid of the doctor or PA or NP. Do you propose to have a computer operator doing the doctoring? I wouldn't bet on that horse.

[anne]

Remind me never to bother to describe the mild gastric distress that struck me in reading such rubbish. Every time I read such rubbish about the need to ration my health care, I find another reason for a doctor's visit.

Hey, Oscar, little Betty is bleeding from the ears. Got any green tea? Duh.

[anne]

About France, by the way, I never was in a country where people so loved to swill drugs and nag doctors. Try rationing French health care and notice what happens. August, though, better not look for a doctor in Paris.

Mildred's turning blue. Green tea?

[anne]

About France, by the way, I never was in a country where people so loved to swill drugs and nag doctors. Try rationing French health care and notice what happens. August, though, better not look for a doctor in Paris.

Mildred's knees are turning blue. Green tea?

[JRossi]

Your local computer operator sees you for a problem: Hoarseness. Just collect the history. What history? Taking a history is a longer process than I thought it would be. How do I know what questions to ask? Oh, I forgot one. Better go back into the room and ask the pt. Same process with the physical. Lab tests? My God, there's a whole pamphlet full of them! Maybe I should just order all of them. Don't worry about those type I ( or is it type II?) errors I heard about in my "Everything you need to know about medicine" correspondence course.
Well, sir, we're finally done and know it's taken a couple hours, but you'll be pleased to learn that you probably have a cold and not laryngeal sarcoma, ectopic thyroid tissue, or ovarian carcinoma metastatic to the throat.

[paine]

mark:

"profit maximization by health care providers .."

i suggest u use another more general term then
profit maxers
perhaps revenue max might come closer
most doctors fit that as their goal seeking better
then profit max
and hospitals that are npos
ie more like ...universities
might fit that goal seeking better too
"piece workers "
kinda has that flavor down pat
so long as one realizes
unlike a factory piece worker
the fees prices and other charges
are not set from above by a profit maxer
but self set by complex forces
of spontaneous emergence

[paine]

"too much like the perfectly competitive model"

not so
the firm here
a doctor would cry libel
he/she is not a profit maximizer

maybe some other doc is well
a net revenue maximizer

the petty commodity production of doctors
fits the pcm
worse by far then farmers
or shop keepers
or households
inas much as they are
in the people's job time selling business
or
the human factor producing "reproduction" business

[Jay]

"The heck with rationing my medical care"

I've never been to France, but I'm going to go out on a limb and claim that there is a finite supply of GP's, specialists, etc., therefore your above statement is deemed "rubbish".

[save_the_rustbelt]

"Brownlee's alternative is to turn doctors into salaried employees charged with doing the job of keeping people healthy, rather than into fee-for-service professionals whose level of compensation depends on how much treatment they prescribe."

This has been tried, and has been largely unsuccessful, with the exception of hospitalists in some specialties. Often only largely medical centers can afford such an arrangement.

Put a physician on salary and the treatments do go down, as the amount of golf goes up. And try to find an orthopaedic surgeon on salary who will climb out of bed at 3:00 am.

I agree with Anne on this, I trust the physicians.

However, based on close up experience I would estimate that at least 25% of CT scans and MRIs are purely defensive medicine. Good news, per unit costs are going down.

[save_the_rustbelt]

The OB fee for a vaginal delivery, to the best of my knowledge, is not increased when an episiotomy is performed.

An episiotomy is performed to prevent tearing and future dysfunction which might require surgery, not to buy the OB a Mercedes. If there is an increase it is not very much (delivery fees are very low considering the risk for the physician).

And as to spinal fusion, there are fusions of two vertebrae for pain control and then there are major fusions for scoliosis. If there is any increase it would be for the more minor fusions, which are normally done only after several attempts at more conservative treatment.

(The prettiest surgery I ever witnessed was a rod fusion to correct a 30% scoliosis in a 13 year old girl. Saved her life and gave her a normal life, damned near a miracle.)

The devil is in the details, and most commentators have no idea the details. Especially Shannon Bronwlee.

And don't get sick in France in August.

[JRossi]

Even though no one asked, here are some of my ideas. I do not suffer under the delusion that medical nirvana would ensue if these came to pass or that these suggestions are even politically possible at this time.
1. Institute universal health insurance through the government. Health insurance companies are parasites. Liquidate them. I sympathize with those who would lose their jobs, but at least they'd have health insurance.
2. Regulate drug and medical device companies. Give them enough profits to keep them in business. Their balance sheets should, to some extent, under the influence of their patients, through the patients' elected representatives.
3. Put doctors on salary for the vast majority of their compensation. Sure, if a young surgeon wants to take extra call for an old surgeon, pay him some more, but do not make the compensation depend on doing more operations. Pay health workers enough to keep them on the job and to attract enough young people into health care.
4. Regulate doctors' activities through formal peer review. If a salaried MD is giving too much or too little or inappropriate care, sanction him.
5. Ration health care explicitly and transparently on the basis of effectiveness and equity. Community health care workers, academic MDs, patients, economists, politicians should all have a place at the table.

Health care is a difficult business, and I do not expect to ever see the American people dancing in the streets celebrating its joys. But it can be better than it is now.

[anne]

Funny thing about France having superb medical care at far less cost than we do, and even, be still my heart, having a better doctor to population ratio. A terrific health care system, but we are not capable of understanding what it means for a country, namely ours, to even allow 4.6 million veterans and family members to go with no health care insurance. Patriotism extends only so far, I suppose. Should I count off the other American categories lacking health care protection?

The idea of needing to ration health care in America is bizarre, but happily not mine. I pledge to abuse every ounce of my coverage, and more.

[anne]

Thank you, J Rossi, but single-payer health care insurnace would be enough. Workers needing to move gradually from the insurnace sector woul have to be provided for, but the saving woul make that readily resolvable.

[anne]

Remind me to have my "d" key fixed or to get another lap-top computer which ever comes before.

[save_the_rustbelt]

jrossi:

I have mixed emotions. The chaotic transition would make me very rich, but I am not certain I would like the outcome.

If this were 1957 or 1967 the transition would be easier, but we are way down the road from those days, way far away from your system.

One of my minor skills is writing transition plans, and single payer or any other major reform would be the mother of all transitions.

It would not be pretty.

(Anne is correct to a point about France, but I suspect underestimates the transition costs and chaos.)

[JRossi]

save the rustbelt, You might be right about both the transition and the outcome, but consider our current situation and trend. No easy answers.
Anne, We currently have rationing on an absolutely brutal scale, based on insurance status. I suspect and would advocate that rationing under universal care would be much less intrusive and would focus mainly on not covering treatments of unproven or no medical effectiveness.

