his NY Times article from over this past weekend is among the most important that I have read recently on the dynamics that are materially changing the fractured U.S. health care system.
That’s not to suggest that the direction of medicine described in the article is a good thing. In fact, my late father is rolling over in his grave over what is described in the article. Patients as commodities. Doctors minimizing responsibilities so that they can get to their yoga class. Patients are supposed to trust such treatment? This is progress?
This is the reason why I pay a premium so that I have a doctor who knows me and my medical history if I am hospitalized for illness or injury.
Do most patients realize that they will not have such a resource when they need one?
no, most do not realize this and, thankfully, most will not have the sad experience of finding out the hard way–this physician apathy is why canadian and european systems have long been inferior yet many/most patients have been “happy enough”, similar to most guys who carry no life insurance not dying early and creating misery.
we are 20+ years into this trend that started when reagan, the biggest socialist in american history, distanced seniors from responsibility for their medical bills by capping what doctors and hospitals could charge. market forces have lead doctors and hospitals to the sorry mess we see now, only we do not enjoy the “single payer” “efficiency” of other countries.
the irony that our beloved reagan is the one that did this and george w. finished the job with prescription drug coverage will serve as one of many things that will have guys like me comfortable in the grave, glad to have found rest from such an unnecessary, sad mess.
between now and then i will keep trying to make your dad happy and folks do well to heed your advice to hook up with a good doc, they are still out there.
An American doctor who dislikes universal healthcare and asserts that Reagan and the bushes were/are
Socialists! Imagine that.
Actually, I agree. They DID support socialism…for the rich — and free enterprise for the poor.
If we want a system that doesn’t encourage doctors
to be apathetic towards patients, avaricious beyond greed, and fewer people dying from lack of affordable care, then we should move to a system
like the one in Canada or those in Europe.
On the other hand, Dr Dewar seems honest in admitting she’s not very interested in primary care. Really, is it any better to have an overworked, sleep deprived doctor because “that’s the way it’s always been done.”–to be a good doctor must you work yourself to the point exhaustion? Can a doctor not also be a good mother?
I think of my mother’s current doctor–between his practice and his research projects he is stretched so thin he can’t seem to remember why he prescribed a particular medication for her from one visit to the next, and he is either too busy or too stubborn to confer with her other doctor–we have to do that for him. I regularly question whether he does her any good at all.
PS My primary care doctor’s group has recently hired two young doctors who 1) seem to get the concept of “bedside manor” and the positive aspects of treating me as an intelligent human being, 2) Seem to want to be doctors and not just technicians who interpret expensive and unnecessary tests. If these folks want to work 40 hr weeks I’m really ok with that.
Tom, I’ve never quite understood how the market based insurance/health care reform you’ve been touting on this blog for a few years now will return us to the type of doctor/patient relationship your father or my childhood doc practiced. It seems to me that if “market forces” drive prices down and if patients, made responsible for a higher percentage of basic medical costs, utilize those services less, primary care docs will be forced to take on more patients just to make a living. We will become even more of a number than we are now. You’ve mentioned the concierge model, but I really don’t expect that to be available for those of us in the lower middle (getting lower by the day). No, I rather expect visiting my “personal” doc at Walmart or maybe Big Kmart, especially when my Medicare becomes privatized.
Actually, if we want to find systems that excel at primary care, we should look at the Europeans and the Japanese and that bugger–universal care, despite what Dr Tom says above. I’m no expert but I’ve certainly read enough to know that the US system (if you can call it that) is only better that those countries at specialization–cancer treatment outcomes for instance. We lag behind in primary care and preventative medicine.
gents,
1)pre-reagan changes, when grandma had to pay more than the current 30 cents on the dollar, no one seriously suggested health care elsewhere was as good as united states–doctors and hospitals could charge market rates, not today’s below market rates and they delivered–markets have that effect and that is why we were the best.
2)”fixes” that do not go back to americans having to pay 100 cents on the dollar for what they receive are lies, unworthy of intelligent conversation.
3) the american system currently being criticized is socialist in that government sets the medicare prices below cost and insurance companies have patient’s by the private parts because the cost shifting of doctors and hospitals to the “private” patients got so expensive, employers offer “managed” care in which the “market” option for almost all doctors and hospitals is to accept the artificially low rates insurance companies pay or have few patients. the net result is docs/hospitals are in a socialist system where pay is too low and consumers too unmotivated to limit expenses that we have the chaos that IS the british, japanese and canadian system that folks endure with grace–i hope those of you who dare to speak such tripe get what you ask for.
4) we do not lag behind in primary care and prevention–you are looking at socialist system numbers–stop it. look at the care tom K. gets from his primary and understand it is best on the planet and other u.s. docs offer this as well.
5) not news to any of us: the system will never get fixed because our country prefers the socialism of bush and reagan and when the government finally gets it all, most hard working folks who can afford better will see their health care system worsen and a lot of folks will be fine with that because “we will all suffer equally” (absurd).
As long as Medicare exists, it poses a threat to health insurance parasites, because it could always be extended to all of us, so the Republicans want to privatize it.
