The future of medicine ...

[kinetic]

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I started this thread because I didn't want to muddy up the other tax thread - let's keep these threads separate. Also, I'll state up front that I'm a conservative who supports Bush, but let's keep this to a discussion of ideas, not a pro-Bush/pro-Kerry thread. (I know you'll all ignore me by the third post. )

My opinion is that people have confused 'rights' with 'privileges' in today's society. People say jobs are rights because people need them to survive, that driving is a right because you need it to get to work, and that health care is a right because you need it to live. Sorry, but those are all privileges.

Now, with that in mind, you can be for socialized umbrella medicine for all (which I'm not). However, understand that by necessity that means two things:

1) People may be able to access a broad range of preventative and general care, but specialized care will, by definition, become quite limited (i.e., if we have a finite amount of money pooled by the government to treat the entire population, then only a fraction of that pool can be used in the more complicated and high-end procedures). This is why we have the theory of 'gatekeepers' and HMOs - because in theory we have to be very cautious about having people run to specialists, who generally perform more complicated and expensive tests.

2) If medical reimbursement is tied to the government and third-party payers, rather than first-person (out-of-pocket) pay, market forces will no longer apply. In other words, compared to elective procedures - which are self-limited to those who can afford it - covered procedures are available to all regardless of ability to pay. Since there is no 'means test' for these procedures, reimbursement is arbitrary and not tied to the actual cost of the procedure. This has led to our current reimbursement system, which many doctors rail against - getting back pennies on the dollar for the cost of a procedure.

So we are at a crossroads. A lot of people, doctors included, feel guilty about saying that anyone should not be able to get any procedure. But a lot of people, doctors included, dislike the consequences of such a system. So what's to be done? If we continue on our present course - especially with a growing elderly population - look to reimbursements to start shrinking even more. If we go to a pay-to-play system, millions of people will not get treatment.

Optimally, as a conservative, I would go for pay-to-play (don't bother posting to call me heartless). However, that would never fly in this world. So my compromise: make primary care available universally, consisting of yearly exams and any necessary initial screening tests. Any people who participate in this preventative step over their lifetime get subsidized by the government for any further costs (e.g., the excision of a tumor found). Any people who ignore prevention and show up after 50 years of smoking 4 ppd with a chronic cough, hemoptysis, and a lung mass; complications of obesity; or other problems have to pay out-of-pocket. That's my opinion.

Whether or not you agree or disagree, it'd be great to start a discussion of this as an issue. I hope we can do it without resorting to name-calling (I don't think I insulted anyone in my post).

 

[MacGyver]

People can have an honest disagreement regarding whether socialized medicine is better for patients rather than the current system.

However, when it comes to doctors, not a soul on this planet can legitimately argue that socialized systems are better for docs.

If socialized medicine comes to be in the US, it will be an absolute disaster for doctors.

 

[beriberi]

This soul would rather work under socialized medicine.

If you think about the things which make medicine anything other than a sheer joy to practice (i.e. arranging for follow-up, trying to find a source for pts rx, disputes over billing) many of these are caused by the burden of caring for uninsured pts in a system which has evolved to care for the insured. Drs may well make less money under a socialize system (though, I am not convinced of that, either) but job satisfacton is not directly tied to compensation (though it would be naive to say it is not correlated). My point: a well-done socialized system may make medicine better and more enjoyable to practice.

Sweden is an example of a place where the system works very well. Drs are well paid (compared to people with equal levels of education, though are paid significantly less than their U.S. counterparts), work 40-50 hours per week, recieve the standard 6 weeks of vacation AND provide higher quality health care at less cost to the country. You probably have neve met an IMG from Sweden; they certainly don't come here looking for greener pastures.

Additionally, many doctors practice a kind of socialized medicine (ER physician, hospital ward attendings). Doctors that treat all comers would not be negatively affected by a single payer system; they may benefit financially from all of the reimbursement that they now cannot collect.

I believe there are many arguements for socialized medicine (not only the "right" to health care) and that rational people can disagree on this topic. However, it is not rational to say that doctors do not benefit froma single payer system.

 

[jalabert]

Originally posted by beriberi
This soul would rather work under socialized medicine.

If you think about the things which make medicine anything other than a sheer joy to practice (i.e. arranging for follow-up, trying to find a source for pts rx, disputes over billing) many of these are caused by the burden of caring for uninsured pts in a system which has evolved to care for the insured. Drs may well make less money under a socialize system (though, I am not convinced of that, either) but job satisfacton is not directly tied to compensation (though it would be naive to say it is not correlated). My point: a well-done socialized system may make medicine better and more enjoyable to practice.

Sweden is an example of a place where the system works very well. Drs are well paid (compared to people with equal levels of education, though are paid significantly less than their U.S. counterparts), work 40-50 hours per week, recieve the standard 6 weeks of vacation AND provide higher quality health care at less cost to the country. You probably have neve met an IMG from Sweden; they certainly don't come here looking for greener pastures.

