Wednesday, July 04, 2007

My Solution

Fourth of July. Birth of a nation. Childbirth. Health care. Seems a good day to step into the breech. As it were. Is our health care system salvageable? Does it have a pulse?

Several years ago, the clinic at which I worked signed an exclusive contract with a fairly large HMO; shock waved around the medical community, who felt we were trying to take over the town. A few years later, we threatened to fire the HMO, and that shock waved around the nation.

We'd come to the point at which the latest cut in reimbursement, announced via the usual one-way communique, was simply too much. Receiving the backside rather than the ear of the HMO, we sent letters to all our patients who were members (around twelve thousand, at the time) announcing the plan, along with toll-free numbers through which we'd help set them up in other plans. The HMO caved. It was, I'm told, written up in several health/finance magazines and hit the Wall Street Journal, as I recall. High fives.

For a while. Of course, it ended up only a holding action. We were able, on some occasions, to negotiate less onerous cuts; it's not as if we turned the tide. There is, however, a lesson. Our ability to get insurers to listen turned on two things: we were excellent, and we were big. Patients wanted to see us; lots of them. In that, I think, are some of the seeds of solution for the US health care crisis.

Let me say it up front: I favor some form of a single-payer system.* It's my view that the many problems with such a system can be overcome: it's not single payer per se, as I see it, to which people seem to object. It's some of the accouterments. Before getting to that, I'll state what I think is the obvious: having countless health insurance companies -- many of them for-profit -- sucks gazillions of dollars out of the health care realm, in form of profits to shareholders, salaries of executives, and tens of thousands of workers in cubicles. Both in the bowels of the insurers' buildings, and in hospitals and clinics and medical offices around the country, people input data, make calls, argue for and against payments, follow differing contractual rules within and between companies; in short, money that could be spent on care of the sick is diverted into pockets of those who provide no actual service to those in need of it. They are money handlers, nothing more. Medicare, for all its faults, has by far the lowest overhead of any payer in the country. By real far. The only way to get the most money going to actual health care is to be rid of the multiple middle men. And women. There are many other needs, as well. But to me, that's where it starts.

The biggest problems with Medicare are that it treats providers like shit, has stupid rules, and responds little, if at all, to input from those who know what's going on. It not only doesn't recognize, but actually deincentivizes excellence. No small things; but there's no reason a single payer has to be that way. What I'm saying, basically, is this: let's have a single payer, and let's make it smart and responsive. I think it's not categorically impossible. Faint hope, I realize. But if we take it out of the hands of politicians (after they approve it), eliminating the kind of politics-based governmental incompetence with which we've been regaled of late, there's at least a theoretical possibility of finding a workable approach.

Which brings us back to the preamble of this post: when the HMO relented, it was because we were big, and excellent. I'm aware it's also because they had competition, and that a monolith has none. But there's a point: when providers are able to have a say in the process, the system works. Better, anyway. The most destructive aspect of Medicare, from the point of view of a hard-working physician who has the ethic of excellence above all, there's nothing more demoralizing than being told, year after year, that that hard work doesn't matter; that there's another cut in reimbursement on the way. That the excellence of one is regarded no differently, in terms of payment, from the mediocrity of another. So: it's surpassingly important that this imaginary system has reimbursement guidelines that result from input from the people that do the work. Is there any other professional group about which it can be said that over the past twenty years the trend of reimbursement for service is steadily downward? It's really and truly perverse, and the effect is obvious.

I can hear the keyboards tapping away in fury: you doctors are a bunch of egomaniacal, money-grubbing assholes. Well, sure. Nor do I claim to know what's a fair level of pay for a doctor, compared to other occupations. But I do know that a system which generally lowers that level, and which disallows the ability to set or bargain for one's own pay, and which pays the same for a given widget whether the widget from one maker is a better product than that from another -- that system is headed for self-destruction. And it's already selecting against the sort of people we'd like to see join up.