[mrrunangun]

Our town's hospital had long waits in the ER and people were complaining. The hospital fired the old ER chief doctor and hired a new one. The new ER doctor says that the old ER doc paid his docs on a $/shift basis. No incentive to see more patients/shift, so they saw on average 1.8 patients/hour. The new doc paid the same crew of docs on a per case basis and they saw 2.6patients/hour. As a result, a shift of two docs working twelve hours increased throughput to 62 patients/shift instead of 43/shift before. Waiting times reduced by two hours. Be careful what you wish for in putting docs on salary unless you are willing and able to pay a lot more of them to get the same work done.

[jeff hoffman]

Billyblog: Medicare pays about $120 for an endoscopy with around $450 ($570 total) for the facility fee and in all likelihood your $2000 payment for that service involved the completely unnecessary and expensive use of an anesthesiologist (one more revenue stream for the endoscopist). About that CT: what if you had had early resectable pancreatic or gastric cancer? (incidentally, your CT also cost way too much if full charges were paid.) To perhaps put alot of this into perspective, bear in mind that the bundled Medicare reimbursement to a surgeon for cholecystectomy and all postop care as quoted to me recently is about $500.00. How much does the average economist think this work is worth? Here's part of a conversation in a doctor's lounge yesterday: Radiologist: " I read chest CTs on two 85 year olds this morning for pulmonary nodules. Now what on earth do you think their primary physicians are going to do with that information?" Internist: " Yeah I know it's pointless and it won't change outcome. On the other hand if I have an 85 year old and her family in my office it can be difficult to explain to them in 15 minutes why I'm not ordering the chest CT (to rule out cancer) that was suggested by the radiologist who found the nodules on the plain film I ordered for her cough. It's much easier to order the scan. I have 15 minutes and I can't pay my overhead if these complex patients and their families spend thirty minutes. " And this latter statement may very well be true. So the irony is that the CT scan ordered by the primary doc was possibly suggested by the radiologist complaining about it. The radiologist reads a film. He sees a few nodules. He reflexively suggests that they are indeterminate, might represent neoplasm and that consideration be given to further CT evaluation. Much later, as an afterthought, he has the insight to realize that 85 yr olds with such findings aren't getting treatment; at this point it's time criticize the internist, who is in a difficult position. "What? Mom may have cancer? and you're not going to order a simple CT?!!" This is how large sums of money are spent in medicine and some docs are much better at spending it than others because of intellectual laziness, little backbone, anecdotal practice bias, poor training and the like but not necessarily for monetary gain. STR is correct about salaried physicians, in my view. It may surprise those who bemoan "the doctor's lobby" that there are really many such factions each representing various subspecialties, some of which advocate single payer (American Society of Internal Medicine, for example), others of which may have had better lobbyists (and payed more to their congressmen) and want no part of change. Maybe JRossi's subspecialty is filled with those purely motivated by altruism, or maybe they didn't pony up for good lobbyists, but most young primary care MDs I meet these days are unhappy with their carreer chice and that is a shame. As far as rationing is concerned, with each decade increment in age the healthcare expenditures rise in a very nonlinear steepening curve and what is appropriate to the care of a 65 yr old no longer necessarily applies to an 85 yr old, but too little attention is payed to that fact. You can call it rationing or letting mother nature take her course, but much closer attention needs to be paid to this part of the equation, and common sense. Finally, Brownlee's article is remarkable in lauding the Mayo clinic as a bastian of healthcare efficiency, insofar as that institution opted out of Medicare assignment several years ago- doesn't reimburse enough to pay their bills, apparently.

[anne]

STR:

Agreed completely, that a dramatic change in insurance structure would have to be gradual. I would prefer simply allowing an expansion of Medicare while private insurers are allowed to compete possibly even with subsidies to private insurers for a carefully defined period. Ending private insurance would not be politically possible or reasonable.

Massachusetts, however, which is seeking universal insurance which is wholly private according to the data I am trying to interpret will almost certainly fail to be either universal or to limit costs in any reasonable way. The problem is not doctors, not hospitals, not medical equipment or drug makers, not rampant demand for frivilous services, but administrative costs.

[anne]

J Rossi:

"We currently have rationing on an absolutely brutal scale, based on insurance status. I suspect and would advocate that rationing under universal care would be much less intrusive and would focus mainly on not covering treatments of unproven or no medical effectiveness."

Agreed, and completely sensible.

Adding to Jeff Hoffman's comment:

I am concerned with administrative cost reduction and gradual rationalization of delivery costs rather than with worrying about what we cannot presently afford and a focus on limiting delivery of services. Japan is affording health care for a population aging far faster than ours. So too, we can afford what Japan can afford.

[anne]

http://www.nytimes.com/2007/12/13/opinion/13druckerman.html?hp

December 13, 2007

Postpartum Impression
By PAMELA DRUCKERMAN

PARIS

I HAD a chance to think about the American health-care debate recently, while I was undergoing a procedure that's mostly paid for by the French state: re-education.

This has nothing to do with adult learning, or with those work camps organized by the Khmer Rouge. It's a girl thing. After a woman has a baby, perineal re-education shapes up her stretched-out birth canal. It also strengthens her pelvic floor for the next child, and helps keep her from leaking a little bit every time she sneezes. My doctor prescribed 10 sessions of it after my daughter was born. (American doctors typically suggest just doing some Kegel exercises, if anything.)

Where do America's presidential hopefuls stand on re-education? I think it's safe to assume that no Republicans would think the government should meddle with my pelvic floor. But if a Democrat wins the White House next year, the United States may be on the road to having a national health system à la française. Could re-education be far behind?

In France, making mothers good as new is a matter of national interest. The state health system pays 60 percent to 100 percent of the cost of re-education for all women after they give birth, and private insurance plans typically cover the rest. I finally solved the mystery of how Frenchwomen fit back into their skinny jeans six weeks postpartum: the state pays for abdominal re-education too.

My re-educator, a slim Spanish woman named Mónica, is technically a masseuse-physiotherapist, but I've come to think of her as a sort of Pilates instructor for the below-the-belt region. Not even my mother was ever this interested in my bathroom habits. Our first session begins with a 45-minute interview, during which she asks me earnestly how often I urinate. Not even my mother was ever this interested in my bathroom habits.

After the interview, Mónica slips on surgical gloves, applies some gel, and leads me in what I can best describe as assisted crunches for the crotch, in sets of 15 ("... and up, and relax ..."). She tells me to close my eyes so it's easier to isolate the muscles. When I peek, she's looking off into the distance in a state of intense concentration. I'm suddenly grateful that she hadn't asked me about the area's other main function.

Afterward, Mónica shows me a slender white wand — the kind of device you might have seen for sale in Times Square a decade ago — which she'll introduce in the next phase. The wand will add electro-stimulation to my mini situps. By the 10th session we'll be ready to try out a kind of video game, in which sensors on my groin measure whether I'm contracting the muscles enough to stay above a running orange line on the computer screen.

