By Dr. Jim Dahle, WCI FounderI know this isn't a strictly financial topic, but I can't resist writing about it from time to time. I often think about starting a third career trying to reform health care. Sometimes it is so embarrassing to be part of it. To make matters worse, both major political parties keep missing the forest for the trees. They focus so much on insurance reform that they forget that the problem isn't insurance, it's health care. I was reminded of this as I received my annual health insurance renewal in November of last year. We buy our health insurance on the open market and, as you might expect, receive no subsidy or employer assistance. Our premiums for 2018 are 13% higher than 2017 ($1345/month including dental if you care.) That's okay, our deductible went up even more – 16%. (Yes, that's sarcasm.) Our out of pocket max went up and our prescription coverage got worse to boot.
I understand why people are mad at the health insurance companies–the insurance companies are the ones you write the checks to. They're the face of a health care system with runaway costs. But they're only that. The face. The symptom, not the disease. The disease is that health care spending is way, way out of control. So naturally, the next place you look is to the providers of health care–the doctors and hospitals and drug companies. If they wouldn't charge so much for that health care, we wouldn't spend so much on it, right?
While health care reform is complex (and anyone who thinks the solution is simple doesn't understand the problem), only a small part of the problem lies with the insurance companies, the doctors, the hospitals, and the drug companies, who are really just doing what they are incentivized to do as any rational economist would expect. The main part of the problem, dear patient, lies with you. “What?! How can that be?”, you say to yourself. Let me explain, and when I get to the end, I think you'll agree that the patient himself shares a large part of the blame, if not all of it. The rest of this post will discuss the four keys to fixing the US health care system, but an almost subconscious theme of it will be that nobody here is innocent.
4 Keys to Fixing Healthcare
#1 Effectiveness Transparency
Problem number one with our healthcare system is that we consume a whole lot of health care that doesn't do any good. Yup. That's right. There are a whole lot of health problems that modern Western medicine simply doesn't have a good answer for. Sometimes we can't even treat the symptoms effectively, must less cure it. A while back I wrote about the importance of understanding the concept of the Number Needed to Treat (NNT). That's the number of people who actually need to take a treatment or have a test done in order to help one person. For most medical therapies and tests, that number is NOT a single digit. That's right. You have to treat more than 10 people in order to help one of them. For some therapies, that number is over 100. Sometimes it is infinite. There is a number needed to harm (NNH) for every test and treatment too. And that number is often lower than the NNT.
What does that mean? That means 90% or more of the healthcare we engage in is unnecessary. People like to blame emergency departments for unnecessary care (even though emergency care is less than 2% of the healthcare dollar.) But the truth is that EVERYBODY is engaging in unnecessary care. Physicians, hospitals, drug companies, device companies. You name it. We're all guilty. But so are the patients. Since healthcare, like everything else in this country, is a business, you can't place all the blame on those who provide goods and services when you can't resist buying them. I see the silly stuff you're coming into the ED for. I can't imagine the silly stuff you're seeing neurology, orthopedics, gynecology, and your primary doctor for. And that doesn't include all the nonsense you're paying cash for outside the Western medical system. We have a serious problem with health care overconsumption. Take a look at your 85-year-old relative on 25 meds if you don't believe me. Think of all the appointments, tests, and pharmacy visits required to keep that list of medications going month after month after month, not to mention the hospitalizations required to treat the interactions.
Doctors and patients need to have A LOT more conversations about whether to do a test or treatment. About what the NNT and the NNH really are for each of them. For those things that we don't know how well they work, we need to focus our limited research dollars there.
But wait, there's more. We're spending a ton of money on stuff that is even LESS EFFECTIVE than western medicine. You think the data is bad on drugs and surgeries and x-rays? Wait until you see the data on chiropractic and essential oils.
For sure there are aspects of Western medicine that are incredibly effective and have helped us to reduce morbidity and mortality. But you might be surprised how few and far between super effective things like clean water, vaccines, insulin, seat belts, and surgery for necrotic bowel really are. Government, doctors, hospitals, and patients all have a role here in really looking at what is effective and what isn't. If we can simply drop the ineffective stuff and most of the barely effective stuff, we can dramatically decrease the cost of health care.