The solution to the US health care problem, then, begins with this: a single payer system which is responsive to those who provide the care, both in terms of setting fees, and in recognizing those who do excellent work. Competition is a good thing. So is doing a good job. Let's build it in. Impossible? Maybe. Will it be imperfect? Of course. There's a need to recognize the special situation of training institutions. And there's always the doctors who (some with justification, and some not) claim their complications are higher because they get the toughest cases. Being excellent attracts challenges. But there are ways to deal with that. Make it like figure skating: toss out the high and the low scores. Borrow from the gassy world of anesthesia and the splashy world of diving: set up degrees of difficulty.

I'm no economist, so I can't say how much money will be saved by eliminating the profit-taking and the inefficiencies of the myriad insurers. But it's significant.

As hard as it would be to make it work, it's the easy part. Really to get a handle on health care cost requires a hard look at best practices, along with the staring right in the face of prioritizing care. I'll talk about it, like unto spitting into the wind, next...

* Need a definition, here. "Single-payer," to me, means something akin to Medicare, as opposed to the Canadian or British system of government-run hospitals and salaried physicians. I still believe in fee for service, because when you have doctors employed by governments on uncompetitive salaries, you have, as we see in England, to import them. And they become terrorists.


Anonymous said...

I'm a British Registered Nurse working in the UK and have no experience of the US health care system. I'm not in a position to agree or disagree about the shortcomings of your health system. But Doctor, you hit the nail right on the head when you refer to importing medics aka terrorists!

Eric, AKA The Pragmatic Caregiver said...

The problem I have with single-payer systems is that I fear a serious erosion in innovation - what compels a single-payer to add coverage for a new-but-expensive lifesaving modality? If your choices are "take what you're given" or "pack sand and pay for it yourself", new technology won't be deployed to save people's lives nearly as quickly.

I don't think the present system is great in this regard, by the way, but there's at least some market forces acting on insurers to cover new treatments as they're developed.

I favor a system that returns to the good old days of the Blues' community rating policies. In a nutshell:

1) Insurers (private, public pools, non-profit, for-profit, doesn't matter) have to take all comers *except* the elderly, Medicaid-eligible-due-to-exceedingly-catastrophic-disease and ESRD patients. No slicing-and dicing to take only the well. Rates can be set by age, gender and broad geographical region (ie, not zip-code-level - county or state) only. No more cherry-picking.

2) Healthcare benefits become taxable income. Using them as a tax-free perk subsidizes big business and penalizes small businesses in the competition for talent. But wait!

3) Offer a refundable tax credit for healthcare, just like the EITC works for income support. This credit could be "vouchered" directly to carriers by low-income workers to purchase coverage with no out-of-pocket expense, and if they didn't spend that much, the money goes in their pockets.

4) Oh. Yeah. You have to spend at least some of the largess. Something like the Massachusetts model, where it's like car insurance - everybody's got to have it, or you lose the tax benefit *and then some*. Everybody's got to be in the pool to make this work.

5) Stop using Medicare as the financing method for medical education. *cough*

The reality is, we're spending roughly the same amount on healthcare as a function of GDP as other countries, and we get less for it. By getting everyone in the pool, we better use the resources (fewer ED visits for strep, for example) and we can do comprehensive health promotion to improve outcomes. We don't have to kill innovation to make healthcare a right, not a privilege.


Anonymous said...

You note the key problem of single payer for physicians -- you can't argue with a monopoly. But you don't really address why that won't be even worse under single payer. It certainly has proven so in other countries - in France the surgeons recently went on a strike after they didn't receive a raise for 20 years. 70k might have been decent in 1985, but it's not really cutting the mustard now.

The other issue I have with single payer is that, fine, you want to jackhammer me with your bureaucracy and spread JCAHO-style goodness to every area of medicine? Fine, I'll just opt out and skip the whole shebang, let people pay what they think I'm worth. Except the single payer plans commonly proposed all would make it illegal to have private insurance and to accept private payment for things covered by the government.

Honestly I'd go into drug development or leave medicine altogether before I'd practice medicine with a government gun to my head on every issue. Most of us do have other options if it comes to that.

Anonymous said...

Here is the solution.