I don't doubt the rewards of re-education, but what about the costs of a system that would provide such a seeming luxury? Well, France spent $3,464 per person on health care in 2004, compared with $6,096 in the United States, according to the World Health Organization. Yet Frenchmen live on average two years longer than American men do, and Frenchwomen live four years longer. The infant mortality rate in France is 43 percent lower than in the United States.

The French bureaucracy isn't so bad either. Typically you pay the doctor in full, then you or he sends a one-page form to the state health system. The state wires its reimbursement right into your bank account. If there's anything left on the bill, it sends that to your private insurer, which wires its own payment into your account....

[Lafayette]

Article: But if a Democrat wins the White House next year, the United States may be on the road to having a national health system à la française.

It works every time

Er ... in your dreams, madame.

NO PRESENT CANDIDATE is proposing National Health Care that is anything remotely similar to what the World Health Organization calls the best national health system globally.

They are proposing MORE OF THE SAME, just extended to those not covered. "More of the same" means expensive health care that has to be covered, somehow, out of federal funds. (Hey, somebody has to pay for it! In the end, it's you and me, however they pitch a solution, that must pay the piper.)

So, the AMA is staying quiet, because the candidate plans espoused just bring more clients to their constituency waiting rooms. The AMA is not calling out the K-street warhawks to bewail "socialized medicine"; which would be its reaction if any one of the present candidates were really, truly proposing a French model of National Health Insurance.

Ever wonder why the AMA was so shrill about Hillary Plan 1, and is so quiet about Hillary Plan 2? Think about it. Hillary Plan 1 called for HMOs (Health Management Organization) mandating of medical practice pricing. (Price caps that would have contained the spiraling cost of Health Care.) That would affect directly the income of the entire AMA membership.

Plutocratic government is a political management where the rich promote the rich, and the rest be damned. In their mental framework or values, there is no place for Public Services that deliver to a larger part of the national population that which (the French think) is their birthright, decent Health Care. (Seven out of the top 15 countries in the WHO survey were European. Have they ALL got this concept of Public Service Medicine wrong?)

Oh, we've got money for sandbox wars in the Middle East. And, we've got money for hi-tech toys-for-our-boys. And, we've got money for a Home Defense system that hasn't yet caught one terrorist in action. And, we got money for oil exploration in Alaska. And, and, and ...

But, there is NO MONEY to make national health care affordable and accessible to the larger part of the nation's population. Nope, those dummies should all "jess go to the ER!".

It's insane. So, no political candidate will touch it with a ten foot pole -- and certainly not any Republican candidate. They will promote to the electorate palliatives that SEEM to be solutions, in hopes of suckering their votes.

It works every time ... a democratic nation gets the leadership it deserves, the one it voted into power.

[Lafayette]

anne: About France ... I never was in a country where people so loved to swill drugs and nag doctors.

But, if you live in the US, you are ALREADY in such a country. The Americans and the French are, by far, the best pill-poppers in the world.

anne: Try rationing French health care and notice what happens.

The problem is not the same. The problem in France is abuse, not inaccessibility or lack of affordability. There are plenty of doctors in France and all GPs practice medicine the same way -- they proscribe medication. "Numerus Clausus" will determine the number of pharmacies in a given area -- like liquor stores stateside.

In fact, you will find in a pharmaceutical outlet stateside prescription-free medication that can be purchased ONLY with a doctor's prescription in France. About all that a supermarket can offer in France is herbal medicine and aspirin. (The entire health care system is locked up, but that's the way it works. The state negotiates the cost of medication with the various pharmaceutical firms.)

anne: August, though, better not look for a doctor in Paris.

Take your August vacation on the Riviera? ;^) No, don't do that ... it's hell from July to the end of August.

For immediate medical service, just go to any ER and you will be attended to in August. If you cannot, there is a "SAMU" (ambulance service) with a national phone number and, more than often, it arrives with a young intern aboard. And, there are doctors who will be on stand-by (even in Paris in August) for a home call.

If your need is more serious, yes, you will have to wait until the sacrosanct month of August is behind you. But, that is also true in most parts of Southern Europe.

Just make sure you have checked with your home insurance company to make sure you are covered in France. Otherwise, you need your National Health Card (Carte Verte), which can be made available (to visiting students/professors, for instance).

Otherwise, you need a permanent resident status to have the card free, gratis and for nothing. Then you will be covered for ALL medical services (but not at 100%, to avoid the abuse there has been in the past).

As good as it may be, it was not good enough to stave off the 19,000 deaths that occurred in an unbearable heat wave about five years ago. It was the "perfect storm", so to speak. It occurred in August, when most people were on vacation and exacted its toll upon the aged suffocating under the sun in their apartments/homes where they died of dehydration. Usually looked after by either a periodic domestic servant or their family ... these latter were "on vacation".

[Lafayette]

JK: Most researchers work for a salary and would receive one if they worked for the governemnt.

And, I have never understood why the government cannot subsidize such R&D at selected universities across the nation, employing graduate students in well managed programs?

Any successful discoveries could be given to manufacturers for testing and ultimate product marketing (since they have the established network for such), but with an agreement on profit-sharing (which would return funds to the university).

[James Kroeger]

This has been tried, and has been largely unsuccessful...It is surprising how uninformed you are on this issue. Please spend some time familiarizing yourself with Britain's [relatively] pure Socialized Medicine model, the National Health Service.

The Brits spend less than half the amount of $$ on their health care that Americans spend, but receive equal or superior health outcomes. In 2002, UK citizens spent only about 8% of their GDP on health care ($2,160 per citizen). This compares to the approximately 15% of GDP that Americans spent on health care that year ($5,267 per citizen). Their doctors are on salary and they even make house calls. According to polls, the Socialized Medicine model continues to be very popular with the British people.

The only real problem is that they have underfunded the NHS, which means that there are waiting lists for elective procedures. (In America, we ration this kind of health care by simply pricing poor people out of the market.) If they were to spend the same percentage of their GDP on the NHS that Americans spend on their health care, all of those waiting lists would surely disappear.

[JRossi]

mrrunandgun.....Getting the incentives right is no easy task. Slacking off on the one hand, expensive and dangerous overtreatment on the other. Sometimes you gotta choose yer poison.

[JRossi]

jeff hoffman, Excellent post about the conversation in the docs' lounge. That is how it often works at the microlevel. And my specialty (Fam med)is filled with more than its share of altruists and our lobbyists do suck, and our specialty is dying, and the med students are heading to rads and derm. And $500 for a chole is a slap in the face. Google general surgeon shortage.