Additionally, many doctors practice a kind of socialized medicine (ER physician, hospital ward attendings). Doctors that treat all comers would not be negatively affected by a single payer system; they may benefit financially from all of the reimbursement that they now cannot collect.

I believe there are many arguements for socialized medicine (not only the "right" to health care) and that rational people can disagree on this topic. However, it is not rational to say that doctors do not benefit froma single payer system.

Unfortunately, (or fortunately for the Swedes) scandinavians, in general, think about their health in a different way. Let's face it, the big problem with health care in the US is not the compensation system, but the mantality of many Americans. That mantality being, one does not need to exercise, pay attention to what they eat, or follow a regular checkup program, and yet, expect to get the best health care in the world when they show up at an ER with a diabetic foot and no health insurance. It is unrealistic to cite a Scandanavian model that works well, as a model for the American system, when the two societies view responsibility for their own wellness entirely differently.

Further, the tax burden is much higher in Scandanavian countries, and this is necessitated by their socialized system of government. Most Scandanavians are comfortable with this and understand you can't get something for nothing. That level of taxation would never fly in the US, so where would the money come from for such a system.

Finally, the US is spreading its nutrional and activity patterns around the world. As obesity and type II diabetes become more prevalent in European countries, I will be interested to see how this impacts their healthcare systems.

 

[kinetic]

Couple of things:

First of all, I don't know anything about Swedish medicine, so I'll take your word for it. But realize that these socialized countries have exactly the problems I spoke about. Only a few years ago, Canada had fewer MRI machines than Pennsylvania - I don't know if that has changed yet or not. And Swedish FMGs might not be coming to train here, but neither are US grads or foreign dignitaries who need care going to Sweden. Every time you hear about some complicated surgery to separate conjoined twins or some person who requires multi-organ transplant, they come to the US.

If you like socialized medicine, be prepared for decreased facilities and fewer resources for any one particular person. I don't think that's rhetoric ...

Any comments on my proposal for reform?

 

[frotteurism]

Excellent posts?

First, I think it?s obviously very difficult to compare the American system to that in other countries for a number of reasons, but most important is the difference in annual expenditure per capita. A quick google search yielded this British document

http://www.parliament.the-stationery-office.co.uk/pa/cm199899/cmhansrd/vo990615/text/90615w14.htm

that contains a report from the Organisation for Economic Co-operation and Development that lists health care costs throughout member countries (in 1996). The rightmost column shows (as I?ve heard many times before) that the US spends $3898 per person per year.

That?s over twice that of nearly every other first world nation. Canada spends $2065 per capita, Sweden $1675, the UK $1317. Thus, it should be no surprise that these countries aren?t littered with MRI machines and CT scanners. If Canada were willing to double its annual expenditure on health care to match us, they would unquestionably have more money to throw around on high-tech equipment and an army of subspecialists.

Thus, the complaints that are frequently heard that ?you have to wait x months for a CABG in England? may be true, but that can?t be blamed on their socialized system of medicine when they?re spending 1/3-1/2 what we are. Thus, health care also does not explain the higher tax burden of Sweden (they have a number of comprehensive federal services that account for this tax burden).

First, I think socialized medicine would eliminate an ungodly amount of waste. Medicare operates with 3% ?overhead? (costs dedicated to administrators, paperwork, i.e. anything other than patient care). The Canadian system operates at about 1%.

HMO?s operate at about 25%. Privatization may reduce red tape and inefficiency in some areas of economics, but it certainly hasn?t in health care.

Anyway, those issues aside, I think your proposal wouldn?t work, simply because we?ve decided (and I think rightly so) that commodities that are necessary for life should never be denied to anyone, which is why we have things like food stamps, public housing, and Medicaid. Does such a safety net reduce personal responsbility? Sure. Does it allow some people to abuse the system and be irresponsible? Of course. But people will always make mistakes. I for one would not want to deny someone chemo (for the patient in your example) simply because he screwed up. For only a few thousand dollars a year, this patient could be kept alive maybe another three years.

Why didn?t this person take advantage of preventative care over the years? I doubt he maliciously assumed that he could be as careless as he wanted and when the time came that he needed treatment figured that society would foot the bill. He may simply have a poor understanding of the significance of prevention and never have considered it a priority to follow up carefully with a physician.

Third party payer may result in less personal responsibility and potential abuses of the system than a simple fee-for-service, but as soon as you force people to be able to pay even for simple lifesaving treatment (even if it?s supposedly ?their fault?), thousands will suffer and die simply due to their lack of understanding of the consequences of their actions. Which is the greater tragedy? To me the choice is clear.

 

[kinetic]

Originally posted by frotteurism
...the US spends $3898 per person per year. That?s over twice that of nearly every other first world nation ...Thus, it should be no surprise that these countries aren?t littered with MRI machines and CT scanners. If Canada were willing to double its annual expenditure on health care to match us, they would unquestionably have more money to throw around on high-tech equipment and an army of subspecialists.

I think that's the point I'm getting at. If we socialize medicine, we have our current pool of money covering more people - the people who are currrently uninsured. That means that we will find ourselves in the same predicament as these other countries. Plus, the amount of money spent per person in the U.S. is inflated because you have to figure in all of the money people DO spend out of pocket for elective (usually cosmetic) procedures - that money would not be part of this pool for everyone.