Doctors can should charge whatever the hell they want. The patient should pay the full cost with no government intervention. People should still be able to take out insurance.

Extend prescribing rights. Make more drugs over-the-counter. Make medicine a common university course.

When doctors are struggling to scrape by on 250,000 a year it a-makka me laugh.

Anonymous said...

Wham-bam: You forgot the other standard hallmark of the crazy libertarian - the accusation that the "AMA is artificially limiting the number of doctors". Despite the fact that the AMA has absolutely nothing to do with med school accreditation or (more importantly) residency slots. In fact, it's the federal government that refuses to open more training slots because it costs $$$.

Americans want all their doctors to have a very high standard of quality and training and are willing to tolerate some inefficiency to do so. I'm terribly sorry if this reality offends the Ayn Rand set.

Greg P said...

My personal pessimistic point of view is that we as a country cannot combine sufficient intelligence with political will to make a positive change in health care delivery.

However it comes about, we need to either get away from or limit health care coverage as a profit-generating scheme where anything goes. Insurance companies like to pretend they are there to deliver care where it's needed but really their goal is the opposite -- that's where the profit is.

And let's make sure we see the distinction between insurance companies do and what physicians do. Yes, I'm interested in profit, too, but my profit comes from delivering a service, not denying it. A big part of my overhead is spent making sure that I get paid according to the terms of the contract that we arranged, and after I've already delivered the service out of trust in that contract.

justme said...

The system is definitely messed up. The US spends more per person on health care than any other nation, yet we rank like 37th in measures of health. I have had (and currently have) many patients who live in unsafe conditions and spend the majority of their income on their health care costs. We spend millions on antidepressants, plastic surgery, and drugs for erectile dysfunction, but have people with cancer who cannot afford the treatmet.Currently my husband and I are on COBRA because my husband's new job does not have benefits. Yesterday my gynecologist's office staff was very harsh and rude because I told them I did not need an appointment so that the doctor could tell me I had a normal mammogram. Insurance companies are in business to make money which means deny or delay claims. I don't know the answer. I truly wish that all people could have personal medical insurance that was not linked to their job. I wish everyone would lose this inflated sense of entitlement and try to use resources wisely. I wish our system wasn't based on the whole concept that we have to have more and more money to buy more and more junk or fill up our empty lives. I wish that a high school graduate three states away did not have the authority to deny payment for health care and require me to spend hours writing appeal letters. I wish people would take personal responsibility for their own behavior---don't have sex if you have no income or capacity to care for a child, don't smoke, don't abuse alcohol, get off the stupid cell phone while you are driving, don't eat until you weigh 300+ pounds, etc. Our choices affect more than just us. I can only change me.

Anonymous said...

Here is my fix: Take all the money spent by government now, and put it in a pot. All the money- Medicare, Medicaid, VA, all of it. Use that to set up a nationwide system of outpatient clinics and hospitals. Maybe base it on the VA system and county hospitals, expanded to every population center in the USA. Free admission for all Americans. Basic care, to keep folks from dying in the streets. Basic surgery, basic imaging (you need an indication to get a CT, not just a bellyache). Full EMR so nobody needs the same test twice, but only clinically relevant documentation is required (the way it used to be). Huge numbers of encounters and good data collection so we will figure out in short order what is cost effective and what is a waste of time and money. Basic drugs- maybe generics only (remember that today’s generic was that blockbuster of a decade ago, and using only the tried and true is not an egregious violation of human rights). No lawsuits, except for gross violations- similar to workers comp. Pay docs fairly- I believe that most of us would be delighted to work at today’s Medicare rates under the conditions above.

Want the latest and greatest? The shiniest new drug, the latest mini knee replacement, the 64 slice CT, the laparoscopic toenail removal? Fine- the private system still exists. Pay for your care, or buy private insurance. No government subsidies, no tax breaks, but big bucks for the successful entrepreneurs, the hard working docs who can please their patients, the innovators. No wasted time documenting irrelevant stuff to get up to the next CPT level. No wasted money complying with stupid JCAHO rules. Charge what the market will bear, make a lot of money if you can and work in the government system if you want or need to. Be careful, they can sue you here.