[anne]

About France ... I never was in a country where people so loved to swill drugs and nag doctors.

"But, if you live in the US, you are ALREADY in such a country."

Judging by the advertising alone, I would expect this is correct but I seldom hear the conversations of who is using what that I routinely heard in France. (Not that this means much.)

[mrrunangun]

"JRossi says...
mrrunandgun.....Getting the incentives right is no easy task. Slacking off on the one hand, expensive and dangerous overtreatment on the other. Sometimes you gotta choose yer poison"

Also in the way of incentives, our new ER doc says that on average, an ER doc gets sued for malpractice in the US once in every c.5,000 patient visits. If his 2.5 patients/hour is right, that is about one suit every year on average. It may be another reason why docs slack off of volume production if the countervailing incentives aren't right. {He didn't say they were guilty of malpractice that often, just that they get sued that often.}

I'd be more comfortable with an NHS salary structure for docs if there were a group of salaried government workers with no private sector prospects or competition who were renowned for their productivity and efficiency. Somehow I doubt the doctors will be any different if similarly situated to salaried government workers now.

[jeff hoffman]

Anne: Your comments are always refreshing. I would like you to meet some of the nice people currently residing at my workplace. Mr. S. Is an 82 year old who has undergone radiation therapy and surgery for advanced prostate cancer this year and has now been in the hospital for almost one month with an (unrelated) intractable case of inflammatory bowel disease involving the entire left side of his colon for which a hemicolectomy and stoma placement would have long ago allowed for his discharge, a simple solution unpalatable to his family. He has failed high dose iv steroids and is now roughly 20% better on infusional therapy with a monoclonal antibody that costs greater than $20k per year, which would be a bargain if successful, considering that he is sitting in a $1,000 per day hospital bed. Put on a pair of gloves and shake his hand, and if you come back next week and do so again he will for all intents and purposes again be meeting you for the first time, considering his advanced dementia. A few doors down in the ICU is Mrs. C., an 83 year old who came in with biliary obstruction and who got palliative stenting to treat her pain and intractable severe itching. The hospitalist, bless his heart, would like her to go downstairs to invasive radiology and have a needle biopsy of what can only be a pancreatic tumor at a cost of hundreds of medicare dollars, a procedure risking pancreatitis. He has called in a surgeon despite my advice to the family that if someone ignorant enough to attempt a Whipple procedure on an 83 year old were to do so, much of her remaining (average four months of) life would be spent recovering. No need for the formalities here; I've visited her 4 times and her advanced dementia does not allow her to recognize me as of yet. So don't bother with the hand shaking. Lets finally visit her neighbor up the hall, Mr. H. who is a delightfully demented gentleman from up North who developed a severe case of ischemic colitis and wound up in the ICU in restraints, gravely ill but with a recoverable disease. I suggested to his daughter that at some point he might be transportable back to Canada, at which point she became teary eyed and stated flatly that he would not receive the same level of care there, where, incidentally she is on faculty at McMaster University School of Medicine. And I believe that. In hospitals throughout this country we have a strong bias to value life over dignity and do things with, for, and to demented octagenarians and their older siblings that I strongly suspect would be considered unpalatable in places like, say, Japan. Or perhaps even Krugman's favorite VA hospital. If the federal government under the auspices of medicare had their own hospital system vis a vis the Public Health Hospitals of yore, staffed them with geriatricians and like minded subspecialists, and mandated that recipients over a specific age be treated at these points of service, they could perhaps control costs and offer better quality to the ever expanding and by far most expensive recipients of health care in our country. And I can assure you that Mr. S, Mrs. C. and Mr. H. wouldn't know the difference.

[jeff hoffman]

Lafayette: I was once told that no practicing physicians were consulted in the formulation of H. Clinton's and I. Magaziner's original healthcare proposal. IF TRUE, kudos to the AMA for not signing on with a plan formulated as if its members were assembly line workers.

[Lafayette]

anne says ... About France

Your response prompted me to look for some updated information.

I found it in the OECD's report "Heath Care at a glance - 2007". Unfortunately, the US is mysteriously missing from the one piece of information (publicly available) that I thought indicative of pharmaceutical usage, namely anti-depressants.

Go figure. I am not about to buy this document to find out why. Frankly, I cannot understand why a non-profit institution like the OECD has to sell such information pertinent to the public's understanding of Health Care policy. Is it only for the policy wonks (or is that wankers?) who can have it purchased for them?

NB: In fact, France is not as badly positioned as I had thought.

[Lafayette]

JH: IF TRUE, kudos to the AMA for not signing on with a plan formulated as if its members were assembly line workers.

Oh, yes, indeed, JH, kudos to those who are ripping off the public at service prices clearly out of line with other developed nations by a margin of four-to-one.

I dare not ask you what your sentiment is about Income Inequality in America. You'd come up with some bunk excusing quasi-monopolistic pricing as "God's will"? "The rules of the game"? "Survival of the fittest"?

Whatever. It doesn't hold water in terms of services that are both affordable and accessible to the largest part of the population (which distinguishes that market from any other and renders it a "Public Service") -- just because a very small minority think they merit ripoff market prices (and BMWs).

Yes, yes -- we all know. Its because they all went through hell for their diploma and final accreditation.

Health Care is NOT a market, it is a Public Service; and its purveyors should align prices according to other Public Services. Not the same, but similar.

[Lafayette]

JH: If the federal government under the auspices of medicare had their own hospital system vis a vis the Public Health Hospitals of yore, staffed them with geriatricians and like minded subspecialists, and mandated that recipients over a specific age be treated at these points of service, they could perhaps control costs and offer better quality to the ever expanding and by far most expensive recipients of health care in our country.

America's benchmark Health Care

That's a good start. Then extend it to the rest of the population by expanding Medicaid and employing single-payer HMOs.

Not only that, but make Health Care university diplomas tuition free, and students participating paid a stipend. Have them also employed according to the federal Civil Service payment structure, but with a honorary amount to compensate for their period of internship.

Yes, indeed, have the clinics and hospitals necessary paid for out of state and government resources to assure that accessibility is uniform across the country. Let's create a norm of so many GPs and Specialists per geographic headcount (sufficient to assure adequate accessibility) -- and these HC practioners would not need to spend one dime to set up their clinics/offices.

And, let's introduce school courses that teach our children basic Health Care facts as well as institute other preventive medicine programs that are far, far cheaper than remedial Health Care.

All that would cost about a third of what the Iraq war costs annually for the past five years. Reduce the DoD budget by a third and increase the DoH budget by that amount ... and presto! The money is there.

And, all that would give America a Health Care system that approaches (key word, "approach") that of benchmark HC systems in Europe.

But, I do dream, don't I. "Socialized Health Care" in the Land of Free Enterprise? Bah, humbug!