Not to worry, privatizers, I personally believe those GOP commmunists and socialists will kill off
the small safety net we still have, and Obama will
continue helping them.
Gore Vidal was right all those years ago: we only have one political party- the Property Party, and it has two wings.
Dr Tom: 1) I’m not reading “socialist numbers” I’m reading policy experts like Laszewski, Paduda, Mahar, I’m reading Health Affairs, I’m reading a healthy dose of economists from Reinhardt to Tom’s beloved Kling. How bout you? You seem to be of the mind that anyone who does not share your opinion is suffering a socialist delusion. How Wisconsonian of you…
2) I don’t know Tom K’s doctor, but I do know mine. You see, I made the unfortunate career choice of becoming a musician who has the gall to not play a style of music the market loves, hence my income is limited. My insurer does not cover wellcare so I only see my doctor when I have to. He may be Marcus Welby on steroids but it won’t matter to me.
My wife has MS and no insurance. She avoids the doctor at all costs, as she gets charged up to 60% higher for their services (yes 60%…you want to talk “cost shifting”) than BCBS patients. Any preventative measures come strictly from her and not the established medical community.
So please tell me again how good our primary care/preventative options are besides the old joke, “the doctor says ‘Don’t do this…” I don’t expect. Forgive me if I don’t have much faith in the market.
Rich, market-based reform of the health care finance system would return the consumer to the decision-maker in terms of the expenditure of health care dollars. Under current forms of health care “insulation” (our third party payor health care system is not truly insurance), the consumer has little disincentive not to spend (or to save) health care dollars. This has caused all sorts of unintended consequences, not the least of which is that many folks rely on medicine rather than preventive measures to maintain health and base employment decisions largely on maintenance of employer-based health insulation.
Reform of the health care finance system should start with the following measures:
1. Either provide the same tax deduction for individuals with regard to purchase of health insurance that employers have, or do away with the tax deduction altogether. I prefer the latter approach.
2. Allow citizens to set up health savings accounts that are “wrapped” by true health insurance that would insure against expenses resulting from catastrophic injury or illness.
3. The government would serve the role of being a re-insurer for private insurers and as an insurer of last resort for the poor. However, specific limits of care would be determined with regard to government-provided insurance.
Details would have to be worked out, such as how to handle pre-existing conditions on the insurance market, but that financial risk could probably be hedged through the government’s reinsurer role.
The foregoing approach would largely remove the adverse unintended consequences of having consumers not having any skin in their health care decisions and relying on employer-based health insulation. And, Dr. Tom is quite right that the Reagan Administration bears a substantial responsibility for placing the health care finance system on a track to its present status. See here: http://blog.kir.com/archives/2010/03/thoughts_on_hea.asp
BTW, I think it’s important to distinguish between the U.S. health care finance system — which is indisputably fractured — and the U.S. health care system, which remains one of the world’s best. It’s a reflection of the remarkable talent pool of physicians in this country that the obsolescent health care finance system has not had a larger impact on the quality of health care than it has.
bill,
hard to understand who “health insurance parasites” might be in a voluntary system–no one can suck your blood if you choose not to participate–it is an adult proposition.
on the other hand, the FACT that seniors only pay pennies on the dollar of their health care costs, at the expense of younger people, is the definition of parasitism–to not deal with this is childish.
rich, your family plight has my genuine interest. the cost shifting because the elderly are parasites has priced your family out of the market and if government must intrude, i believe “making” the market offer “true” insurance in which underlying health does not affect premium cost would be helpful as would lower premiums because seniors, who have had 65 years to prepare for it, start paying their fair share.
by “socialist numbers” i mean you are quoting comparisons of united states to other places that ASSUME the role of government is to “run” health care, that such numbers are a fair, apples to apples comparison of who is “best”–this IS a “socialist” assumption. hence, i plead, “stop it”, stop acting like socializing medicine is wise unless you are willing to take responsibility for being a “socialist”, which, given 20th century history, one might want to reconsider.
lets keep american health care the best in the world and let charity in the united states pick up the slack for those who, in spite of the good fortune of being in the easiest country in economic history, can’t/won’t get it done for themselves.
doctor, wake up. This is 2011, not 1955. That old time right wing propaganda and demonizing of those of us who support the role of government beyond merely coddling abhorrent greedy people and businesses (e.g. insurance) is way out of date.
Thanks in part to the internet, more and more people
are aware that our approach to healthcare is a disaster and is unworthy of a modern nation.
But keep up the HL Hunt brand of propaganda and labeling of RR and the bushes as communists — ther’s bound to be a few old codgers out there who still fall for that kind of nonsense.
bill,
for the last time: 1985, grandma paid 100% for her health care, as she should have and her care was good and affordable. musicians who played unpopular music and had sick wives were able to obtain good care at a reasonable price and NO ONE suggested american healthcare was anything but the best.
what has changed is the cataclysmic departure of seniors taking financial responsibility for themselves and the decline in american health care can be ENTIRELY accounted for by this.
Your account actually frightens me. That a seemingly intelligent man can believe that charity will make up the difference for those of us that can’t cut it in your eyes. Do you really believe that the beloved market will find a way to insure my wife cheaply? Where the profit in it
? Do you really think some great philanthropist will pay $3000 a month for the cocktail of medicine she might someday require? (That price won’t come down because no one will dare touch the patent laws).