Whaddya think, Sid?

Anonymous said...

Wouldn't a single payer system succumb to the massive fraud we see with medicare? In 2000, (probably much worse now) medicare lost almost 12 billion to "waste, fraud and mistakes". Other statistics for the year 2000 were:

Fraud amounts to 10 percent of U.S. healthcare expenditures.

Seniors and other taxpayers pay up to $1 billion a year in inflated drug prices due to potential fraud and loopholes in Medicare. The overpayments represented 1/5 of Medicare spending in 2000.

80 percent of healthcare fraud is by medical providers, 10 percent is by consumers and the balance is by other sources.

Medicaid fraud is far worse - 20 billion a year. And this only represents what was discovered.

Sid Schwab said...

several really good comments here. In fact, some of the points are ones I'm addressing in the next post (still working on it.) I think Greg is right about the lack of intelligence and will in our lawmakers.

When you think about it, it's really a bizarre system that interposes an entire industry devoted to profiting from handling health care money, between the people who pay for it and the people who deliver the care. Granted, that's what all insurers do -- auto, home, etc -- but health care seems different: other forms depend on the idea that most people won't use it. Virtually everyone uses health care and the amounts of money are huge. And auto/home insurers actually provide a service: they come out, inspect, arrange repairs, help people through the process. Not true of health insurers.

Sid Schwab said...

anonymous: I'm no expert on fraud, but my reaction is that it isn't because of single payer per se. The possibility is there no matter what, and needs to be addressed by proper oversight. The other side of the coin is the extent to which there's a "guilty until proven innocent" approach among all payers: some "fraud" is actually innocent coding error, etc. Nevertheless I agree it's a problem. One might argue that having a single system would allow more coherent supervision. Whether that's true, I can't say with any authority; but it makes sense off the cuff.

rlbates said...

Wham-Bam, you and the rest of the general public need to realize that most doctors don't "take home" $250,000 a year. I am in solo practice and by the time my overhead (rent, utilities, insurance, etc) is paid , I take home less than a starting university professor. My husband complains when he has to work overtime and he gets paid time and a half or double. I don't get paid "extra" for going out in the middle of the night, on weekends, or holidays. Do you? And Medicare, etc have consistantly cut reimbursement over the last 10+ years, while all the other overhead cost (including salaries, ask a secretary or nurse if they are willing to take the 4-11% cut doctors have been hit with the last few years). And please quit calling them "free" clinics, they aren't. Someone pays the bills, buys the supplies (syringes, gowns, etc)needed to provide the care. The clinics may be charitable, but they aren't free! I was raised in a family of eight kids, poverty level income, but we paid our doctors bills rather than go on vacation. I am tired of listening to patients (with a smile plastered on my face) while they tell me about the vacation they just took or are leaving on, but never offer even $10 on their bill. I am tired of being called "money-grubbing". I simple want to make a fair living and a retirement (which isn't happening) while I provide good care.

Anonymous said...

Canada has a single payor and is still considered fee for service. The fees are determained by the payor( an exam is so much, a basic appt another amount, surgeries are a set amount etc. Some docs are salaried ( er docs, and some employees of the hospital)

Anonymous said...

Small note about a comment in the bird seed. England is actually churning out a surplus of doctors these days. Even with the "uncompetitive salaries" offered by government, medical school is still a very popular option.

ms bates:
I wonder how nurse practitioners manage to survive on 80% medicare rates? Is it because they haven't such a huge expectation of what they are worth?

Have you guys noticed how the AMA is terrified of minuteclinics? All in the interest of patient safety of course...IMHO it is egregious turf protectionism.

Folks, the day of the locust is at hand. Find a job you enjoy and then money won't seem so important.

Anonymous said...

I'm still a student, so I'm a long way from getting paid/reimbused on anything, so I'm afraid I can't contribute to the good ideas I'm reading. However, I do think that health care reform is, in our fscked-up overly-litigious environment, is inextricably linked to tort/malpractice reform. There would be no need for the defensive medicine waste ("do I do x and not get paid because I know their insurance won't pay for it, or do I cover my a$$ and save money in the end?").