[Patricia Shannon]

http://www.msnbc.msn.com/id/22357873/

updated 1 hour, 5 minutes ago
GLENDALE, Calif. - A 17-year old died just hours after her health insurance company reversed its decision not to pay for a liver transplant that doctors said the girl needed.

Nataline Sarkisyan died Thursday night at about 6 p.m. at University of California, Los Angeles Medical Center. She had been in a vegetative state for weeks, said her mother, Hilda.

[Patricia Shannon]

http://www.cbsnews.com/stories/2007/12/20/health/main3634686.shtml

ATLANTA, Dec. 20, 2007
(AP) Uninsured cancer patients are nearly twice as likely to die within five years as those with private coverage, according to the first national study of its kind and one that sheds light on troubling health care obstacles.

People without health insurance are less likely to get recommended cancer screening tests, the study also found, confirming earlier research. And when these patients finally do get diagnosed, their cancer is likely to have spread.

[Jeff Hoffman]

Lafayette: This thread originated with an article about how practice styles are variably costly with regional differences. These are very significant. My pithy examples are more common in my opinion in Florida than they are in Minnesota (I've practiced in both places). Last time I checked, age and severity of illness matched medicare reimbursements for care was 1.7 times that of Minnesota in Florida, and that's with no difference in outcomes. You can rail all you want about those overpayed physicians but harking back to the general surgeon and his $500 bundled medicare payment for cholecystectomies, how many of those does he need to do to cover his malpractice insurance ( I pay $40k per annum in a less litigious subspecialty); you do the math. Re: distribution of wealth issues, we have them across the board in medicine where pain managers can rake in one million a year and GPs that I know can make less than the drug reps knocking on their doors. That is a major unaddressed issue and I have no idea why reimbursements across subspecialties aren't adjusted by medicare appropriately except for the efforts of the subspecialties individual lobbyists. I am not disagreeing with much of what you say but your overly simplistic view of things doesn't take into account that medicare reimbursements don't generally cover the operating costs of the hospitals that they make payments to, irrespective of the physician reimbursements. Rationing and increased expenditures will be needed to afford universal healthcare in many experts' opinions.

[Lafayette]

JH: ... your overly simplistic view of things doesn't take into account that medicare reimbursements don't generally cover the operating costs of the hospitals that they make payments to, irrespective of the physician reimbursements.

Good, factual rebuttal. Thank you.

I posted not long ago a study made of the exact nature of Health Care costs. Blame whatever that suits as the principle costs, but that study (done in California) showed manpower being the most important portion of the cost.

Let's presume that insurance coverage is a major culprit, but that too is of entirely American-specific nature. Juries do not fix damages in France. Judges fix them based upon the extent of the damage as a function of real cost estimates of the disability being reimbursed. The maximum is total disability, meaning either death or inability to work -- which is determined by the victims career-span income. Damages are reparable and not punitive, unless willfulness of the doctor is proven.

As for salaries, let us first consider that of GPs. Go here (BLS data) to see that the GPs mean salary in the US is very close to $150,000. Now, go here to see that most engineering professions earn a third of that amount. Look elsewhere in the list and you will find that hi-tech systems analysts earn two-thirds of GPs. That
Biological Scientists earn 42% of a Doctors mean salary. And that our heroes, Economists, earn 55% of that same salary.

I think you get the point. The GP is one of the highest professional earners in the US. So, if your contention is correct, that malpractice insurance policy must be astronomically costly -- to bring their net down to the level of other professionals. (In fact, I suspect strongly that the figures cited are net of all profession-related costs.)

Rationing and increased expenditures will be needed to afford universal healthcare in many experts' opinions.

And, I think rather not. Regulating Health Care practitioner service pricing is the only way to bring costs down. Of course, that argument is conditioned upon the other propositions that I made above regarding the "operational costs" of a GP practitioner, including their education/training and installation.

As well as malpractice damages caps. Tell THAT to John Edwards, who made his fortune as a lawyer fighting malpractice suits. Who paid for his fortune. Not the insurance companies he defeated, because they just past the cost onto consumers. No flies on the insurers. Ever.

[Patricia Shannon]

One cause of overtreatment I haven't seen mentioned is many patients' insistence on getting an antibiotic prescribed for infections caused by viruses, which are not affected by antibiotics. Antibiotics kill bacteria, not viruses. Unneeded antibiotic prescriptions hasten the emergence of resistant bacteria, so that the antibiotics don't work when they are needed.

[Lafayette]

PS: Unneeded antibiotic prescriptions hasten the emergence of resistant bacteria, so that the antibiotics don't work when they are needed.

Worse yet, the overuse of antibiotics will nullify resident antibodies that are employed to kill invading antigens.

They thus leave the body even more vulnerable. The use of common cold antibiotics too often is one such medication that does more bad inevitably than immediate good.

[Patricia Shannon]

Good point, Lafayette.

[JRossi]

Lafayette,
Comparisons among salaries doctors, engineers, economists are interesting but irrelevant. They of course take no account of the single most important reason why doctors earn so much compared with others of comparable education levels and barriers to entry-- difficult working conditions. Few would want to be a doctor for 50k or 75k per year, at least not in this country. You say open the borders and let foreign MDs in. Fine, they'd do it for a few years until they realized they were getting screwed. And their kids sure as heck wouldn't do it. Why on earth would an American with any brains at all doctor for 75k per year when he or she could do law, or engineering, or business with much less education or stress? Few would. We already have a shortage of 150k FPs here.
On the other hand, if we did pay MDs 75k per year, I'm sure health expenditures would decrease.
Hoffman, Another great post on the ICU.

[JRossi]

Lafayette, Nullify resident antibodies?I haven't heard of that. References if you please, in reputable English-language journals.

[Jeff Hoffman]

"Worse yet, the overuse of antibiotics will nullify resident antibodies that are employed to kill invading antigens." I'd like to see the literature on that.

Let's see the hourly compensation figures, MDs vs engineers. I work 13 hour days and 36 hour weekends when on call. This is excessive to me but I have to keep up with with the flow at multiple hospitals. Fortunately I do weekends every 5, but some primary MDs work harder. The bell curve for MD salaries in any subspecialty is to be expected wider than that for a 40 hour worker, since the amount of time they work varies.

If it costs 1.7X as many medicare $s to treat the same acuity patient in FL compared with MN, Lafayette's average Fl physician is making out quite well compared with his Minnesota counterpart, since (he states) salaries are the major cost. Afraid not. Look at National figures, not SoCal. Hospitalization tops salaries.

Ask any primary physician practicing for the last 20 years to compare his workloads and salary then and now. The former has risen markedly, the latter has diminished comparatively, yet the marked rise in healthcare costs in the last 5 years is largely their fault.

