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Tuesday, December 10, 2002There’s nothing wrong with being passionate about a cause. In fact, it’s admirable to care so deeply about something. But the problem with passion is that it is also blinding. Dr. Young assumes that 1) medical care is a public good, and 2) that all medical care is equally good. Neither assumption is correct. To some extent, medical care is a public good, but only in the sense that a healthy nation is a vital nation. But this applies to the basics of health - clean water, control of infectious diseases, curing the curable. It does not apply to treating obesity, lowering cholesterol levels, freedom from arthritis pain or from the discomfort of indigestion, or the right to have the latest and most expensive drug for whatever ails you. Marcia Angell acknowledged this when she added, sotto voce, that her ideal of expanding Medicare to all “would have to have price regulations.” Note that she didn't say "rationing of benefits," but "price regulations." Good care costs money, whether it's spent on proper staffing levels at nursing homes, hospitals, and doctor's offices, or on research for better medicines. "Regulating prices" too often means cutting reimbursements to unsustainable levels. Only doctors, hospitals, and nursing homes feel that pinch now. Expand the government programs to include drugs, and the pharmaceutical industry will feel it, too. You can bet that would lead to fewer research projects into new and better drugs. Dr. Young expounded on Dr. Angell's idea of expanding Medicare. He often referred to Medicare as “flawed” and “in need of reform,” but the flaws weren't what most of us consider its flaws to be - poor reimbursement, Byzantine rules and Draconian enforcement of those rules. He thinks its flaws are that it doesn't cover enough - not mental health, not nursing home care, and not drugs. The reform he has in mind is to increase Medicare spending and then to increase it further by covering everyone regardless of age and need. What he wants, is a world without limits. The third guest on the program was Karen Davis, an economist and member of the panel that wrote the recent Institute of Medicine report on health care reform. She advocated a much more realistic approach to the problem. When asked about the possibility of a “protest movement” to force a single-payer system, she pointed out that surveys the IOM had done showed there wasn’t much support for that sort of system. In fact, most people are satisfied with the coverage they have now, as long as they aren’t in any danger of losing it. That’s why the IOM report favored letting states experiment with different methods for universal coverage that incorporated private insurance as well as government programs. Of the two, her approach is the more sensible and practical. The Mote in My Eye: A reader pointed out that my own passion on the subject of Medicare/Single-Payer system may be blinding me: As a faithful reader I fear you have gone over the hill and confused ideology with facts and common sense--you said referring to a post on Medicare: "The same thing would happen if we shift every man, woman, and child, regardless of age, to a single-payer system. Instead of taking up 20% of our GNP, healthcare will end up taking up most of it. Where will that leave us for defense and infrastructure?" . On what possible basis would you say that? I should have said “20% of the federal budget”, not the GNP. I meant to correct that before I posted it, but somehow it slipped by. Physician error. I say that from experience. I have no confidence in the ability of our system to ration care as long as the patient is left out of the loop when it comes to cost decisions. Managed care companies weren’t able to do it. They came under pressure politically and legally to expand coverage, and they got a lot of bad press for “denying care” when they tried to limit benefits. The government is no better at limiting benefits. No one wants to shoulder the politically distasteful task of rationing care. It's much easier to just cut back and delay payments to providers. Not only that, our lawmakers are already notorious for inserting themselves into treatment issues. Senators declare illnesses an “epidemic” if they or their family members have it (autism, most recently), they make pronouncements on the efficacy of mammography screening (In favor of, of course. Don’t want to alienate women voters) and they badger the NIH about its educational material (from both sides of the aisle). There’s no reason to think they would remove themselves from the debate when they have control over how every healthcare dollar should be spent, and there’s no reason to expect that they would exercise restraint in that spending. They’re too easily influenced by advocacy groups. But, back to the letter: I am submitting this link which accurately, and with out a partisan bent (I think), offers comparative date on health costs, mortality, etc. among 14 industrialized countries. A few observations. Data is current (1998-2000). Of 14 industrialized nations: 1) The U.S. health care cost per capita is the highest ($4,178) versus a median of $1,783--Most of the countries have a much simpler, if not single payer, system 2) The U.S. commits 13.6% of its GDP to health care versus a median of 8.2% Yes, but that’s because we use more high-tech medicine. As I mentioned above, not all medical care is equally worthy, but we aren’t very discriminating in our choices. We do more coronary bypass surgery, for example, than other nations, without much gain in life expectancy. We spend a lot on cholesterol lowering drugs to decrease the rate of heart disease by 3 or 4 percentage points. We spend money on newer, more expensive antihistamines and arthrititis drugs that aren't any better than older, cheaper drugs. Yet, if an insurance company, or Medicare, denied coverage for those treatments, they would be accused of denying needed care. Having a single-payer system isn’t going to change that. Not in our political system, anyways, and I’m not willing to give up our political system. I think it works pretty well for other things besides doling out health care. 3) The U.S. life expectancy is the second lowest ( 70 years) versus 71.7 for other countries. Our life expectancy is 77 years, or at least it was in 2000. I don’t know how that ranks, but here’s an excellent explanation of why life expectancy isn’t the same as life span, and why you can’t put much stock in those WHO figures. 4)The U.S. infant mortality rate is 7.2--the highest of all countries by a wide and significant margin. In 2000, our infant mortality was 6.9 per 1,000 live births, 28th among nations. The majority of those deaths were due to congenital anomalies and low birth weight. That doesn’t necessarily mean that we have deficient care. It could reflect our better prenatal care. Pregnancies that would end in miscarriages elsewhere, end in live births here, but live births with sicker babies. 5) The US is rated number one in responsiveness, last in system performance and near the bottom in percent satisfied with the health system. I understand that each statistic can be rationalized--however--there is a message and it is not hard to find--costs can be contained and do not need to take over a nation's budget, quality of life has many dimensions and need not be substantially compromised by reducing total expenditures, and satisfaction is not necessarily driven by expenditures. That’s true. Satisfaction isn’t driven by expenditures. It’s driven by perceptions of quality. As I said earlier, though, I have no confidence in our political system’s ability to contain cost. No one wants to deny care, and no matter how marginally beneficial a treatment may be, there will be groups out there prepared to fight for our right to have it, and to have it for free. Also--regarding charity care--I doubt if you can find any provider who ran into trouble with Medicare because they provided charity care--to over simplify--one must generally charge all patients the same--this does not mean that there is the same expectation for payment. As for discounting to friends, professionals, etc. Since your Medicare or Medicaid rate is significantly driven by your costs, not your income--if you offer discounts to colleagues what you are essentially doing is having the tax payer subsidize the services you are giving away. This is absolutely true. The idea of professional courtesy never made sense, except in the case of medical students. They have no money, and deserve charity care. And, it’s true that you would be hard pressed to find someone who was penalized for offering charity care. However, the fact remains that a lot of doctors have interpreted the Medicare rules to mean that no one can be charged a lower rate than the Medicare rates, and that to do so means to incur stiff legal penalties. That perception, right or wrong, has had a definite impact on charity care. ADDENDUM: I have more to say on the subject here. Better Said: More eloquent dissertations on the issue of health care coverage can be found in this Cato Institute paper, and in First Do No Harm, by the Cascade Policy Institute. posted by Sydney on 12/10/2002 05:55:00 AM 0 comments 0 Comments: |
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