#2 Price Transparency
Imagine going to a restaurant and ordering a meal off a menu without prices. You then walk out of the restaurant without paying any money. Six weeks later, the bill is sent to your “restaurant insurance” company. Six weeks after that, the insurance company sends you a bill for your portion of the meal. Crazy, right? You don't even remember what you ate 3 months ago. If we're going to have health care be a business in this country (and having worked in socialized medicine, I don't necessarily think that's a bad idea) you have to have a functioning market. And guess what you need for a functioning market? That's right. Prices. You need to know the price of stuff. Both patients and doctors. You want to bring down the cost of health care? You want to see what competition and a true market can do to reduce costs? Mandate that every health care provider in the country post its prices in the waiting room and on the internet.
Now I know it's complicated. You don't exactly know what a patient is going to need when they check in to the ED or show up in clinic. But you can post averages. You can post the price of common tests and treatments. You can post a sample bill for your most common complaints. As it is right now, even a savvy consumer (or a savvy doctor) has no idea what the price of anything is. Doctors, hospitals, pharmacies, and drug companies are all incentivized to make this as opaque as possible. Nobody is going to post their prices unless consumers (probably through their government) force them to do so. But you can't have a market without prices. And I'm not talking about chargemaster prices. I'm talking about the real prices. It's ridiculous that every patient has a different price list. It's amazing how much the price can come down when insurance is taken out of the equation. I drive by an outpatient plastic surgery center every day and they have a big flashing billboard- “Saline $4800, Silicone $5800.” LASIK surgery is similar. Concierge clinics have proven effective in some specialties, but surely we can come up with a system where we can have both insurance coverage AND price transparency.
# 3Skin In the Game
The other factor required for a market solution to bring down health care costs is skin in the game. When you're spending someone else's money, you're far more likely to overspend. Too many health care consumers in our country don't have enough skin in the game. They're on Medicaid, or Medicare, or Tricare, or VA care, or a plan subsidized by their employer. Or perhaps most of the cost of it is covered by the taxpayer through PPACA tax subsidies.
My family buys our own health insurance on the open market, but we are a tiny minority- just 16%. It's not that I'm against insurance, even insurance run by the government. But people need a meaningful amount of skin in the game in order to have a functioning market. Even having to pay $100 for that MRI is going to make most people think twice about it. If Levaquin costs you $75 and Cipro costs you $4, you might rationally conclude that you'd rather take the whole family to the movies twice and have to take Cipro twice a day instead of Levaquin once a day. But if they're both $10 after the prescriptions get “run through insurance” what do you care? You don't.
I had a patient the other day who I shocked out of a-fib after he came off a cruise and flew across the country to see me. He didn't have health insurance because it was too expensive. Yes, that's right. He can afford a cruise and airfare, but not health insurance. I didn't entirely fault him. He had made a rational decision that he'd rather go on several awesome vacations a year than have health insurance. When people have skin in the game, they can make rational economic decisions. An MRI or a used car? Knee replacements or taking the extended family on a cruise to Alaska? An expensive arthritis drug or living in twice as nice of a house? Chronic suboxone treatment or a live-in masseuse for your fibromyalgia? You could do this all day, and when people do, they will spend less on health care.
This is actually the area where recent healthcare changes have had the most effect. This trend toward higher deductibles has made many of us reconsider how we want to spend our dollars. But there has to be a middle ground somewhere between $3 ER Medicaid co-pays and $8,000 annual deductibles.
#4 Death Panels
There, I said it. I'm a huge fan of death panels. In fact, nearly everybody I know who works in health care is a fan of death panels. They get a bad rap, of course, but they exist all over the world. A death panel is simply a group of dispassionate professionals who look at various tests and treatments in various medical scenarios and decide whether they should be allowed or not. It breaks our hearts to hear “no more should be done,” especially when it's our beloved grandma on the vent or a 23 week million dollar preemie. We hear about the miracles and say “there is no price too high for life.” Well, guess what? That's not true. Want to know what a life is worth? Check out the latest round of malpractice awards. Most of our lives are worth less than policy limits (generally $1 Million.) And if the number needed to treat to put grandma on a vent for a month is 200, and it costs $100K, well, you can do the math. We're saying Grandma is worth way more than any reasonable jury would indicate.