[JRossi]

People, if you wish to learn something about health care costs, re-read Hoffman's ICU post and doctor's lounge post Therein lie the keys to the problem with HC costs. Most people get old, and most people sick before they die, and medical care for people who are very old or very sick involves a tremendous amount of high-skill human effort, both direct and embedded. Should we give these people less care? Choose yer poison, America.

[Patricia Shannon]

http://health.yahoo.com/digestive-overview/antibiotic-associated-diarrhea/mayoclinic--1CA38BA4-1AD5-47B4-BFFE6A66CF08493C.html

Antibiotics first came into general use with soldiers during World War II. Since then, antibiotics have saved millions of lives. But like all drugs, antibiotics have side effects. One of the most common is antibiotic-associated diarrhea (AAD) a potentially serious condition that affects up to one in five people receiving antibiotic therapy.

Antibiotic-associated diarrhea occurs when antibiotics disturb the natural balance of "good" and "bad" bacteria in your intestinal tract, causing harmful bacteria to proliferate far beyond their normal numbers. The result is often frequent, watery bowel movements.

Most often, antibiotic-associated diarrhea is fairly mild and clears up shortly after you stop taking the antibiotic. But sometimes you may develop colitis, an inflammation of your colon, or a more serious form of colitis called pseudomembranous colitis. Both can cause abdominal pain, fever and bloody diarrhea. In cases of pseudomembranous colitis, these symptoms may become life-threatening.

Effective treatments exist for mild antibiotic-associated diarrhea, as well as for colon inflammation. In addition, taking concentrated supplements of beneficial bacteria (probiotics) or eating yogurt may relieve symptoms or help prevent antibiotic-associated diarrhea in the first place.

[Patricia Shannon]

Jeff Hoffman
if you are a doctor, you should know about the problem of antibiotics killing beneficial bacteria in the intestinal tract and female reproductive tract. (hope that is antispeptic enough for the spam filter).

[JRossi]

Patricia, I am a doctor, and I assume Jeff is too. The phenomenon of the killing off of beneficial bacteria by antibiotics, as in C. difficile colitis, is taught to first-year medical students. We MDs test for it not uncommonly in pts who have diarrhea after antibiotic treatment. Lafayette wrote about nullifying resident antibodies, a completely different (and, at least to me,unknown) physiologic phenomenon.

[Patricia Shannon]

I assumed (maybe wrongly) that Lafayette, not being a doctor, was not quite clear on the terminology and specific mechanisms, but that this is what he was talking about. I guess doctors, just like in any profession, are used to being around others who are knowledgable about their field.

[Patricia Shannon]

This looks like it might be a perfect example of miscommunication between doctors and non-doctors (like patients).

[Patricia Shannon]

I have sprained my ankles either 7 or 8 times, at least 3 times each ankle. After a couple of times, I knew there was no reason to go to a doctor, nothing they can do, it just takes time to heal. But friends and co-workers would sometimes badger me to see a doctor. One time to placate somebody I called a doctor, and the doctor confirmed there was nothing he could do for a sprained ankle, which quieted my friend. (I haven't had a sprained ankle in years. I think the tissues (ligaments or tendons?) are too stretched out to sprain easily anymore!)
When I fell and hurt my rib, I believed I broke it. I wasn't going to bother going to a doctor because, while it hurt horribly, it didn't appear to be piercing my lung or anything. My friends insisted I go to a doctor and get wrapped. So I went to a doctor, he agreed I probably had a broken rib, and said they no longer wrap them routinely, because it constricts the breathing and can cause pneumonia. He asked if I wanted an x-ray. I asked if it would make any different in treatment, and he said no, so I said no. I'm sure a lot of people would have insisted on an x-ray, which would have been overtreatment, but not one the doctor really wanted. It did heal on its own after some months.
If I get the flu, some people will ask me if I went to a doctor. The flu usually doesn't need a doctor, but some people will always go.
So I see a lot of overtreatment as being due to patients, not all due to doctors. I have no idea of the percentage breakdown.

[Patricia Shannon]

http://www.eurekalert.org/pub_releases/2007-12/bu-far121907.php

Public release date: 19-Dec-2007
Contact: Laura Gardner
gardner@brandeis.edu
781-736-4204
Brandeis University

Farmers and ranchers pay top dollar for inadequate health insurance protection
Access Project and Brandeis University report from Great Plains states finds health care costs threaten farmers and ranchers
Waltham, MA—A new report issued today by The Access Project and Brandeis University found that farm and ranch operators, like many Americans, are seriously challenged by the cost of health care. While the vast majority of farm and ranch operators had insurance coverage, one in four said that health care costs contributed to financial problems for their families. The report, How Farmers and Ranchers Get Health Insurance and What They Spend for Health Care, shows a link between how farm and ranch operators get coverage and the amount of their overall healthcare expenses.

The report found that farm and ranch operators are far more likely to purchase coverage on the individual market than the population at large. It cautions that families forced to rely on this market may have no alternative but to pay high premiums for policies that also include significant deductibles, thus resulting in high overall costs for those who experience illness. Research has also shown that Americans delay seeking care due to medical costs and steep insurance premiums.

“Family farmers and ranchers struggling to maintain their operations are not well-served by the current health insurance marketplace,” said Carol Pryor, lead author of the report and Senior Policy Analyst at The Access Project. “We found that those purchasing coverage directly on the individual market pay the highest premiums for coverage that often leaves them financially exposed.”

[JRossi]

We don't routinely Xray suspected rib fxs unless we suspect multiple fxs. Most of my pts (80-95%)will defer Xray when I explain that Xray is not needed. Influenza can be treated with anti-virals like Tamiflu if caught in the first 48 hours. Improvement is statistically significant but often not that important clinically. And tamiflu is expensive. I use it mainly for high risk pts--asthma, diabetes, immunodeficiency, etc. Google tamiflu if you're interested. When I get the flu I take ibuprofen and soup. Flu shots are an excellent idea, especially for those with underlying illnesses, the very young and the aged.
Overtreatment is a complicated phenomenon and probably varies by diagnosis, pt population and dr. population, and with the times.

[jeff hoffman]

JRossi, thanks for the comments , my earlier posts being efforts to put the phenomenon of overtreatment into human terms. We are talking about withholding costly and unnecessary care. I personally think that more emphasis on the construction and implementation of best practice algorithms in and out of the hospital is necessary, especially in an environment in which not only physicians but their PAs and ARNPs make variable and sometimes seemingly cavalier decisions on how to spend scarce resources. P Shannon, thank you for your individual effort at keeping health care costs down. Your microcosmic comment about others demanding x-rays gets to a part of the problem. About the unfortunate family farmer, his plight is not unlike many others in this country, and will improve if/when large corporate America in general has had enough of this health care system, I suspect.

