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November 26, 2010

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Hey look, colonoscopies, brain shunts, lung transplants, and liver CAT scans on sale, short time only! Hurry!

http://cunningrealist.blogspot.com/

Just like shoes.

All healthcare systems ration. A completely free-market system would ration purely on ability to pay. Out of money? No more healthcare for you, unless you're lucky enough for a charity to step in.

A completely socialist system would ration based on some sort of cost-benifit analysis of procedures. You get waitings for non-life-threatening stuff. You get, at some point, denial of additional care (pull the plug on grandma).

Either way, you get rationing because no system can deliver unlimited healthcare to everyone. Both approaches have their weaknesses. Looking around, I pick the single-payer approach as the better of the two. Failing that, give me some type of Wyden-Bennett thingy, I think.

We got neither. Joy.

"This is interesting, but how many get their hips replaced who otherwise wouldn't?"

And how many get new hips they don't need? Orthopedists got bills to pay, too.

Health Affairs pegs the cost of defensive medicine at 2.4% of the total. As Morat says, not the chief cost escalator.

I wish I could read this paper; I'd be interested in seeing how the determination was made. The estimate actually seems to be about the amount spent on malpractice insurance in this country, and lower than other estimates as well.

It's difficult to measure the costs of "defensive medicine" because once you've trained a physician in residency to practice it, that's the way they'll practice in any environment, habits being hard to break. You can't evaluate how medical costs change immediately following changes in malpractice law; it's a change that you would almost have to wait generations to see.

I'm still not convinced it's a major contributor to costs, though. A creeping standard of care probably contributes more. As more technology and specialists are introduced, the standard of care rachets ever upwards. In the 70's, a stroke would be diagnosed by a generalist or medicine specialist with a physical exam and history; now everyone gets a non-contrast CT, MRI/MRA, carotid dopler and cardiac ultrasound, at least, as standard of care, independent of the patient. This is exactly what happened to my grandmother, in spite of the fact that she suffers from advanced dementia. What makes sense in a 50 year old doesn't in a dying 90 year old, but one deviates from the standard of care at one's peril.

So what you're saying is that, when faced with this challenge, the LAST think the US should do is go "Hey, why don't we go after the low-hanging fruit, convert to a system like France, the UK's, Canada's, and cut our costs in half?"

Bluntly, I don't think we can have a system like France's (still the most expensive in Europe) because we're not France. You can talk about "plucking the low hanging fruit," but chopping physician reimbursement in half while cutting medicare reimbursement to 70% of costs is only low hanging fruit if you're picking from the top of the Chrysler building.

There's not magic to the European system. You just pay your doctors and nurses less, and voila, savings out the wazoo. In a European labor market, you can get away with this. In the US, you would have a mass exodus from the field of medicine as doctors decided that seven years of post graduate work and $200,000 of debt to work sixty hour weeks was not worth $65,000/year (minus malpractice insurance and business costs).

And yes, I know, Europe subdizes medical education, which simply allows them to hide a portion of their medical spending in their education budgets, making American and European comparisons more apples to oranges.

A lot of these comparisons to Europe or Japan are useless because we can't get there from here. We're talking about societies that have been evolving for hundreds of years or even millenia, and the healthcare system, like the rest of the economy, is an expression of the society and can't be changed by governmental fiat with any reasonable degree of ease.

A lot of these comparisons to Europe or Japan are useless because we can't get there from here.

If what we do now is not sustainable, which arguably it is not, we're going to get somewhere from here.

Might as well be somewhere good.

There's not magic to the European system. You just pay your doctors and nurses less, and voila, savings out the wazoo.
Wow. That is so completely wrong. I mean, REALLY wrong. Like "The Sun orbits the Earth" wrong.

The various nationalized systems are cheaper for a handful of reasons. "Lower Doctor Pay" is not a major one.

It starts, of course, with the fact that the incentives of a single-payer or national system are preventative medicine. It helps that there are not multiple profit-seeking layers, of course.

And the big one: The pool is the entire population. The healthy subsidize the sick, because you never know when you'll move from one group to the other. EVERYONE pays in.

Here in America? The incentives are to deny care, as long as possible. (Hopefully you'll be on another insurance plan by then, and it starts over). Everyone's out to make as much money as possible -- heck, it's the law for the public companies! Way too much is spent on overhead -- from dealing with a million and one plans, to trying to get them to pay, to just trying to get them to OK your procedure.

Preventative medicine? Please. I have great health care -- who charged me the full cost for a lab because it was not 'routine and necessary'. Never mind that it was a test for a specific, genetic propensity to clogged arteries -- but one that isn't paired with high cholesteral. (My father has it. He's had several heart attacks. Yet a 40 dollar a month medicine drops him back down into the 'normal' risk zone, instead of the risk zone for a guy whose arteries are basically full of lard).

A sane system would have paid for that test, because knowing it NOW prevents expensive hospital stays and heart attacks later.

Single-payer and socialized systems cost less not because of 'European Evil' or whatever, but because they approach the problem from a sensible perspective. They start with the realization that they won't let the poor die without care, and then move onto "how to pay for it the most efficiently".

Here in America? We let the poor get to the brink of death from treatable illnesses, and then let them clog up the ER and ICU's, running up huge bills...that get passed onto us.