“But we don't want to ration care,” you say. Don't kid yourself. We already ration care. We do it all the time. Usually by what type of insurance a patient has or how much money they have. What do you think insurance pre-qualification is all about? Do you really want the insurance company or your wallet functioning as your death panel rather than a committee of docs guided by the data? “I see everybody,” you say. Try calling your front desk sometime and pretend you're a patient without insurance and try to book an appointment. See how that goes.
The death panel could also get involved in malpractice situations. There are plenty of guidelines out there for doctors to follow, but there is no back-up for the doctor who does less (per the guidelines) and then suffers the inevitable bad outcome. She still gets drug through court for 5 years. It would be far better to have a “No-fault” system where those who are harmed are compensated whether there was an error or not and the frivolous 85% or so of lawsuits never get filed. And instead of having attorneys and courts police the medical profession, the death panel can do it. Everybody already hates them anyway.
While I'm on this rant, let's talk about the whole “healthcare is a right,” thing. What a ridiculous bit of poppycock. You can't go to the store and get food without having to pay, no matter how hungry you are. You can't go to a hotel and sleep in their beds without having to pay, no matter how tired you are. If we don't have a right to food or shelter, why would we have a right to healthcare? That doesn't mean that government doesn't have a responsibility to its least fortunate citizens to provide some basic level of necessary health care just like food and shelter. But doctors, hospitals, and pharma companies seem to only recognize one level of healthcare without regard to the patient's ability to pay. It sounds super noble, I know, but it becomes much less noble once you bankrupt the patient. “First do no harm” applies to their wallet too. The death panels can determine what that basic level of health care looks like, and if people want to get the deluxe version, they can go without $1,000 iPhones and cruises to get it.
Healthcare reform is a huge, complex problem. We're all part of it–government, healthcare providers, and patients. But if we want to bring down the cost, the best way to do so is to consume less healthcare. These four keys will help us to do that.
What do you think? Do you agree these are the four keys to bringing down the cost of healthcare? What would you add or take away? Comment below, but avoid inflammatory and ad hominem statements and references to political parties and figures if you wish your comment to still be there when you come back.
Agree with so much of what was said above. Obviously this is a many-headed beast and includes: waste, overtreatment, skyhigh pharma prices (we are the only developed nation that doesn’t control drug prices, so we subsidize R&D for the rest of the world).
I think we need to change the culture that equates expensive care with “best” care. I’ve seen this attitude in medical schools and academic centers as well as in the public discourse. The majority of an individual’s health care consumption comes at the end of life (meaning, terminal illness and elderly), when it is least appropriate. What is best for the patient then is, often, the least expensive care. Death is not the worse thing that can happen to a person. We need to do a better job educating our patients and ourselves.
For years we have been saying “nothing will change until the system finally breaks down”, but we have been on the verge of breaking down for decades. Not sure what it will take to actually motivate us to change the system, because it seems set to continue on the current path for at least the rest of my career.
Love this article. Well-written and concise. Agree with a lot of the above comments as well. Healthcare reform must happen.
Wouldn’t these measures lead to lower income for those in the healthcare delivery system? Fewer procedures, more cost-effective alternatives, and comparison shopping all point to less work and lower reimbursement for doctors.
For most docs, there’s plenty of work anyway, but yes, we should consume less physician services too.
Productivity gains results in more being accomplished with less effort. Price competition lets you eliminate the basic if you choose. Work as much as you wish or raise your prices. Each physician will find their own comfort zone.
I’m sorry Jim, but I have to chime in to say I don’t think this article is carefully considered at all.
A few counterpoints:
Studies comparing healthcare utilization between the US and Western European countries really don’t show a tremendous difference. Europeans like going to the doctor, having tests, and undergoing procedures. The biggest difference is how much it all costs? Centralized price controls. That explains nearly the entirety of how Canada, Germany, the UK, etc. provide a similar quantity of care for far less than us. The same CT just costs less elsewhere. If all we did was reform pharmaceutical and device purchasing costs that alone would make a huge difference.
As for the notion that people/patients should be more knowledgeable, comparison shop, and have lots of extra money to contribute to their care, I’m surprised that someone who works in an ER thinks this is a realistic way to administer a healthcare system. We have to admit that a significant share of healthcare expenses and resources wind up going to a small percentage of very sick, disabled, or mentally ill people who are never going to put in more than they take out. Any decent prescription for a national healthcare system has to acknowledge this and ethically account for it. You can say “healthcare isn’t a right”, but it’s not a practically useful declaration when coming up with population-wide solutions. What do you do with sick people who can’t pay?