[Lafayette]

I was interested in mean salaries of the medical profession. I culled this from the BLS statistics (for May, 2006):

Anesthesiologists -- $184,340

Family and General Practitioners -- $149,850

Internists, General -- $160,860

Obstetricians and Gynecologists -- $178,040

Pediatricians, General -- $141,440

Psychiatrists -- $149,990

Surgeons -- $184,150

Physicians and Surgeons, All Other -- $142,220

Physician Assistants -- $74,270

Podiatrists -- $118,500

Not a bad, eh?

[Lafayette]

JR: Comparisons among salaries doctors, engineers, economists are interesting but irrelevant.

A bit predictable, that response.

And, off base. Doctors walk on water? Uh, uh.

Should we give these people less care?

You are a practitioner in denial, JR. Health Care should not cost more than 4 times other developed countries that have a similar responsibility to their aged and poor. It's a Public Service, not a meat market.

Yes, GPs and most specialists earn less in Europe because the "market" is not "free" to set its own prices. Interns working for state-run hospitals? Why state-run hospitals? Because the notion prevails that a Public Service is one that must be accessible uniformly to all -- which in a "market model", would not happen.

Like firefighters -- if they were free to chose where they work and the remuneration they are paid, wouldn't they rather work in the Fire Station closest to Wall Street rather than Dubuque, Iowa? (And, in case they were negligent and didn't put out the fire, wouldn't they surely want malpractice insurance?)

NB1: Some European surgeons are in great demand and they make similar amounts -- as those noted in a separate comment above -- because they opt for a non National Health Insurance practice. They are mostly plastic surgeons, but they are not the only ones.
NB2: I can introduce any American hospital manager to a LARGE number of competent specialists (really, first-rate) who would jump at the chance of working for the salaries listed in my previous post. In fact, they'd probably go at half those salaries mentioned.

[Lafayette]

PS: I assumed (maybe wrongly) that Lafayette, not being a doctor, was not quite clear on the terminology and specific mechanisms, but that this is what he was talking about.

Lafayette is not a doctor.

He was just trying to explain what he had heard on a French TV health program, in France. Maybe antibiotics don't kill antibodies. (Next time I come across an antibody, I'll ask. ;^)

There are prime time TV commercials trying to convince people that antibiotics are not necessary to treat EVERY illness. In hopes that people will ask their doctors first if there are some alternative solutions that might not be more appropriate -- if they have had recently antibiotic treatment. The effort is intended to raise public consciousness regarding some recognized, untoward "side effects" of antibiotic over-treatment.

[JRossi]

Lafayette, Antibiotic overeuse is a bad thing. Universal HC should be available.
But in a lot of ways, you are a poster in massive denial. Denial that the idea of comparable worth is a recipe for shortages in some fields and gluts in others. This is Econ 101, Lafayette, not brain surgery. Denial that US culture is different from other cultures and that paying MDs 50k per year would absolutely collapse the health care workforce. Denial that working conditions play a crucial role in labor supply and demand (Econ 101). Denial that the time and expense of education and the working conditions for MDs are in no way comparable to those of the other professions (respectable all )you compare with medicine (look up compensating differential). Denial that slashing MD salaries would not solve the problem of HC inflation, even if it gratified your sense of equality, because of obvious fact that although MDs control HC expeditures, most of those expenditures accrue to others. Look this up in Krugman's new book. This is basic information for anyone who wants to post intelligently about HC economics. Please re-read Hoffman's posts about 14 times if you wish to gain some insight into the true causes of HC inflation. Or you can continue on your path. Your choice. Whatever.

[JRossi]

HC costs 4 times as much in the US? You're making things up Lafayette. Kinda like the nullifying antibodies and the large number of competent specialists.

[Lafayette]

JR: HC costs 4 times as much in the US? You're making things up Lafayette.

You are pop into this forum to dally from time to time. Stick around, you might learn something about Health Care costs. The figure noted is widely quoted as about correct.

The other verifiable piece of information quoted often is that the 2000 study of the World Health Organization placed ten European countries in the Top Fifteen of Health Care systems. The US was, just ahead of Slovenia, as I recall, at 36th. (Note: All the European country HC-systems are government run. Must be a bunch of pinkos at the WHO!)

How could this be, you might ask. The two main criteria of that study where accessibility and affordability -- not just state of the art. And, in both those criteria, the US came out woefully inadequate.

You probably think like lead-head at the WH ... for health care "all ya needa do is go to ER". Watches to much TV, that one.

Strange for a doctor -- who should know better.

Next time in France, let me know. I'll show you a world class national health care system -- it was classified as N° 1 in the WHO's global survey.

Finally, yes, I have argued purposefully for "socialized" HC in this forum. But, you are not to worry. I believe I am wasting my keystrokes. It'll never happen in the US, not in my lifetime and not in yours.

So, keep cool Raoul; you've nothing to worry about. (BTW ... you drive a new BMW? My GP drives a ten-year old VW! ;^)

[JRossi]

Risky strategy, Lafayette, to make unsubstantiated claims and then change the subject, toss in a few irrelevancies here and there, bring up some topics that were not under discussion, throw in a few barbs. Creative if not very logical. But this guy is not buyin' the crazy that you're sellin'. See you on the next HC thread.

[jeff hoffman]

'Yes, GPs and most specialists earn less in Europe because the "market" is not "free" to set its own prices.' I can imagine that an uneducated reader would impart from this statement that physicians in the U.S. set the cost of their services. If so, here is a brief primer. The benchmark reimbursement rate against which all physician payments by insurers are compared is set forth by the US government-Medicare. When a physician contracts with an insurer to become a member of its provider panel the terms of payment are generally discussed as "% of medicare reimbursement". Let's take GPs as an example and a large provider like Blue Cross/Blue Shield. There tend to be more GPs than are necessary to constitute a panel to cover the lives insured by a large such company, and in any one location there are usually no more than a few major insurers, thanks to consolidation. Commonly but not always, this puts the GPs in a difficult bargaining position when negotiating contracts, MDs tending to operate in small independent groups competing with eachother. It is illegal,for example, for individual groups of MDs to share information and attempt to fix prices when negotiating with insurers. On the other hand, insurers are able to mine data available to them and sit at the table knowing exactly what their competition is paying the negotiating physician for his services. In this setting, the insurer largely dictates what is payed to the GP, it being a buyer's market that is dominated by a few players with all the requisite information to ratchet down as best they can their reimbursements. The unenviable position of the GP is probably best illustrated by the fact that it is not uncommon for them to be payed by insurers at a fractional rate of medicare (as in "Aetna pays me 80% of medicare"). Whether this fractional rate is above or below the benchmark medicare rate depends in large part on how scarce a commodity the individual subspecialist is in reference to the needs of the insurer. There are generally alot of GPs. Therefore it would not generally be accurate to suggest that GPs set the market price for their services , and I assume that the above-referenced quote was not intended to suggest such.