I do agree that slashing the bureaucracy would certainly help, but considering that costs for medical care will explode with a growing elderly population, those savings are sure to only go so far for so long.

Anyway, those issues aside, I think your proposal wouldn?t work, simply because we?ve decided (and I think rightly so) that commodities that are necessary for life should never be denied to anyone.

OK, I can accept that. And I'm not saying that these people who show up all of a sudden with a 50-year history of smoking, DM, CHF, and ESRD in DKA with a lung mass do it purposely or maliciously. (Like, "heh heh, I'm gonna make myself sicker just so I can make society pay more!! Yeah!") I'm just saying that a lot of these people certainly have not done their part in their care. A lot of problems today arise with the "it's broken now, so fix it at any cost" mentality, with no responsibility to practice prevention or participate in their own health. I'm sure you have all met the patients who think that "you're the doctor, so make me better and I'll just lay here in bed". That's why my proposal rewards those who are diligent in participating in prevention.

All I'm saying is that we can't have it both ways (that I know of). We can't say that we treat everyone for all these diseases regardless of ability to pay and maintain our current levels of care ...UNLESS we wring cash from those who CAN pay. I know that some people don't have problems with that way of thinking, but I do. It seems to punish those who have earned money and reward those who haven't. Which is the whole problem of socialism, in my book.

P.S. Thanks for keeping it civil so far, guys!

 

[Adawaal]

Great job so far keeping this a positive discussion. One thing that I think gets lost in the typical conservative-liberal debate on how to provide care for the 44 million uninsured is, "What is socialized medicine?"

If we can use the term socialism for services in the same manner that it is properly used for industry, socialism is the government ownership and control of the means of production. (I know, for many of us, 8th grade civics was a loooong time ago )

A single-payer system is not necessarily socialized medicine. Socialized medicine is where all physicians are employed by the government and the government owns all the hospitals, CTs, etc. It is not difficult to imagine a system in which there is some sort of public-private (but not fed) ownership and where physicians work for themselves or another group, but where the federal government is the single payer. This is what Medicare is after all. (And before anyone starts going on about the impending death of Medicare, it's due to a number of fixable structural factors and not "just 'cuz those wacky feds are too stoopid" to run things well. Differences of sociopolitical opinions are fine, but let's not resort to the misinformation that we see in the popular press.)

In fact, our VA system is precisely what socialized medicine is: federal govt owns the hospitals, clinics, equipment, floor wax, etc. and actually hires the medical personnel.

Anyway, I just wanted to clean up this language about "socialized medicine." I'll keep my opinion about whether or not a single-payer system is the best model to myself.

 

[mdblue]

It depends on the people who practice medicine and who receive the care, not any particular ideology. Just look around all those scams that are happening all around(the latest I heard is the tx of sweaty palm syndrome), be assured they will be there whatever from of health-care delivery we use, and artificially driving up the cost of medicine/health-care services.

 

[kinetic]

Socialized medicine is when people pay into a pool and those resources are distributed to cover the costs of medicine for the entire population. Although we are not there yet, we have a partially socialized system in insurance - insured people pay companies, who maintain a pool of money to care for those people. (I don't particularly agree with the figure adawaal gave about the number of uninsured people, but that's not the point of this discussion. Let's keep this a discussion about concepts, rather than have this become a statistical battle where people quote where they got one figure or another. ) To convert our current system into a truly socialized system, we would expand coverage to those who don't pay into insurance (essentially, but not precisely). I agree that our VA system is a good example of socialized medicine, but it is kept in isolation and for a specific population - expand it to everyone and you've got it!

 

[jalabert]

Originally posted by frotteurism
Excellent posts?

First, I think it?s obviously very difficult to compare the American system to that in other countries for a number of reasons, but most important is the difference in annual expenditure per capita. A quick google search yielded this British document

http://www.parliament.the-stationery-office.co.uk/pa/cm199899/cmhansrd/vo990615/text/90615w14.htm

that contains a report from the Organisation for Economic Co-operation and Development that lists health care costs throughout member countries (in 1996). The rightmost column shows (as I?ve heard many times before) that the US spends $3898 per person per year.

That?s over twice that of nearly every other first world nation. Canada spends $2065 per capita, Sweden $1675, the UK $1317. Thus, it should be no surprise that these countries aren?t littered with MRI machines and CT scanners. If Canada were willing to double its annual expenditure on health care to match us, they would unquestionably have more money to throw around on high-tech equipment and an army of subspecialists.

Thus, the complaints that are frequently heard that ?you have to wait x months for a CABG in England? may be true, but that can?t be blamed on their socialized system of medicine when they?re spending 1/3-1/2 what we are. Thus, health care also does not explain the higher tax burden of Sweden (they have a number of comprehensive federal services that account for this tax burden).

First, I think socialized medicine would eliminate an ungodly amount of waste. Medicare operates with 3% ?overhead? (costs dedicated to administrators, paperwork, i.e. anything other than patient care). The Canadian system operates at about 1%.