The problems with our healthcare system are vast, complicated issues that even most physicians don’t understand well. Why is it good public policy to put the solution on the shoulders of individuals? I would argue that is a recipe for failure. Universality is a good tenet for effective and popular public policy, and it might even make it cheaper. And throw in some price controls.
So you don’t think we should be more transparent with pricing and that you don’t think people should have any skin in the game? It’s not clear to me what you disagree with.
No, I don’t have a problem with pricing transparency or comparison shopping, nor do I have a problem with people who want higher deductible plans because they can afford them or they are willing to gamble on low utilization and good health. What I’m saying is: these aren’t population-wide solutions to healthcare delivery. These are solutions that smart, savvy, and more affluent people like you, and I, and the other readers of this blog would be attracted to and would benefit from, but would very likely have only a marginal benefit to the system as a whole. I am saying I am deeply skeptical these would make any meaningful impact on healthcare spending, access, or utilization across the country, and pushing more burden onto healthcare consumers adds complexity and frustration to system that is begging for simplicity and universality. I, as an individual, can’t actually do much to influence healthcare prices even if there was more of an open marketplace, so why pretend that the individual can fix this? It will require a bolder systemic solutions to fix our healthcare problems.
I agree with what you’ve said here, but this article declares “I am listing the 4 things that will fix American healthcare”, and I am saying “these are 4 nice things that I would like to see, but that in reality they would only chip away at the margins of improving our nation’s healthcare system”.
So self insurance with a high deductible is legally taken away from an individual that can afford the risk.
The benefit is to pay higher premiums in order to reduce premiums of others.
Socialized medicine completely. One size fits all? On average everyone is the same. The bottom half pays zero and the top half pay double. So wealthy with zero income pay zero. Many hidden problems with socialism.
I guess I have more faith in my fellow Americans than it seems you do. Sounds like you want a very paternalistic system of some type but you don’t actually describe what you think should happen so I’m not totally clear.
If you asked a resident of the UK, Canada, Germany, Switzerland, or France, “Don’t you resent the paternalism of your nation’s healthcare system?”, I don’t know if they could stop laughing long enough to have a decent conversation. Not to lionize these programs – they have problems – but their citizens wouldn’t swap with what the average American experiences.
I’ve been pretty clear about in which direction I think the solutions lie – not sure about the confusion. I get that you’re very individualistic, and that is the foundation of the excellent personal finance advice you hand out here. But why is individualism the only or the best way to tackle complex and widespread problems? When so many young physicians are experiencing financial stress, of course its great WCI is there to tell them to take responsibility and do the right things, but I also hope there is someone else out there noticing the problem and saying “Maybe this way of financing medical education and creating doctors is insane and needs to change”. And the list goes on. There are so many really big problems right now – retirement savings, college affordability, obesity, climate change, gun violence, racial and gender discrimination – that if the answer to each of these problems was “it is 100% on you to deal with this because our political society is not going to change a thing – here’s a tax credit, and by the way don’t mess it up” then most people would be walking around on Zoloft of Xanax or Oxycontin…(thinking emoji) Its funny, from my viewpoint yours is the far more pessimistic prescription for change.
Thanks for the smile. It is true that the vast majority of Canadians value their healthcare system and universal health insurance very highly. As a provider I certainly enjoyed my time in the system and was able to retire at 52 from a standing start. And I have never had a concern about my own healthcare or that of my family. Healthcare insurance just isn’t on the radar for most Canadians. It is just there. As a practitioner, the government didn’t ever seem to have any negative impact on my care of patients and in fact seemed absolutely disinterested in what we were doing. We never had to call anyone to get approval for any procedure although it is true that there are occasions when funding for very expensive drugs must be approved which doesn’t seem unreasonable to me. We are all hopeful that you will get the system sorted out. We’d really like to continue to visit the US in our retirement years!
A very succinct comment Josh that I think gets to the heart of the matter .I might add that on the payment side Single payer system like Canada has effectively mandate s payment through taxation. Gas may be 1.25 a liter (60% tax), there is a 7% GST on goods and services and high taxation on booze and cigarettes. Notice that these are items that you have choices to buy but when you do you are paying for healthcare (and education). Again I think the role of government is the key. Does it provide price controls and protect the consumer or sell the entire system down the river as it is lobbied by corporate interest?