It's not the only thing to solve, of course, but no reform will work with a for-profit malpractice business simply changing their strategies to fit whatever new paradigm emerges.

Pursey Tuttweiler said...

Wow, I have a lot to read and learn here, but Enrico, I do not think that tort reform is the answer. I live in Texas where we have tort reform, no individual claim can exceed 250k, but more than one claim can be filed if more than one party is accused of causing the medical malpractice, but I have not heard the statistics of how the med-mal rates have dropped for doctors since tort reform. I have a feeling the insurance companies did not rush out to give the doctors huge discounts.

I am also not sure that a single payor system would impede innovation. Right now, a new medical innovation has to be approved by hundreds of insurers before reimbursement is profitable and convincing medical directors or hospital systems to adopt a new practice requires tons of economic studies, and regardless of the benefit to the patient,if it doesn't pay off, the hospitals will not introduce a new standard of care.

Bongi said...

we, like uk and canada have two systems. private and state. state employs doctors on a salary, reguardless of services rendered. like uk, we must import. cuba supplied us with many doctors, but there is essentially a problem with a country without rights sending people to a country with rights and then still denying them their rights. too many defected. now our brilliant government has decided to import iranian doctors. watch the news for the terror attacks. amazingly enough we have the skills here in our own country (with the possible exception of general surgery where there is a growing shortage) but our wonderful government would not dream of adjusting the system to use home grown talent.

Anonymous said...

I agree with Eric and anon. 12:45 that flexibility and competition are important to preserve innovation and leave the door open to change. How would Schwab's group have fared if they had tried to do the same thing to Medicare? A monopoly has no incentive to change. Patients and providers would have to take whatever sucky coverage and rules the payor handed out and the only people who could make a change would be the next politician with a bright idea who will be long gone or already re-elected before the implementation goes sour.

I believe in the market: greed is good (except when greed is bad;) Government's role is to regulate, not suppress or subsume. I like eric's points so won't repeat them. What I would add is this: increased transparency and standardization of certain processes on the part of health insurers would help restore the connection between their profits and actual health care, as opposed to obstructionism and money-laundering which is where they make their $ now. If patients could contract portably and individually with insurances and knew what they were getting, insurances would have to actually provide a service. Not just "levels of coverage," but up to date(!) lists of participating providers, AND WHAT THEY PAY THE DRS. Not to mention having to tell the physicians what they would get paid. The claims process could use some mandatory simplification as well.

Basic levels of coverage could be mandated as well.

Re: physician incomes
If we want the best and the brightest, or at least the good and the bright, to go into medicine, we ought to pay the going rate.. otherwise the profession will become largely populated by mediocre clock punchers. Those bright stars who love medicine so much as to not only suffer but also get paid peanuts will move to Rwanda where people need them more.

Re: medical terrorists: I can't help wondering, if they were paid better would they have been less likely to become terrorists. Investment in the status quo is a strong deterrent to political activism, and a comfortable lifestyle makes one spend less time thinking about the life to come.

Sid Schwab said...

mwfp: I agree with most of what you said. Still, having so many insurers, who add no value into the system, taking so much money away from it, seems insane. To have a single-payor system function properly, there'd need to be meaningful input and influence at the top by panels of providers and consumers, set up in such a way as to actually be in control. I think such a thing is possible -- whether or not it really is, given the pathetic displays by our leaders in Washington, is another matter. But if it were, I'd be for it! That's part of what my next post is about...

Pursey Tuttweiler said...

I became hooked on this blog several days ago when I was researching information on my husband's recent colectomy, June 14th. Now I am fascinated with surgery and want to become a surgeon, but alas, I am too old. I will read this daily, I have so many problems with our healthcare system and enjoy learning about surgical procedures plus the varying opinions of how we can improve the healthcare system I am very interested in healthcare advocacy.

Anonymous said...