HMO?s operate at about 25%. Privatization may reduce red tape and inefficiency in some areas of economics, but it certainly hasn?t in health care.

Anyway, those issues aside, I think your proposal wouldn?t work, simply because we?ve decided (and I think rightly so) that commodities that are necessary for life should never be denied to anyone, which is why we have things like food stamps, public housing, and Medicaid. Does such a safety net reduce personal responsbility? Sure. Does it allow some people to abuse the system and be irresponsible? Of course. But people will always make mistakes. I for one would not want to deny someone chemo (for the patient in your example) simply because he screwed up. For only a few thousand dollars a year, this patient could be kept alive maybe another three years.

Why didn?t this person take advantage of preventative care over the years? I doubt he maliciously assumed that he could be as careless as he wanted and when the time came that he needed treatment figured that society would foot the bill. He may simply have a poor understanding of the significance of prevention and never have considered it a priority to follow up carefully with a physician.

Third party payer may result in less personal responsibility and potential abuses of the system than a simple fee-for-service, but as soon as you force people to be able to pay even for simple lifesaving treatment (even if it?s supposedly ?their fault?), thousands will suffer and die simply due to their lack of understanding of the consequences of their actions. Which is the greater tragedy? To me the choice is clear.

I just wanted to make myself clear on a couple of Frott's points prior to reading the other posts. My apologies for any redundancy.

First, I wasn't saying that socialized medicine was entirely responsible for the higher tax burden in Sweden, or any other scandinavian country, just that it has to be considered a component. That's why I said,

"Further, the tax burden is much higher in Scandanavian countries, and this is necessitated by their socialized system of government. "

The health care system has to be viewed within the context of the socio-economic-political environment. I'm not aware of the data that explicitly states what percentage of the tax burden is a result of the health care system. It's probably out there, but I'm not aware of it. The point was that Scandinavians, in general, view the role of government, and level of acceptable taxation, differently than most Americans, IMHO.

Second, I was not arguing that the individual whom has neglectful of their personal health for many years, and shows up with diabetic foot, be denied medical care. I was commenting more on the mantality of some individuals whom do not take responsibility for their own health, and yet expect to have the latest greatest technology available to treat their ailments. I too would like to see everyone treated.

Many Americans, if not most, want the best of anything they have access to. That means they would like to have the best health care that they have access to, and that means the best technology and the best doctors. The best technology and the best trained doctors are going to be somewhat mutually exclusive with socialized medicine. What drives innovation , and development of the best health care is entrepeneurship, and the desire to make money. Socialized medicine removes these motivations or forces, and ultimately reduces the quality and, in some respects, access to services.

 

[DuneHog]

Very interesting discussion. Healthcare in the united states is facing two dichotomous goals. The first, as others have mentioned, is that most people feel that everyone should have access to health care, regardless of ability to pay. The second is that health care is a very profitable business those that have vested interests in health care continually push the limits of our abilities to treat patients with more technologically advanced (and consequently more expensive) diagnostic tools and treatments, and people are willing to pay for them. As long as we continue to try to achieve both of these goals with a single system, health care expendatures will continue to grow out of control and the most disadvantaged people will fall through the cracks without access to care.

The solution I envision is to essentially have a two-tiered system of healthcare. This system would provide "basic" care to everyone, and more technologically advanced care with more frills to people willing (and/or able) to pay for them. The basic health care (provided by a single payer - the US government) would cover routine preventative care and health maintenence as well as basic, inexpensive treatments to certain defined conditions. For instance, prescription drug benefits would only include generic medications, which could actually be manufactured by the governmental health care program or by companies they contract with. Covered surgical procedures would include more basic interventions with very well proven benefit. Waits for most covered elective procedures would be long, and may included manditory lifestyle modifications prior to being scheduled for surgery. Also, hospitals within the government health care system would be very basic with mutiple beds per room, no TVs etc. They would be places that people would not want to stay in but would only stay there out if necessity when they are very ill. The institutions and individuals providing this basic level of health care would be exempt from law suits or have low caps on all legal settlements. THis would prevent excess expendatures on "defensive medicine."

The second tier of this health care system would basically be the system we have now, without any sort of ethical or legal obligation to treat all comers. People would have the option of either buying private health insurance that would cover health care at defined private institutions, or they could pay out of pocket. Certainly COBRA laws would exist in some form and would require stablization of all patients with true emergencies. But transfers for patients without private insurance or ability to pay would be quick. The hospitals and clinics in this second tier could be as fancy and technologically advanced as people are willing to pay for, and in fact could be multi tiered with posh clinics and hospitals for the very wealthy. Some of the more advanced life-saving procedures which may be only available at these private institutions could be subsidized by the government on an ability-to-pay basis.

When you think about it, the system I propose is very simlar to system we have already in many cities with county hospitals (LA county, cook county, grady etc). We like to maintain the illusion that we can "do everything" for someone's loved one, regardless of their ability to pay, but the reality is that we can't afford to do it and in many cases already don't. At some point we will have to admit to ourselves and to the public that the best and most advanced health care will only be available to people with the ability or desire to pay for it.