Interesting.
-Government price controls needed to regulate costs. (Providers)
-Government administration needed to regulate
approval of service requests. (Patients)
-Funding provided by taxes or a combination of fees and taxes mandated by the Government.
Thoughts:
1) Will a “black market” be allowed? Can one obtain or provide care outside of the system or is it just not under “insurance “?
2) Will dental and eyecare be included?
3) Does Government have the ability develop and administer healthcare by regulation better than a free market approach?
4) Does Government have the ability to shield a national healthcare system from special interests?
Think Supreme Court nominations.
I can see many regulations trapping individuals or providers in unintended situations with no way out. A bureaucratic mess could result. Currently, patients and providers vote with their feet and pocketbook. That approach doesn’t work very well with a government run system which moves sloooowwwwlly. Think of IRS and the US Postal Service. I vote for free market with prohibition of predatory practices.
Medicare is funded by a payroll tax. Social Security is funded by a payroll tax.
There’s nothing novel or surprising in the government using tax revenue to pay for health care or private benefits.
What makes a single payer system unworkable when it’s been implemented by every other industrialized nation with good results?
The taxes current collected are insufficient for the commitments made for people that have worked 40 years. SS and Medicare are going broke. 49% of the people working now are covered by employer health insurance.
https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/
If I read this correctly, 37% is funded from the working population for those eligible for Medicare (over 65%).
This is not intended to be any type of analysis. Funding sources need to be developed for 63% of the medicare current payments and for 51% of employees not covered by employer plans. Those are big hurdles.
https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/
Medicare and Medicaid,Chips, and ACA are at 26% of the federal budget.
My point is simply the economic numbers are going to be extremely difficult.
Defense spending is at 15%, to compare government spending to another country, one would need to look at the total.
The US economic model had private providing some functions that others are private.
I simply am leary of adopting other countries models in the face or China and Russia. If we add significant healthcare funding, something will need to be cut. Raising total healthcare costs will be paid in some fashion. Quite honestly, I don’t care if its single payer, increasing healthcare is going to increase costs. Can we afford it? The assumption that Medicare is paid from employment taxes is in correct. Not an arguement, it’s the “slogan” of single payer needs numbers behind it that I am not capable of doing.
If we move towards universal, government-sponsored (in full or partially) health care, it relieves the burden on employers to provide this to employees, and it relieves the burden on employees to pay for health care through payroll deductions. Framing the question “where in our current US Budget can we fit in universal health care?” isn’t right. Money spent by employers and employees on private health care will be transferred (ie taxes of some kind) to pay for the bigger government system. Some will win, some will lose. Just like in everything in life. The idea is to make the whole system more efficient.
The only healthcare system that seems to be working is Medicare. And that is partially broke. Forecasted to run out of funds in 2026.
The remaining healthcare is a mixed bag, company sponsored, individual plans, ACA, and Medicaid.
The costs and terms of these plans vary greatly. My plan has $150 annual deductibe and a $20 copay.
Would I choose to pay for that plan when another plan has a $7000 deductible? My cost and the employers cost would drastically change.
The total dollars available are insufficient to pay for coverage most people would find meet “universal coverage”. It is a “battle of the have’s vs the have not’s”.
The current “basic” is ER care. That’s it. The ACA affordable plans seem high cost and involve significant high deductibles. Many counties have only one option. It’s not that the “have’s” want to deny healthcare, it’s the costs are currently broken, expanding coverage and adopting single payer doesn’t solve the problem. A significant segment of the population either can’t or won’t be able to pay for healthcare.
The shenanigans used for Obamacare promotions turned out to be misleading. Saying “single-payer” has the same impact as “you can keep your doctor and your plan. Costs will go down”.
The political slogans are a problem as well. Rebranding is not the solution. What will be the “coverage” and “what will it cost me” is the answer we all need. No one cares who pays it, government or private.
It is simply the “have’s” versus the “have not’s”. The have’s would include those with employer coverage and those that currently pay on their own. They currently outnumber the have not’s.
Further moves to socialized medicine will be resisted due to the failure of Obamacare promises. Anyone making $50k is being drastically impacted already. What is “single payor” in terms of coverage and cost to me? I get the feeling it would be much higher. I respectfully submit that I would not be willing to pay healthcare for a brother or his family. Sorry, should have had insurance. It’s economic and a personal choice.