There's a reason Singapore -- poster child for the free market -- took one look at the US system and ran screaming for something sane.

"If what we do now is not sustainable, which arguably it is not, we're going to get somewhere from here.

Might as well be somewhere good."

Can you chisel that in stone somewhere?

"You can talk about "plucking the low hanging fruit," but chopping physician reimbursement in half while cutting medicare reimbursement to 70% of costs is only low hanging fruit if you're picking from the top of the Chrysler building."

The lowest of the low-hanging fruit is obvious, but politically a third rail: Stop paying for things that don't work or don't make people's lives better.

We need more effectiveness research, but we've already got a fair amount of it -- we're just afraid to use it.

Phil: "Do you mind if I ask how, as some kind of engineer or another, you're qualified to diagnose sociopathy, which is an actual medical thing?"

Do you mind if I ask how you, not an astronomer, are qualified to notice that the sun rises in the East, rather than the west? I might be unqualified to treat mental illness, that doesn't stop me from noticing that somebody is nuts. And that sociopathy is common among politicians is hardly an observation I'm alone in making.

"We need more effectiveness research ...."

That's a death panel. I learned this as part of FOX's minuscule viewership and after listening to Rush Limbaugh's highly influential variety show.

Better that we have Death Palins:

http://news.opb.org/article/18524-arizona_budget_cuts_put_organ_transplants_at_risk/

Morat20:

Thanks for your comments.

I have proposed in the past a radical, extreme, virulent tax revolt on a national scale from the Left -- as in ..... the opening bid to counter the Right's refusal to permit a rise of several percentage points in the high marginal tax rate would be "fine ... then we don't pay a single cent of the lowest marginal tax rate to any government run by the Right, and that includes SS and Medicare taxes.

Either taxes are theft .. or they are not. Let's settle it right now.

Just so, a nasty, virulent movement to counter the treatment of the poor and uninsured and many of the insured you reference should adopt the tactics of the extreme anti-abortion Right, starting with extravagant use of the word "murder".

No sarcasm intended.

We're talking about societies that have been evolving for hundreds of years or even millenia, and the healthcare system, like the rest of the economy, is an expression of the society and can't be changed by governmental fiat with any reasonable degree of ease.

Health care systems are a relatively new, dating to about the time of the end of the Industrial Revolution. They differ enough from traditional medical practices that I don't think traditional medicine can be termed "medical" as we know it. We also have examples of countries (Taiwan and Singapore for example) choosing from existing Western/European systems for themselves. Changing our current system, with entrenched, powerful constituents, will be hard, but to argue that it's current existence is part of a preexisting cultural underpinning is going to take more than implying it's there. If anything I'd argue that our current medical system's inertia is more a result of the fragmented nature of our medical system than the inverse.

Brett:

Do you mind if I ask how you, not an astronomer, are qualified to notice that the sun rises in the East, rather than the west? I might be unqualified to treat mental illness, that doesn't stop me from noticing that somebody is nuts.
Brett, without elaboration, you're qualified to notice east/west, or I'm prepared to stipulate that without checking, at least. You're obviously unqualified to make medical pronouncements, and "nuts" and "insane" and "sociopathic" aren't even medical terms.

A kluger vaist vos er zogt; a nar zogt vos er vaist.

"that doesn't stop me from noticing that somebody is nuts"

Not stopping yourself doesn't make you correct. It's not even headed in the right direction. "Noticing" isn't what you're doing, either.

Folks interested in health care costs would be interested in this recent editorial in the New England Journal of Medicine, which examines some of the reasons for the low cost of medical care in Grand Junction, CO, compared with the rest of the nation. Atul Gawande also discussed this in his New Yorker article cited upthread.

I think the idea that only psychiatrists and psychologists are able to notice and correctly talk about obvious psychological problems is both a fallacious appeal to authority and shows inappropriate deference to a very immature science.

Diagnosing the fine DSM category may be more than a layman can do, but noticing the broad outlines isn't. It's like you're asking only physicists to talk about gravity. I don't need to be able to talk about the mechanics of bending the space-time continuum to be able to notice that the stick falls. Brett doesn't need to have a government license to prescribe medicine to note that high level politicians seem to have more high functioning sociopaths and scary narcissists than the average population.

Chris J, where's the tort reform?

Sebastian, well said.

But what cracks me up is when the "average population" (yes, Marty, I'm one of those, too) prefers and elects low-functioning sociopaths and scary narcissists to office on account of the fact that the latter are just "one of us".

More to read:

http://www.dailykos.com/storyonly/2010/12/1/924523/-Top-economist-calls-bullsh*t-on-Deficit-Commission

Chris J, where's the tort reform?

It's a small piece of the total costs. There's a good deal of research about this. I think the most important point is that torts are actually a very poor way to compensate injured patients: those who are injured typically don't sue, and the majority of of cases find for the physician (80% or so, as I recall).

Defensive medicine, a downstream effect of fear of lawsuits, accounts for about 2.5% of total costs, according to the Health Affairs link I posted earlier. So there are some savings possible there.

I practice a very high-risk specialty for getting sued. After 30 years of doing this, I agree -- it's a small piece. I'd like to see some sort of workmans' comp panel approach to compensating injured patients. That might even increase costs a bit, but it would be much fairer to patients than the lottery we have now, with folks looking for the big score.

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