 

[jalabert]

Originally posted by DuneHog


When you think about it, the system I propose is very simlar to system we have already in many cities with county hospitals (LA county, cook county, grady etc). We like to maintain the illusion that we can "do everything" for someone's loved one, regardless of their ability to pay, but the reality is that we can't afford to do it and in many cases already don't. At some point we will have to admit to ourselves and to the public that the best and most advanced health care will only be available to people with the ability or desire to pay for it.

Actually, the system you propose is actually in practice currently in Canada. The Canadian system is a system many reformers cite as a workable model for a reformed American system. The first tier is the level most Canadians have access to. Most of the controls you propose, minimal defensive medicine, few lawsuits, with low caps, spartan hospital accomodations, and minimal access to cutting edge technology are in effect.

The second tier is for Canadians that can afford to come to the United States to get the best care they can afford. The thing is, if the US system is reformed, where do people who can afford excellent care go?

 

[kinetic]

DuneHog, I think your proposition is certainly interesting. A couple of observations, though. It seems to skirt the underlying issue. If your position is that health care is something that people should all be able to access, should they not be able to access it equally? I only ask this because, with the two tiers you proposed, there would be a number of inconsistencies.

1) If we have to define which conditions are going to be universally covered and which are not, who picks and what is the basis? If cost is the basis for excluding coverage, does that not deny people treatment (i.e., does that not beg the question of 'universal coverage' all over again)?

2) Do we deny people access to new medications, which are non-generic and usually protected by patents for a certain period of time? Even if that could cure someone in the lower tier?

3) If we only allow more affluent people access to more advanced treatments, does that not penalize poorer people?

4) If litigation caps are only set for the base tier, does that not imply that poorer people are not 'worth' as much or don't deserve recompensation for errors?

I know everyone says that life is shades of grey, but I sort of think that this issue almost has to be black and white. If you are for universal or socialized medicine, you are saying that your values dictate that everyone is deserving of treatment - and by extension, to me that means that everyone is deserving of EQUAL treatment.

I know there can be compromises. Heck, I said in my original post that if it were up to me I'd only treat people who could pay, heartless bastard that I am. But I knew that would not fly with anyone, so I proposed my own mixed bag solution. But I think that it is still more consistent to base treatment on how involved people are in their medical care (as demonstrated by participation in prevention), rather than leave the system based on ability to pay. Reward people who do things to DECREASE the burden on the system and penalize those who INCREASE the burden on the system.

 

[rustybruce]

Obviously, not everyone has the time or the motivation to research the different health care systems of the world, but I encourage some of you (especially kinetic) to learn about the Dutch system of health care. They, unlike the Canadian and British systems, have devised a successful plan in which healthcare is a multi-tiered system of which some levels are universal, and others are controlled by private and/or government insurance groups. The basic things we have already discussed like preventive care, prenatal care, and pediatrics are covered. Other systems are left up to the competitive market.

I find it interesting when people against one way of doing something (in this case universalizing healthcare) try to dictate the way things could or could not be done by the supporters of the other way.

Kinetic (and I say this with no sarcasm/criticism), it seems that you are not in favor of a system with more equal distribution of care but you also think that if there is such a system, it should be ENTIRELY EQUAL. People like you could relax in a Dutch-like system where the wealthy/upper/middle class could get access to competitive plans and better care while coexisting with a non-paying population that receives basic coverage.

And, most of the projections for such systems have concluded that the US would SAVE money. (please don't ask me where I got this data as I studied it 3 years ago)

 

[DuneHog]

Originally posted by kinetic

1) If we have to define which conditions are going to be universally covered and which are not, who picks and what is the basis? If cost is the basis for excluding coverage, does that not deny people treatment (i.e., does that not beg the question of 'universal coverage' all over again)?

One way to do it would be to appoint a panel of physicians and citizens to make a ranked list of conditions and procedures that would be covered. For instance an appendectomy would be high on the rank list, whereas diskectomy for herniated disk would be lower. Then the number on the rank list below which would not be covered would be determined simply by budget allocations. That way, voter, or voters via legislators, would be able to essentially decide what types of procedures would and wouldn't be covered.

In answer to the second part of your question, cost will always be a basis for excluding coverage because financial resources are finate. It's just that many people don't want to admit this. I don't think I'm an advocate of universal coverage the way you define it. I think that a basic level of care needs to be provided to all because 1) it will allow for a happier and more productive society and 2) the public will demand it. I don't think health care is a "right" and I don't believe in equality in health care.

Originally posted by kinetic

2) Do we deny people access to new medications, which are non-generic and usually protected by patents for a certain period of time? Even if that could cure someone in the lower tier?

There may be certain situations where people die because they don't have access to the newest and most expensive treatment, medications or otherwise. But this happens in the current system as well. People who have MIs and have no insurance probably don't get caths as often or as quickly as those with Blue Cross, even though we know early catheterization leads to better outcomes. People with cancer and no insurance who don't qualify for medicaid may not get the latest, most expensive chemotherapeutic regimin. This is a reality of the current system. It's just more prominent in the system I propose.

