A recent discussion about access to healthcare caught my eye. Like many such posts, there was a brisk repartee in the comment section on the topic of fixing our daunting healthcare accessibility issues. Many of the comments were knowledgeable and informative; some, as is always the case, were idiotic or pedantic. One comment in particular, however, caught my eye, posted by a fellow from the progressive side of the opinion spectrum. It was a lengthy screed, which I excerpted here in part:
I notice that people who enjoy making reflexive attacks on any and every possible change in the current system have this one thing in common: They love to mock the idea of preventive medicine. … The number of students accepted by American medical schools was increased substantially about a third of a century ago … and then was held static. Some attribute this freeze to pressure from the medical lobby (it creates an artificial scarcity of doctors). We should increase entry level spots in medical schools by fifty percent or so … Of course none of this is all that hard to figure out. The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity.
Now, my intent is not to beat up the poor fellow; he is, after all, a progressive, and therefore possessed of a profoundly misguided understanding of human nature and motivation, and a strong inherent (and incoherent) proclivity for finding in government the solution to every imaginable problem. He is more to be pitied than censured.
But his comment prompted me to begin thinking about some of the more common medical myths; those axiomatic convictions which seem to drive every discussion about healthcare policy, and show up in virtually every comment section on a health policy-related post. This particular gentleman’s comment mentions at least two such myths, and therefore provides lush green fodder for a rambling rumination on my part.
The healthcare system will save money & lives if we will focus on preventive medicine.
Like all such truisms, this one actually has a grain of truth. There certainly are areas of healthcare where preventive medicine – best defined as measures taken by physicians and patients to prevent disease or detect it early – are clearly beneficial.
Examples which come readily to mind are prenatal care, where careful management of maternal nutrition, blood pressure, blood sugar, and other parameters has a significant beneficial effect on the health of the baby; pediatric immunization; and screening for early detection of diseases with significant long-term morbidity, such as hypertension, lipid disorders, and diabetes.
Take, for example, the idea of an annual physical exam. This is widely perceived by patients as an important measure of preventive care, but is an almost entirely worthless exercise. It makes the patient feel better, but completely lacks in evidence of substantial long-term health benefits. Screening tests for cancer are another such area, which not only provide a false sense of security when negative (since many false negatives occur), but also pose a significant risk of their own. This risk arises from the fact that all such tests have a substantial false positive rate, which when multiplied across a population while looking for relatively low-incidence diseases such as cancer, generate an enormous amount of unnecessary cost and potential health risk chasing down abnormal tests in patients who do not have cancer.
Rich, greedy doctors are bleeding the system dry,
— and —
The AMA restricts the number of doctors trained to ensure shortage and maintain physician incomes.
Well, like many myths, there may be a tiny grain of truth here: There no doubt are a few doctors who drive up healthcare costs by gaming the system; in the medical field, we call these fellows “crooks.” Most health care fraud – especially in Federal programs (Medicare, Medicaid, VA, etc.) – is driven by non-medical criminal organizations, both here and overseas. But the harsh reality is this: physician reimbursements make up only about 10 to 15% of total healthcare expenditures. If you can figure out a way to get physicians to work for nothing (and there appears to be a strong interest in this subject among insurance companies and government), we would still have an extremely expensive healthcare system sucking up a huge numbers of dollars. The insurance industry alone may consume as much as 40% of the healthcare dollar, with their burgeoning bureaucracies, intrusive regulation, and 7-plus-figure CEO incomes.
Oh, and the “AMA-is-keeping-the-lid-on-the-number-of- doctors-to-make-their-incomes higher” theory — popularized by the otherwise astute Milton Friedman — is nothing more than an economist’s wet dream. It assumes, first of all, that healthcare is a free, competitive market: it is anything but. In fact, it much more resembles Soviet state industry: micro-managed, price-controlled, and utterly anti-competitive. The AMA has trouble figuring out which shoe to put on their foot in the morning, and borders on being an utterly incompetent professional organization — which is why very few physicians outside of academic medicine (who are typically required to join) are members. One could only wish that they had some influence on physician income, and reimbursements; they are worse than irrelevant to the profession. Oh, and by the way: they have no say on the admission numbers for medical schools.