[Lafayette]

JH: I can imagine that an uneducated reader would impart from this statement that physicians in the U.S. set the cost of their services. If so, here is a brief primer.

Don't imagine. Market prices are those set by supply and demand. The S/D model for medical services is "warped" in the US, meaning the demand for such services outstrips its supply. In fact, this model is warped in just about every country, given the nature of the service.

Which is why "market prices" are higher. In many European countries, practitioners have the choice of charging "what the market will bear" or adhering to a price set by state authorities (and that covers "fair return" to the practitioner), which is why they are considerably lower than stateside.

Which is also the reason that coverage can be extended in a net that covers all citizens -- whilst in the US at any given time 16 to 18% of the workers have no coverage whatsoever.

In France, anyone can walk into a Doctor's waiting room knowing they will be paying $30 (at today's exchange rates). This nominal fee is rarely a barrier to accessing competent health care. So, they are "taken in", meaning symptoms are treated at the earlies possible stage.

Doctors do house visits and if, perhance, an ambulance is called -- in the larger cities it will arrive with an intern. Administration starts immediately, not some time later. And, the ER is not a palliative service, but the first step in a patients treatment of whatever malady they may have.

Should a malady by "serious", then the state will assume the total cost of (say, oncological) treatment. No need to dicker with private insurance as a middle agent. No need to sell your house either to get the treatment deserved.

Health Care is a birthright, not a business, neither a privilege. It should rightly be a low-cost, uniform Public Service accessible to all. When are you (plural) ever going to learn that simple fact?

NB: I am not implying that American doctors are guilty of monopoly practices, just that they are profiting illicitly from a "special market situation". And, that situation should be corrected.

[Lafayette]

JH: The unenviable position of the GP is probably best illustrated by the fact that it is not uncommon for them to be payed by insurers

Talk about botched priorities

You have put your finger on the other grievous fault of private Health Care. The fact that both the practitioner of Health Care services and the user must deal with an intermediary agent - the Insurer. (The other being cost, which I have pointed out in the previous posted comment.)

Why should this be? Is health care an "accident" for which insurance is needed? Oh, it is? Since when? Like fires or burglary, they are matter of "unfortunate happenstance"?

Not in my dictionary. Health Care is intrinsic to the human body, like maintenance to a car. You have insurance for Car Maintenance? You have a life-time guaranty from the manufacturer (your parents)? Of course not.

Health Care is, as I said, a birthright. All citizens of a nation have the right to expect proper health care as a Public Service -- like fire fighting, a judicial system, defense of the nation, air traffic controllers and host of other such services that are necessary to our existence.

If it isn't a Public Service for which accessibility and affordability is universally assured to a population, then a serious error has occurred in the development of that country. [And, yes, such a Public Service IS as expensive as it is an imperative. Besides, America has the money. It is simply being spent badly.]

In a few words, "they got it all wrong". And, there is NO proposition on the table of any existing PotUS candidate today that addresses the fundamental problems. There is no Change Agent, the world employed in business when a process must be altered because it does not meet the necessary standards.

Extending coverage simply enlarges the net at the cost of taxpayers, it does not lower the costs. It’s a boon for practitioners, who will have more clients and even less time per client.

We can spend billions to send a man to the moon a fight a useless war over in the sandbox, but we cannot provide universally accessible and affordable Health Care.

Let's talk about botched priorities.

[jeff hoffman]

Lafayette, if you want to engage in a serious discussion about this topic try to get your facts straight. I started to get a feel for your mindset when you managed to transform something that you think you heard on French TV into an authoritative statement of fact about a biologic phenomenon that you obviously know nothing about. Then there was the statement about salaries constituting the largest expenditure of U.S. healthcare dollars, based upon some SoCal study you think you remember (almost anyone could do better than this within three minutes of Googling). Then, to underscore a point, you stated that engineers in the US make 1/3 that of GPs. Look at the data YOU REFERENCED and go find yourself a schoolchild (circa 3rd grade) to do that math properly. OK, we get it, meticulousness is not your forte, especially when flailing away speculatively, like Don Quixote on a mousepad, about the car your blogging adversary drives. So be it. Keep pounding on that little drum of yours, as if there is anything novel to that, and making ridiculous remarks like "When are you (plural) ever going to learn that simple fact?", apparently unaware that large physician organizations including the American Society of Internal Medicine advocate single payer. In the meantime those of us who exist in the trenches of this rather broken healthcare system will continue to care for those who need our help irrespective of their finances, and that includes the month of August.

[jeff hoffman]

Incidentally, Prof. Thoma did the math regarding your misguided assertion that MD salary is a major contributor to cost on June 5, 2007, and summarized:"So the difference in physician salaries only explains $410 of the $2,943 difference in costs {between per capita US vs French annual healthcare expenditures} (about 14% - I should acknowledge that some of these numbers are from different years, but all are during or close to 2003 so that shouldn't make much difference). " Unless you can show that the period between 2003 and now is different (my own medicare reimbursement rate has been on unchanged for 5 yrs and will go down roughly 8% in 2008), you don't have much of an argument here.

[mrrunangun]

Within the past year, our town's hospital has taken over the practices of two small family practice medical groups who went or were going broke. Another larger such nearby group was taken over by a its town's hospital. A fourth may be nearly ripe for such an arrangement. The doctors seem happy to have a steady paycheck. From what I know of these instances, a good tradesman with an established reputation outearns many of our established family doctors hereabouts. This sort of thing would probably not be true of the specialists. As Dr. Hoffman pointed out, the doctors have had little or no fee raise over the past 5 years, but Medicare and the insurers cannot control doctors' business costs. The hospitals now have complete control over the doctors' referrals for tests, surgeries, hospitalizations, etc. The hospital can probably defray its expenses going toward the doctors by monopolizing their referrals for such profitable services.

[Lafayette]

mr: The hospitals now have complete control over the doctors' referrals for tests, surgeries, hospitalizations, etc. The hospital can probably defray its expenses going toward the doctors by monopolizing their referrals for such profitable services.

I presume the hospitals you refer to are "privately owned"?

So, why should you expect a situation that was other than that which you have.

I never tire of repeating it: Health Care is NOT a business. It is a Public Service ... like Firefighting or the Police. Only one helluva lot more costly, as it should be. Which is ample reason why the costs should be mandated by the state, or supervised by regulatory body consisting of both the representatives of Health Care practitioners and the government authority that (should be) paying the expenses (as done for Medicare and Medicaid).

Which leads to the notion that Medicaid should be extended to ALL citizens -- and supervised nationally.