Originally posted by kinetic
3) If we only allow more affluent people access to more advanced treatments, does that not penalize poorer people?

Don't we already allow affluent people to: 1)higher quality, more nutritious food 2)better and safer homes and living conditions 3) Better schools and education 4)nicer, bigger cars with better safety features, etc, etc, etc? Don['t these also "penalize" poorer people? These are the realities of capitalism. Why should health care be any different?

Originally posted by kinetic
4) If litigation caps are only set for the base tier, does that not imply that poorer people are not 'worth' as much or don't deserve recompensation for errors?[/B]

If care is being paid for by the government, people shouldn't be able to sue the government for large settlements. The reason for this is utilitarian - if individuals get large settlements it takes away from resources that would otherwise be used to provide needed services to everone else. It is true that some people may not be compensated justly for errors, but the savings in avoiding large settlements and defensive medicine would be better for the common good. Of course there would be oversight committees etc that watch for negligence and errors and repremand repeated offenders. If the number of errors or degree of negligence got out of control, voters would call for reforms. Keep in mind, many systems run this way now. The entire VA system is essentially exempt from law suits.

Originally posted by kinetic
I know there can be compromises. Heck, I said in my original post that if it were up to me I'd only treat people who could pay, heartless bastard that I am. But I knew that would not fly with anyone, so I proposed my own mixed bag solution. But I think that it is still more consistent to base treatment on how involved people are in their medical care (as demonstrated by participation in prevention), rather than leave the system based on ability to pay. Reward people who do things to DECREASE the burden on the system and penalize those who INCREASE the burden on the system. [/B]

I think we agree on a lot of things. I certainly think that people should be rewarded for health maintanence and avoiding self-destructive behaviors. This ideal could be reflected in the system I propose by providing coverage for health maintenence and preventative care, and not providing coverage for heroic treatments for end stage alcoholic cirrhosis, lung cancer or endocarditis for IVDA.


By the way kinetic, this is a great thread. Thanks for starting it.

 

[aphistis]

Originally posted by DuneHog
One way to do it would be to appoint a panel of physicians and citizens to make a ranked list of conditions and procedures that would be covered. For instance an appendectomy would be high on the rank list, whereas diskectomy for herniated disk would be lower. Then the number on the rank list below which would not be covered would be determined simply by budget allocations. That way, voter, or voters via legislators, would be able to essentially decide what types of procedures would and wouldn't be covered.

In answer to the second part of your question, cost will always be a basis for excluding coverage because financial resources are finate. It's just that many people don't want to admit this. I don't think I'm an advocate of universal coverage the way you define it. I think that a basic level of care needs to be provided to all because 1) it will allow for a happier and more productive society and 2) the public will demand it. I don't think health care is a "right" and I don't believe in equality in health care.

There may be certain situations where people die because they don't have access to the newest and most expensive treatment, medications or otherwise. But this happens in the current system as well. People who have MIs and have no insurance probably don't get caths as often or as quickly as those with Blue Cross, even though we know early catheterization leads to better outcomes. People with cancer and no insurance who don't qualify for medicaid may not get the latest, most expensive chemotherapeutic regimin. This is a reality of the current system. It's just more prominent in the system I propose.


Don't we already allow affluent people to: 1)higher quality, more nutritious food 2)better and safer homes and living conditions 3) Better schools and education 4)nicer, bigger cars with better safety features, etc, etc, etc? Don['t these also "penalize" poorer people? These are the realities of capitalism. Why should health care be any different?

If care is being paid for by the government, people shouldn't be able to sue the government for large settlements. The reason for this is utilitarian - if individuals get large settlements it takes away from resources that would otherwise be used to provide needed services to everone else. It is true that some people may not be compensated justly for errors, but the savings in avoiding large settlements and defensive medicine would be better for the common good. Of course there would be oversight committees etc that watch for negligence and errors and repremand repeated offenders. If the number of errors or degree of negligence got out of control, voters would call for reforms. Keep in mind, many systems run this way now. The entire VA system is essentially exempt from law suits.

I think we agree on a lot of things. I certainly think that people should be rewarded for health maintanence and avoiding self-destructive behaviors. This ideal could be reflected in the system I propose by providing coverage for health maintenence and preventative care, and not providing coverage for heroic treatments for end stage alcoholic cirrhosis, lung cancer or endocarditis for IVDA.


By the way kinetic, this is a great thread. Thanks for starting it.

Thoughtful, well-reasoned post. Muy bueno.

 

[jalabert]

Originally posted by DuneHog


By the way kinetic, this is a great thread. Thanks for starting it.

Ditto

 

[edfig99]

This really is a great thread ? I am frankly amazed at the eloquent arguments and the civility. I had to make sure I was really on SDN

Here?s my 1.5 cents for whatever they?re worth.