Excellent point that the devil is in the details. Not all single payor systems would be good, nor would all necessarily be bad.
Many people consider plans like yours with $150 annual deductibles part of the problem. WCI talks about skin in the game. $150 is nothing when it comes to health costs. You (general, not specific) will be incentivized to go see doctors more, request tests of all kinds, use inappropriate resources for your care. You pay a flat fee every month, why not get the most bang for your buck? That’s not a moral fault, it’s just employing the tools you have. Higher deductibles change that behavior, for everyone’s benefit.
I think you are painting with too broad a brush when criticizing the ACA. Ask an artist or self-employed 50 year old with diabetes or cancer how they like the ACA. A not insignificant portion of ACA’s ‘failures’ can be attributed to purposeful mismanagement by its detractors.
Again, you already pay for your brother’s insurance. That’s how insurance works. You aren’t paying just for your costs, your paying for everyone’s. Including those without a plan who get sent to the ER and slapped with a $200k bill they won’t pay. More people in the system will make it cheaper for me; that’s my economic and personal choice.
I do greatly respect your point of view. For an employer to offer various plans, there is an employee cost as well. I am eligible for Medicare, but the cost of a 2 dependent plan vs an employee only plan vs a family plan are much different. How we choose to spend a paycheck is our choice.
The artist and self employed 50 yr old if they make $50K per year will get screwed under ACA.
Full premiums and a big deductible. Two times if they get sick in December and it drags to January.
I 100% agree that life threatening emergency care and preexisting conditions need to be addressed.
One example with two components: birth control and delivery of a child.
Birth control is not expensive and is a personal choice in family planning. Is it a financial issue really? I have never heard of it presented as an “affordability” issue. Why is it free?
Delivery-the ER sign might as well say “FREE”, some have a plan when to hit the door.
The front desk intake door you actually register. If you have a plan, you will pay your deductible upfront. All because of the subsidies that can be gamed.
You have “wealthy physicians” talk about managing income to hit the the limits to get ACA subsidized rates.
My point is it is the have’s vs the have nots. The middle 10% to 90% pay dearly for this plan. The concept of basic health care was expanded to redistribution of wealth.
It’s a good point that money is fungible, whether it is paid as salary and you buy your own health insurance, whether the employer provides insurance, or whether you pay more in tax and are provided state-sponsored health care.
However, I find it interesting that in pretty much every country with a single payor system, there are still people and doctors interacting outside of it for cash or private insurance benefits.
Great Post! One factor which is missing from your analysis is the negotiated discounts insurance providers (ie private insurance, Medicare and Medicaid) are able to negotiate from providers, especially when it relates to hospitals, Surgicenter, and drugs. The opaqueness that you mentioned is indeed very real. As a previous principal of medical insurance plan, we would commonly see cost inflated 200-400% above negotiated rates charges to large insurance providers for the same procedure. What other industry in the US has such disparity in rates charged for similar services?! Why should a cash paying-patient be required to pay 2-4x what a patient with insurance does?! We could go a long way to reducing health care cost by full disclosure of providers fees AND regulating the % reduction of allowable contracted payments permitted by insurance companies (say 20-30%).
I appreciate this post very much, and applaud your courage for clearly stating your thoughts beyond a shadow of a doubt, even those which are controversial.
When DW has a hospital stay, I get separate bills from the hospital, the surgeon, the anesthesiologist, the hospitalist, and so forth.
When I go to the auto dealer, I get an estimate in advance. There is one bill. I do not receive separate bills from the dealership, the mechanic, the tire company. I do not get a bill from someone I never saw six months later.
Even Dr Dhale miss the point: Socialized Medicine is like curing the brain tumor cutting the head: you want to see a terrible use of resources, try socialize medicine.All the points are relevant, along with legal reform. For somebody that lived and worked in three different countries , and have closed relatives working in Europe , our is the less worse of the systems. For around 15% of the population is very unfair.
All I can say is you better have your advanced directives in place.
I am serving as caregiver for someone who had the foresight to have a health care POA.
And who was diagnosed with stage IV cancer last month, as well as severe COPD (heavy smoker for 50+ years)
I moved them from their nursing home (post hospital stay) to an assisted living facility near me…even with the nursing home wanting them to stay “so their medical needs can be met.”