Forget 1955, this isn’t 1985 anymore. We’ve developed a whole bunch of new technology since 1985, yet we haven’t figured out how to use it efficiently. Forgive me if I’ve swallowed somebody’s Kool-Aid besides yours, but most experts and providers like Mayo seem to think the major fracture in our system is on the provider side–they point to a %30 savings that could be achieved if organizations practiced real coordinated care, avoiding redundancy and unnecessary testing–doctors that actually talk to each other–unlike my mother’s doctor. This has nothing to do with consumer choice and you can’t blame grandma either–you can partially blame providers for trying to maximize profit and rip off Medicare (I watched up close and personal as my father was dying and I see it in my mother’s doctor). One wonders why the market hasn’t created more Mayo-like structures or even the Kaiser HMO model that achieves quality care at significantly lower cost as the norm. I don’t have much faith that the market will on it’s own.
In 1985 the majority of insurers were non-profit which is no longer the case. One might say the last 30 years or so has been a failed experiment in the for-profit health insurance game. That’s not grandma’s fault either.
Sorry to disappoint you Dr. Tom but I’ll gladly call myself a Socialist when it comes to health care. I believe in the concept of universal care and the individual mandate particularly when one of the best arguments I’ve read in favor of such a mandate–the free rider argument–came from a Heritage Foundation position paper from back in 1994 when universal care was considered good conservative policy–not communism. Nothing I’ve read about “consumer choice” makes any sense in the real world–people don’t act responsibly all the time, they flock to the whim of the best advertisement–I don’t want my health care based on that nonsense. Moreover, this consumer choice stuff doesn’t address the incredible waste within “the best system in the world.”
Regarding “socialist numbers” again. Yes I’m comparing how easy it is for a German or Englishman or Dutchman to walk into a doctors office and receive care which by experts accounts seems to lead to better preventative/prenatal etc care. What the heck is wrong with that comparison? Your point seems to be “we have the best health care for those who can afford it” to which I reply: So what?
Tom K: Thanks for the reply but my question to you was how you saw market based reform improving the doctor/patient relationship–I really can’t see it working for any but the wealthy.
I’m clear on the concept of insurance vs. insulation, would agree that the employer tax deduction probably ought to go and I agree that HSAs are a good tool, though they’re not worth much to lower income families who would not be able to put away any sizable savings or realize any tax benefits. All in all, though I call myself a liberal, my position closely mirrors the Republican plans of the early 90’s (as does Obamacare) which really makes the politics of this whole issue beyond disgusting in my mind.
Unlike you, I want any health care plan to name specific numbers about subsidy for the poor and sick–avoiding this is ignoring a major political elephant in the room. I could be wrong but I don’t hear specifics from the Cato people. Do they not hear half of America screaming, “I don’t want to pay for someone else’s health care.”
Rich, the primary way in which market-based reforms improve the doctor-patient relationship is that it places the primary financial decision regarding health care choices in the hands of the consumer, who will choose the doctor he or she prefers. As it stands under the third party payor system, that relationship is becoming attenuated (for example, the rise of hospitalists) because the patient does not control the payment of most health care decisions.
HSA’s and concierge practices are not just for wealthy people, either. An HSA is really nothing more than a savings account and concierge practices are emerging for people of all income levels (see here: http://blog.kir.com/archives/2011/02/a_low-cost_conc.asp ).
As for specific numbers, I invited that exercise awhile back here: http://blog.kir.com/archives/2010/02/how_much_is_aff.asp I agree that it is a useful exercise.
rich,
i respect you and think you are smart. please dont be frightened. you were good enough to say you are liberal and favor socializing medicine i will reciprocate by saying i am conservative and do not.
we both believe morality calls for helping the less fortunate. i believe it is NOT moral for the state to steal money from people for the purpose of giving charity to someone, you seem to believe differently. i believe i have a keen responsibility to help the less fortunate by giving CAREFULLY to charity.
i believe an insurance system that does not raise premiums for pre-existing would absolutely be affordable and provide coverage for your wife.
should your wife need highly expensive treatment with little prospect of benefit (may it never be so), i believe you are describing our current, unaffordable dilemma and my “solution” is not that the state take what is not yours to give to you, nor that insurances, striving to be affordable, be required to cover such but rather that you and yours avail yourselves of either buying secondary coverage or use your savings or face the ugly but affordable prospect of foregoing marginal, expensive therapies or that your friends, family and community CAREFULLY decide whether to chip in and help on a case by case basis—this is humane, rational, doesn’t take from others and does not bankrupt our nation with pie in the sky.
you make some decent points on other ways to save and some of our disagreement is philosophical difference of conservative/liberal opinion but i must say, your refusal to deal with the fact that seniors, who use most of the services, are not taking responsibility and have put us on an unsustainable path, is breathtaking. i dont think any of you guys who do not address that can be taken seriously–you are fostering that which CANNOT be sustained–put something constructive on the table that doesnt penalize bill gates–he has EARNED access to the best.