In our constitution, we are endowed with the inalienable rights of life, liberty and the pursuit of happiness. Implicit in this is the right to health. Although health CARE itself is not a right (at least, not recognized in this country with this administration), health cannot be achieved without adequate access to some level of preventive services and health education.

Let?s put it out there that there is a lot of stuff that we do in the American medical system that really is not helpful, may actually be harmful in some cases and almost always costs a hell of a lot of money. We think we may have the ?best care? yet our life expectancy ranks lower than many other countries.

We spend millions of dollars a year on cancer treatment research ? yet incidence and mortality for all cancer deaths has not changed significantly over the last 50 yrs. Someone mentioned early cardiac cath for MI leads to improved outcomes, and the reality is that this is not true if the outcome of interest is death. Cardiac catheterization with stenting and CABG have not decreased mortality from heart disease. Neither have statins. The single biggest intervention leading to decreased heart disease (and decreased cardiac mortality, i.e. better outcomes) is smoking cessation and second, lifestyle modification. One will say, ?well, it?s personal responsibility and that person should have known not to smoke,? but government protected the tobacco industry for quite some time (and to some extent still does,) and provides tremendous amounts of financial subsidies to agriculture, i.e. corn (which is in practically EVERYTHING we eat and drink) ? so who?s responsible? We have a world wide obesity epidemic ? WHO put out some guidelines and the U.S. was the only country not to adopt it (and in fact attacked it) ? why ? many reasons, but partly because corn was taken out of the base of the food pyramid!

We need changes in attitude if we are ever really going to have the "best care". Money needs to be shifted from protecting industries (tobacco, PhRMA, agriculture,) to focusing on prevention and promoting healthy behaviors. We need to focus less on proximal (immediate) causes of disease, and look more distally to the role of society, politics, economics Attitudes need to shift from high-tech, low-touch, to prevention and health ed. Rugged individualism needs to yield (in part) to social solidarity. Capitalism needs to be removed from healthcare because it doesn?t fit with this supposed ?higher calling? we are responding to when taking the Hippocratic oath. What I do I can't REALLY put a price on - how do you price health? human life? The medical jurisprudence system needs to change dramatically (I like the system proposed by ourcommongood.org). And government needs to be involved ? for example, by passing sin taxes on unhealthy goods, environmental policies (example speed limits, seat belts, drinking ages) and providing universal coverage for preventive services, and subsidized services for those that are diagnosed with serious medical disease determined not by a group of people who have their own agenda, but by data ? our leading causes of death and disability.

Thanks for getting through the post.

 

[kinetic]

You're welcome. Thank you guys for providing some thoughful replies.

DuneHog, we DO agree on a lot.

Originally posted by DuneHog
...cost will always be a basis for excluding coverage because financial resources are finate. It's just that many people don't want to admit this ...I don't think health care is a "right" and I don't believe in equality in health care ...

The questions I posed to you were just intended for people who - unlike you - think that medicine should be equal for everyone and to get them to start thinking. That's part of the thing behind the whole thread. I think for a lot of people, inequity has become such a dirty concept that they don't think about it.


edfig99, whether or not the government protects tobacco (and PLEASE let's not have this thread turn into a tobacco debate - start a new thread for that) it's still a matter of people having chosen the behavior and implicitly the consequences. I think it's precisely because we have been taught to remove responsiblity from action that we're getting into our health care pickle.

As physicians, we have come face to face with the fact that, for a lot of people, lifestyle modification is not "an option". Current guidelines state that, prior to initiation of anti-hypertensive or anti-cholesterol therapy, we try a period of lifestyle modification - but how often has that ever worked? When I ask patients honestly if they have changed things, they just say "nah ...just give me a pill, doc". And bariatric surgery is still a relatively dangerous procedure (due to the patient population who undergoes it), but who wants to bet that people try to use it as a weight-loss substitute in years to come?

I don't disagree that people need to make better choices when it comes to their health, but if there are no consequences for making bad choices - if we have to give everyone the "full court press" regardless - there will never be incentive to change.

Keep it up, guys!

 

[edfig99]

Originally posted by kinetic

edfig99, whether or not the government protects tobacco (and PLEASE let's not have this thread turn into a tobacco debate - start a new thread for that) it's still a matter of people having chosen the behavior and implicitly the consequences. I think it's precisely because we have been taught to remove responsiblity from action that we're getting into our health care pickle.

As physicians, we have come face to face with the fact that, for a lot of people, lifestyle modification is not "an option". Current guidelines state that, prior to initiation of anti-hypertensive or anti-cholesterol therapy, we try a period of lifestyle modification - but how often has that ever worked? When I ask patients honestly if they have changed things, they just say "nah ...just give me a pill, doc". And bariatric surgery is still a relatively dangerous procedure (due to the patient population who undergoes it), but who wants to bet that people try to use it as a weight-loss substitute in years to come?

I don't disagree that people need to make better choices when it comes to their health, but if there are no consequences for making bad choices - if we have to give everyone the "full court press" regardless - there will never be incentive to change.