I'm a third year medical student, female, 25 years old. So far I've spent about $180,000 on my high school education, $130,000 on college, and I'll spend roughly $120,000 on my medical school education. After that, I get to make about $44,000 or so for 3-7 years... during which I'll be working 80 hours a week. Heck, I'm in the hospital 80 hours a week now, and I still have to study for SHELF exams when I'm home.... but back to money, when I start making that $44,000, I'll be spending about $1700/month paying back student loans, (do the math, after taxes, that's barely affordable). And then, when I'm done with residency, and a fellowship, I'll be a great pediatric oncologist and you know how much I'll make then? I might start at $160,000, and I can probably count on making $200,000/year or more by the time I'm done (according to 2006 AMGA Physician salary survey).

Bottom line, it doesn't pay to be a physician. Not only is it turning into a financially unviable situation, I'm totally giving up my life to medicine! I live in a grubby apartment, with roaches and mice and three other medical students. We all eat ramen noodles and rice . I try to go 'out', for a walk, a run, but who has the time? I'm in the hospital at 5:30, and I don't leave till 8.

I'm at the point where I think Dad was right. I could've gone into anything, and medicine isn't feeling worth it right now. I hate how patients think of me as such a wealthy person. Besides not having any money and being in debt, I'm exhausted, I never see friends or family, and I don't have time to do any of the other things I used to love. I cherish my interactions with the 'good' patients, and I do anything I can for them, but I can't stand the demanding, self-righetous idiots I have to treat every day. I still have to give them the same level of care, and as a medical student, I'm in no position to do anything about them.
I'm exhausted. I have to sleep. Single-payer, or whatever, something's gotta change.

Sid Schwab said...

anonymous: I was with you right up to the "demanding self-righteous idiots" part. Maybe you just need sleep. In any case, it's never too late to make a change.

Eric, AKA The Pragmatic Caregiver said...

Not to pick on oncologists or anything, but does that salary figure include compensation from drug markup?

Readers may not know that oncologists are the only medical specialists who directly profit from you agreeing to take life-saving medication. They buy at wholesale, sell at retail, and pocket the difference. It's not noble practice of medicine - it's filthy commerce.

I agree, Anonymous, that you've put a lot of money into the process. And yes, residents make crappy money for hideous hours. Let's compare what you've spent on graduate education to, say, an MBA..

Figure $60K in additional cash outlay and two years without wages . . . average MBAs with no industry experience make about 80K in their first year, so you're losing out on two years of earnings while you're in school...160K.

So, before you start your residency, you're $220K in the hole. Add four years of slave-labor wages, where MBAs earn closer to 100K, you're another $220,000 in the tank.

So after four years, when both you and your evil twin MBA cohort who went to work in health insurance can practice your trade without restriction, you're earning 200K, and they're closer to 115. Doesn't take long to make that difference up, now, does it?

Additionally, MBAs don't have that side business of buying drugs cheap and selling them at a markup. Oncologists get to operate a lemonade stand, but instead of sugar and lemons and a 50-cent profit per serving, you get to hand out stuff like Zometa - average markups for that (independent of the office visit and infusion-related charges) are closer to a *$400* profit per dose.

Cry. Me. A. River.


Anonymous said...

Anonymous 3rd year here again... Last nights post was after a very tiring day, and I did get to sleep... thanks Dr. Schwab.

But here's some more rambling, I'm 25, I'm in debt to my ears, I don't have time to enjoy myself, and I'm not going to get to do that anytime in the forseeable future.
My life is medicine and most of my patients don't understand or appreciate that, many of them think they DESERVE everything I/we have to give them. My friends and family have a hard time understanding why I work so much, but, I don't really have a choice at this point. It's full on, 80 hours a week from 3rd year of medicine until end of residency. If I don't want to work that much, my only option is to drop out. There's no part-timing allowed (at least in my medical school).
Today medicine is an underappreciated and underpaid job. So why am I still here? I'd like to think it's because of all the successes, the wonderful patients for whom I'd give my own kidney, but I also know that right now my debt keeps me here. I was blind and idealistic going into this but I've dug a hole, and I have to stay in it to get myself back out.
It's not just the money, I'm giving up my 20's, between working hard to get into medical school, and working hard to stay in, my 'me' time is very limited, and I consider myself one of the lucky medical students. I have no kids, no family to feel guilty about leaving all day. But then again, when am I going to do it? As a female in medicine, when do I take the time to have a child, or two, or three? I'm wandering way off topic here, but again, sacrificing having a family for medicine is something that's required to keep going. 80 hours a week, on your feet and pregnant just doesn't work.
Again, I realize this is a problem every woman faces, and medicine isn't the only job that requires 80 hours/week and a huge amount of education. I have to remind myself that the woman who works two/three jobs at $10/hour isn't all that much different than me, and, I at least have the promise of $150,000/year one day...