It was clear that the other residents I saw at the nursing home were having everything done to them to keep them alive a few days, weeks, months longer…whether or not they wanted it, or whether or not it was something they should have had done to them.
Fortunately I got my loved one on Hospice…but most won’t.
I have “heard” that virtually every ER physician has advanced directives in place.
The reason ,as I understand it , is that the standard protocols , even if successful ,result in outcomes they prefer to decline.
Similar to your choice of hospice care for the reasons you noted.
“And instead of having attorneys and courts police the medical profession, the death panel can do it. ”
I think it’s a bit naive to think doctors will robustly police malpractice by other doctors. Not saying Tort does a great job, but hoping that doctors, who have more affinity with doctors and can put themselves in their shoes more than they can a patients shoes, will bring the hammer down seems…misplaced. Indeed, just getting doctors to stop making residents work 30-hour shifts (which is effectively like working drunk) took way too much effort–so I don’t buy the “doctors will look at the evidence dispassionately” argument.
In a country where the number of deaths annually due to malpractice runs into the hundreds of thousands, less accountability seems neither effective nor just.
(https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us)
So…you think the death panel should be populated by plaintiff’s attorneys as a way to reduce health care costs?
Yep, that’s literally exactly what I said (dripping sarcasm)
What I said had nothing to do with “reducing healthcare costs” and at no point did I say anything about plaintiff’s attorneys sitting on death panels. (I read it again to make sure)
My point was that if you are concerned with accountability and reducing deaths due to medical error/neglect, letting doctors have complete power over which doctors should be held responsible for their actions is a bad way to go about it. I have no particular love for the tort system, but it has a long history in English common law in compensating victims for the damages they incur (in all fields) and it works much better than the way outlined above.
Said simply, reducing healthcare costs isn’t the only goal of the healthcare system.
I made the point I did b/c I agreed wholeheartedly with the first three points/goals, just not with the fourth.
Hi. I’m not in the medical profession….I read posts over here following links from the Oblivious Investor e-letter. This is a really interesting post & thread on health care reform. But, it is all based on the premise that we (the US) are spending too much money on health care. Maybe I’m one of the few people in the country who disagree with that … I don’t think we, as a nation, are overspending. Sure, we can find all kinds of areas where wasteful and unneeded spending is taking place. That is inevitable in any large, complex system that involves humans. But in general, as a society, we are meeting every material need of our citizens. Beyond that, everyone has access to beautiful parks, cultural resources, entertainment, leisure activities, etc. We have to continually think up new things to make that we can spend our money on (have you seen those 65 inch LG OLED TVs? Awesome!). Abject poverty has been eliminated, and there’s little more that can be easily done to improve the lot of people living on the bottom rungs of the economic ladder (because poverty can be self inflicted .. you can’t force people to live responsible, productive lives).
So, given this, why wouldn’t we want to spend a substantial fraction of our wealth on improving our health? Look around at what the last 50 years of major spending on health care has bought us. It is amazing. And, like any technology, it starts out very expensive but gets cheaper and cheaper. I’ve been on Lotrel for 30 years and Lipitor for 15 years. Used to be expensive, but I can buy generic versions today for peanuts. The investment has been made and paid for. Now the stuff is cheap, but is giving me a level of health that was not available to my dad. Imaging technology is astounding. Genetic therapies are on the verge of having some success. Hi tech artificial limbs. Pacemakers. Joint replacements. MS treatments. The list goes on and on. And all of this stuff becomes a permanent part of our civilization. And most of this has been developed because US citizens have been willing (even though complaining all the way) to pay for it. And, there are still plenty of resources left over for guys like Bill Gates to try and solve 3rd world health problems where the profit motive in not available to drive the kind of innovation we see in the US. So, I guess my thought is I would hate to see some giant health care reform that saved a few bucks in the short term but killed the engine of innovation.
An excellent point. Maybe we should be spending 20% (or whatever) of GDP on health care. Certainly since people want it and it’s expensive we should expect to spend a big chunk of personal income on it.
An amazing post – all excellent points – thank you for telling it like it is!
How did Buffet, Bezos and Dimon not choose you to lead their healthcare initiative??
I just got an email from someone showing me their Utah ballot. They wrote me in for Congressman. I guess they couldn’t decide between Mia Love and McAdams.