Tort reform will bring down medical costs by stopping unnecessary testing and defensive medicine.
Now, tort reform legislation has proven almost impossible to implement, so the point may be moot. But for the sake of argument, let’s pretend that legislatures — comprised as they are predominantly of attorneys — become willing to pass reasonable tort reform. Let’s assume that the court system, manned by judges who are also attorneys, will not gut or invalidate such legislation, as they have routinely done. Let’s ignore the fact that attorneys contribute vastly more money to the political process — nearly a 100 to 1 disparity — than do physicians, to defeat such legislation. Let’s assume that this mythical law is a carefully-crafted statute, which limits attorneys fees, puts a reasonable cap on often emotionally-driven pain and suffering awards, mandates mediation in most cases, and perhaps a host of other widely-accepted reforms which evidence indicates can reduce liability premiums.
Such legislation would likely ease some pressures on malpractice premiums, perhaps improving access to high-risk specialties while lessening economic pressures on physicians in general. The one thing upon which it would have no impact whatsoever — the one factor in the malpractice mess which, more than any other, drives up overall healthcare costs — would be the practice of defensive medicine. And it is pure fantasy to believe otherwise.
Here’s why: the practice of defensive medicine — ordering tests with very low yield and often high cost to ward off the risk of future Monday-morning legal quarterbacking — is now fully ingrained into the health care system. It has become the de facto standard of care. We will not rip out the extra CT scanners and MRI machines installed to handle the excess load. Doctors will not stop ordering tests which have become the standard workup for a given problem, even if low-yield, for they have done so for so long it is now routine. Furthermore, you have not changed the fundamental calculus: if you order a test to protect yourself against a future $5 million-dollar lawsuit, will you now stop ordering it because you are only at risk of being sued for $2 million? Only a drastic, top-to-bottom elimination of medical torts — the chances of which are exactly zero — could bring about such a reduction in defensive medicine costs. Sorry, but they’re here to stay — tort reform or no tort reform.
Pay for performance will improve health care quality.
First and foremost among the questionable underpinnings of this noble venture is the presumption that much of the care paid for by government and insurance is in fact substandard and in need of quality improvement. Of course, this assumption is almost certainly wrong, and certainly unproven — and in fact cannot be proven — as the standards by which such quality is measured have, by and large, yet to be developed. Physician organizations are scrambling to develop them (under the threat that government and insurers will establish such guidelines for them, based on economics rather than medical criteria) — an effort which is no small feat, as forcing the complexities of medicine into nice cookbook formats is daunting, if even possible.
The potential problems with this approach are legion — from physicians avoiding higher-risk or non-compliant patients who are more difficult to treat successfully; to the enormous challenges of gathering, standardizing, and transmitting quality data (including the medical information systems needed to manage it, which are complex and correspond poorly to quality); to the strong economic temptation to pay no more for quality but much less for “substandard” care; to the termination of physicians who do not meet “quality” standards — as defined by the insurers. Insurance companies are already headed in this last direction: a local carrier in the Puget Sound area in the past issued a letter to patients announcing the termination of their doctors from their provider panel, stating their care “did not meet quality standards.” The doctors’ offense? Not quality issues at all, but cost: they were not the lowest-cost providers. The defamation lawsuits are flying — but expect to see much more of this sort of thing in the future.
But the biggest risk from this looming lunacy directly relates to the quality issue it purports to address: pay for performance schemes will fossilize health care, effectively freezing innovation and stunting medical advances. Once you have regulatory specifications detailing just what is “quality” — i.e., allowable — standards of practice, and connect such standards to reimbursement, you will create a strong financial disincentive toward trying new and better ways of addressing difficult health problems.
Got a better way to treat diabetes, or cancer, or arthritis? Sorry, your approach doesn’t meet our government-approved, forever-carved-in-stone “quality standards.” “No soup for you!!”