Anonymous said...

Pursey: I never said tort reform was the answer; I said that any sweeping change to physician reimbursement/salaries, etc. while not simultaneously having tort reform is beyond a waste of time. I live in Texas too, and the vast majority of carpetbagger med mal attorneys folded up and went elsewhere (Carolinas), and the locals simply changed focus. $250,000 sounds like a lot, but it costs a lot of money to put on a successful case, and if an medmal attorney is looking at a fraction of what's left after paying the bills, he'll go and chase other vehicles other than ambulances.

Tort reform is as much about changing the paradigm for what makes attorneys money, for the "profit of human suffering." Step 1 of 3. Step 2 of 3, cap the profit of human suffering from insurance companies (how, I have no idea--I'm just a student). Step 3 of 3: reform the practice of medicine to go back to its roots, where one doesn't need to order unnecessary tests, has time to spend with patients, feel good about being a healer, etc.

I'm just throwing this out there, but I'd venture to say most doctors would take a pay cut to ensure a better quality of life, autonomy, and quality of care for their patients. Doctors get good coin, sure, but doctors are motivated other than money.

Medmal lawyers and insurance companies are motivated by nothing else.

Sid Schwab said...

In general I've deleted comments which are ads and solicitations. I'll leave the above because it would seem to be important and sincere. I've not looked at the book, nor do I have "house physicians" to whom I'd give it. Still, it's a serious problem that deserves attention.

walt dandy said...

Dr. Schwab,

I'm posting this more in the spirit of a long question than that of an opinion because I'm interested to hear what you have to say. It seems, generally, from what I've heard and read about the socialized systems in the UK, Australia, Canada, and India that the advent of nationalized health care systems have led those systems in a remarkably common direction (the exception may be Canada). The government systems seem to become increasingly inefficient and inevitably lead to rationing of care. That fact, in turn, leads to a two tiered system in which the wealthy demand better access to care and a robust private health care system becomes available to those who are able to afford it. As I understand it that private health care system for Canadians currently means going south of the border. In any event, the ultimate result seems to be that the wealthy still pay a lot of money for access to the health care they feel they deserve, resulting in a private health care system that is quite profitable for both the physicians and the private institutions. Meanwhile the less fortunate (or whatever label one wishes to attach) still face (more?) hurdles to unimpeded health care access. In my understanding, that is no different than the system we currently have in the US. Contrary to popular belief I would argue that there is currently a de facto rationing of care in the US. That is, the lower middle class who make too much money to qualify for medicaid but too little to afford meaningful healthcare insurance only have access to medical care for disasters. They have to take a gamble and hope that their health holds out until better times, and in the mean time they don't really have access to routine primary care (BP management, routine screening, etc.). The other issue at hand is what happens to physicians in these systems. Again, with Canada as an exception, physicians become faced with the choice between a profitable private practice career and a not so profitable and bureaucratically laden (read frustrating) career in the public sector. My point is that both systems inevitably lead to rationing of health care in one form or another. Neither seems fair.
Atul Gawande, in his book Better, explores how much is fair for a physician to earn. This is a very delicate and supremely difficult question to answer. As a medical student I thought I would be willing to do this for 100 hours a week as long as I got 3 square meals, a sleeping bag, and an alarm clock. As I've progressed through my training I've become much less idealistic in this regard. I've developed a much better sense of the personal sacrifices one makes in this career, especially when compared to my friends in the banking and technology sectors who are by now very well established in their careers making a decent living with a lot less time spent away from home. The constant stress that comes with the responsibility of caring for people who might become severely crippled as a result of the decisions we have to make on a daily basis also tends to wear one down a bit. Would I spend 100 hours a week slogging away for 30K a year? 50K? 100K? I honestly don't know the answer to that question. It is not only a question of pragmatism and economics, but at its core it is a moral question. Less so for us here in the US, where shortages of physicians are much less of an issue than, say South Africa, as Bongi has pointed out so poignantly. But still, I find myself wondering how and when you decide to say no more and still be able to sleep at night. On the one hand there is the real example of a hand surgeon I saw refuse to come see an uninsured patient on a holiday weekend, and on the other is the group of physicians I see who can't say no and end up getting all the uninsured patients dumped on them (thus working harder and getting paid less). Maybe it is still the last semblance of the idealistic medical student in me, but I still feel some obligation to the community. Money just makes it all seem like a dirty enterprise, yet money remains a very real consideration. Do I need to drive a BMW? No. Do I need to live in a palace on the lake? No. But I do have 160K in educational debt that is accumulating interest like gangbusters, and I guess I have accumulated a feeling that I deserve to be compensated reasonably well for the unique risks I take and the sacrifices I've made to get here. To try to bring cohesion to this treatise, I guess my point is that it seems that nationalization of the health care system in this country ultimately will not help the less fortunate, and we as physicians will still be faced with the prospect of having to decide between taking care of those who need it and be paid less, or taking care of the wealthy and making a lot more money doing it.