The miracle of the internet.
“If nominated, I will not run.”
“If elected, I will not serve.”
Politics can get so dirty. At least as a write in, “no comment “ is reasonable. It could have been a prank, ask your wife. You might need a PR firm before Fox and CNN send cameras.
Hope it’s not on Twitter.
I wish our Senators and Congressmen would look as these discussions, but they are only listening to the Big Corporate Medical Groups that fund their pocket books. Our Medical System wouldn’t have to collapse to make true reform possible if these elected “representatives” of ours would put their noggins together and figure something out. Obama tried but he was stonewalled all the way, by insurance companies and hospital corporations and the Pharmaceutical industry as a whole. Capitalism is what has destroyed HC in American. Shocking Statement, but true. Used to be Doctors were altruistic human beings who often didn’t charge for their care. They took their Hippocratic oath seriously. Now, it’s about overhead and profits and how many patients can I see in a given hour. How can we hold our Congressmen and Senators responsible to work to combat the Merchandizing of Medicine?
1) Become involved
2) Contribute your time and expertise
3) Get involved in making your local community a better place to live.
4) Support developing policies that aren’t based on slogans or party affiliations, but rather unbiased facts that consider not only the specific issue, but unintended consequences as well.
Democracy is a messy terrible way govern the USA. It’s just less terrible than any other system of government.
5) Vote – Hold your nose, pick the least terrible candidate.
No one will do it for you. When’s the last time you wrote to anyone in government? Local, state or federal?
Pick an issue, define it, support it, ask to be involved. Then send it. Getting some of the brightest minds involved would seems to be an unrealistic dream.
I don’t see why the best and brightest would want to be involved in politics given the way politicians are treated by half of the country. There must be a lot of idealism present to be able to combat that.
I mean, look at this Tweet I just say on my feed (with 9.4K likes):
Who needs that? I mean, it stinks to have to take your work home from time to time. But to have to take it with you to the park, to the restaurant, to the movie theater etc. Give me a break. If you treated elected officials that way you’ll soon get the officials you deserve.
“No politician was conscripted to serve. They asked for the opportunity.”
Who we are as American’s is the fundamental flaw with a significant portion of the population’s attitude now. (Regardless of which way your believe the country should go).
Elected officials were “public servants” representing the voters that elected them. Local residents that were successful and were trusted to vote and advocate for the majority of their districts or states. Sacrifices were made but some compensation was allowed for campaign expenses and time taken away from their own personal interests. The concept was “public service was sacrificing to serve the interests of their voters”. The best and brightest would find a way to do their civic duty.
Now it is drastically different. A wealthy person in Oklahoma picks out a person or group to “harrass” someone in Toledo or DC with orchestrated TV simply because they have a different view on an issue. Home, restaurants, in the airport – make them so miserable they submit. Quite honestly, the way the laws are written, harrassing a politician or government official should be treated exactly the same way as a private citizen. Should Dr Ford be harrassed? Should a Senator be harrassed?
The American way requires equality. Protesting or stating your views has limits. The same limits for all people, elected or not.
Thank you, I agree this whole “health care is a right,” thing is idiotic and have been telling my friends and family this for a long time. Until we have free food and shelter there is no way we should be talking about free health care.
Pareto Principle. It’s like that in every industry. 80% doctors are just not that good. You have to find the 20% that have specialized knowledge and can troubleshoot clinically and intuitively. But most doctors have too much built in debt and a perpetual debt laden lifestyle in which they feel the need to prove themselves (because of their inferiority when they were younger and labeled geeky) by achieving status. (Cars, homes, clothes etc.)
Demand, but also supply. How about the fact there simply are not enough physicians in this country?
Med school acceptance rates are lower than Harvard undergrad. A decade of training and licensing and hundreds of thousands in tuition with a risk of not even getting a residency.
If the shortage is not addressed, large swathes of rural America will not receive medical care. There simply will not be capacity.
I don’t think there is actually all that much of a shortage. Last I checked the bigger problem was a maldistribution problem. Rural America doesn’t have docs because docs don’t want to live in rural America. They thought APCs would solve this problem, but APCs don’t want to live there either.
And your statistic about Harvard undergrad is bunk. The Harvard acceptance rate is 4%. Med school is about 40%, probably 60% among “serious” students. The recently higher unmatched rate is an issue though, I agree.