Keep it up, guys! [/B]

don't worry dude -- ain't tryin' to hijack with tobacco

I think it's too simplistic to think that people are making conscious choices without thinking of consequences. Meredith Minkler out of Berkley has written a fair amount on this subject (personal responsibility) and one thing she reminds people (to paraphrase) is that choices are only as good as the other options. Especially in communities of color and poor communities where health disparities are significant (and fast food joints abound in), the options don't deal with tomorrow -- they deal with right now, forget the "consequences". And even if they did think of consequences - it's too late when they're all 'grown up'. We're expecting people to make good choices too late in their lives, but our eating habits, physical activity, alcohol, etc, are all shaped while we are young, and even if they did change behavior 'now', it doesn't affect the damage already done.

Furthermore she argues that "the programmatic emphasis on individual responsibility for health, in short, frequently [is] not accompanied by attention to individual and community response-ability, or the capacity of individuals and communities to build on their strengths and respond to their personal needs and the challenges posed by the environment." (Minkler M, Health Education and Behavior 26(1):121-140 Feb 1999 -> nice read) So ultimately what is needed is a balance between personal responsibility (making choices) and social responsibility (i.e. gov't) for creating better options and improved health outcomes.

And I am not so convinced that our health care 'pickle' is a result of removing responsibility from action. It's because of an overreliance on action and technology instead of promoting responsibility that got us into trouble. Representation of health care in the media also contributes. "Why eat healthy and prevent a heart attack, when, even if my heart stops, i can go to the hospital and they can restart it." Health care professionals also contribute to the problem - yup...they do. Health care professionals can choose to do the health education and be aggressive in promoting lifestyle mod (i can get a few of my patients to do it, the same way i've gotten every mother to agree to immunizations) but physicians don't want to do it because they want to get paid. We're too quick to 'blame the victim' instead of looking at the bigger picture.

okay...i'm out. g'night folks.

 

[jalabert]

Originally posted by edfig99
This really is a great thread ? I am frankly amazed at the eloquent arguments and the civility. I had to make sure I was really on SDN

Let?s put it out there that there is a lot of stuff that we do in the American medical system that really is not helpful, may actually be harmful in some cases and almost always costs a hell of a lot of money. We think we may have the ?best care? yet our life expectancy ranks lower than many other countries.

Is this due to the medical care, or the current health care system?

We spend millions of dollars a year on cancer treatment research ? yet incidence and mortality for all cancer deaths has not changed significantly over the last 50 yrs. Someone mentioned early cardiac cath for MI leads to improved outcomes, and the reality is that this is not true if the outcome of interest is death. One will say, ?well, it?s personal responsibility and that person should have known not to smoke,? but government protected the tobacco industry for quite some time (and to some extent still does,) and provides tremendous amounts of financial subsidies to agriculture, i.e. corn (which is in practically EVERYTHING we eat and drink) ? so who?s responsible? We have a world wide obesity epidemic ? WHO put out some guidelines and the U.S. was the only country not to adopt it (and in fact attacked it) ? why ? many reasons, but partly because corn was taken out of the base of the food pyramid!

So, is tobacco illegal in countries with higher life expectancy? Do you want government to make different types of food illegal?

We need changes in attitude if we are ever really going to have the "best care". Money needs to be shifted from protecting industries (tobacco, PhRMA, agriculture,) to focusing on prevention and promoting healthy behaviors. We need to focus less on proximal (immediate) causes of disease, and look more distally to the role of society, politics, economics Attitudes need to shift from high-tech, low-touch, to prevention and health ed. Rugged individualism needs to yield (in part) to social solidarity. Capitalism needs to be removed from healthcare because it doesn?t fit with this supposed ?higher calling? we are responding to when taking the Hippocratic oath. What I do I can't REALLY put a price on - how do you price health? human life? The medical jurisprudence system needs to change dramatically (I like the system proposed by ourcommongood.org). And government needs to be involved ? for example, by passing sin taxes on unhealthy goods, environmental policies (example speed limits, seat belts, drinking ages) and providing universal coverage for preventive services, and subsidized services for those that are diagnosed with serious medical disease determined not by a group of people who have their own agenda, but by data ? our leading causes of death and disability.

It seems you are arguing for a socialized system of government overall, and not just for a socialized health care system in particular. This thread is not about different systems of government. I believe you are right, that individual attitudes toward their own health need to be changed. Unfortunately, attitudes can typically not be changed by government.

Smoking has been a known cause of cancer and lung disease for decades, and still people smoke. In Canada, pictures of disesased lungs are shown on the package, much stronger statements from the Surgeon General are also on the package, and yet, people still smoke. But..... increasing the price of a pack of cigaraettes reduces smoking. I am going off on a tangent a bit, sorry. I personally feel cigaraettes should be illegal, there is no reason for them to be legal, and they kill innocent bystanders. People who smoke though, argue for their right to make personal decisions, when they are cognisant of the consequences. So, if they make those choices, they should be made responsible for the consequences.

Now to get back to the original point of the thread. At this point I guess I am warming up to the original proposal. One of the few things that will change behavior is when that behavior affects the pocket book. If individuals know that their behavior will negatively impact their pocket book, they may be more likely to change.