Sid Schwab said...

Walt: good questions, and excellent points. Clearly there's no perfect solution, namely one in which everyone gets equal and perfect care, and one in which providers get what they think they deserve.

One point: there's a difference between "nationalized" care and "single payer." Medicare is single payer, but the care is delivered through private and some public institutions. The argument for single payer is to eliminate the enormous costs involved with the complex system of dozens and dozens of payers. "My solution," such as it is, also includes a governing board with meaningful power to see that providers have a real voice in the rules of the road. I'm not saying it could happen. It's just the solution that I see making some sort of sense.

Would there be two tiers, and if so, would it affect the distribution of care? I'd guess in the US people, at this time, wouldn't stand for enforced single-tiered care; maybe for the same reasons people who'll never have to see taxes are their estates (nearly everyone) are against the estate tax: they think someday they might get there.

In my community, each specialty has a designated doc on call each night for "no doc" patients. By hospital rules, that doc may NOT refuse care when called for such a patient. And, of course, if there were universal coverage, none of that care would fail to be reimbursed. It's hard to imagine that access could be overall worse than it currently is.

As to level of reimbursement: I don't know, either. When I started in practice, in 1977, it was still the old days, where doctors got pretty much what they charged, and, in many cases, I think it was too much. At the end of my career, I was getting -- in REAL dollars -- around a third of what I was getting, per case, when I began. As I've said, I think we're at the breaking point in cutting reimbursement: any lower, and more people will bail out, or not enter. The way to know, I suppose, is to observe what is and what will be happening. There are already shortages in general surgeons, and more are predicted. The trend, as I've also said, is toward subspecialization, and toward the "hospitalist" model. In large part, I think, these are "life-style" choices: people are no longer to work as hard as I did for the kind of compensation that's evolving. If "society" wants to pay less, at some point they will get less. Maybe I'm wrong: maybe plenty of people will have the commitment I did, and the willingness to put work above all else, no matter what the compensation, because they feel called to do so. Or maybe those willing to enter and stay in the profession will be people (some excepted, I'd assume) will provide less in return for getting less.

I actually had BMW. I bought it new in 1971 at the end of my internship: I was paid $8K of which I was able to save $4K, which is what I spent on the car. I kept it for 20 years, finally donated it (after having it mechanically rebuilt and re-painted) to the local Little League auction. (It became an expectation, for the next three or four years, that whoever bought it would re-donate it the next year.) My current car is 13 years old and has 185K miles on it.


Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...