A standard to response to criticism of the American health care “system” is that it is the best in the world. In a sense, this is true–if you have the money, you can buy the best health care (mostly). However, the quality of a system is not just a matter of what can be bought at the top. To use an analogy, if a restaurant was considered the best because its most expensive meal was the best, but everything else that most customers could afford was not so good, then it would be odd to consider it the best restaurant for everyone. Naturally, the American “system” could be praised as the best for those who have the resources to afford it, but that would be somewhat dishonest.
One serious issue with health care, at least for those who cannot afford to have their own doctor on call, is the matter of time. For most of us, there is a wait before we can get an appointment, then we wait at the office to see the doctor. This can be problematic for people with schedules that lack flexibility and people who need treatment sooner rather than later. I have good insurance, but it took me two months to get an appointment with a new primary care doctor. Having more medical professionals would reduce these delays, but this is a problem that has not been addressed.
After a long wait, a patient typically gets very little time with the doctor or medical professional. For example, I have usually gotten 10 minutes with my primary doctor or nurse for my physical–I spend far more time in the waiting room. This is not to say that these doctors did not care–they did and did the best they could with the time allocated.
Part of the reason for the short time is that most medical professionals have too many patients and too little time–as such, they can only allocate so much time to each patient. In other cases, the medical facility is a for-profit business first and a place of medicine second–the faster customers can be dealt with, the more customers can be seen, thus increasing profits. Whatever the reason for the short time available to patients, this can certainly impact the quality of care, especially if a patient has questions. Because of this, patients are often on their own in terms of educating themselves about their health concerns. Obviously, having people with no medical training doing this can be problematic (and it helps explain the huge market for dubious supplements and remedies).
Since part of the problem is the need for more medical professionals, steps should be taken to encourage and enable more people to enter the field. Since part of the problem is the for-profit approach, this should be addressed–while it is often assumed that the purpose of life is to make money, applying this to medicine results in worse rather than better health care. This is not to say that medical professionals should not be generously compensated for their work, just that the for-profit business model of medicine needs to be modified. At the very least.
“…This can be problematic for people with schedules that lack flexibility and people who need treatment sooner rather than later.”
There are many situations that have a negative impact on people who have schedules that lack flexibility. It’s a fact of life. If you need to go to court for a traffic violation, for example, or if you are called in to the IRS for an audit – you are given an appointment and that’s that. Jury duty is the same.
I don’t know what it’s like in your world, but any time I want to schedule a well-visit with my doctor, I am asked if I can wait, and I am given all sorts of options to schedule an appointment. Is it sometimes inconvenient? Of course – but so are my kids’ school plays, little league games, appointments at the bank or at my lawyer’s office.
Those who need treatment sooner rather than later have always, in my experience, gotten preferential treatment. A couple of years ago, I was referred to a cardiologist for tachycardia. In talking with the scheduler, I was given a range of appointments for the next week and the following week. However, as soon as I gave the details of the purpose of my visit, I was told to come right in. Now. It’s because of people like me that you have to wait three weeks to go see your primary care physician. My apologies.
You have a somewhat twisted view of our healthcare system. I am not wealthy by any stretch of the imagination – I’m sure you can relate to that because we are in the same profession. I have never, ever, walked out of a doctor’s office or a hospital without feeling as though I have received the best care available. When I need to schedule a non-emergency well visit, I do wait weeks or even months – but if I have a problem, I am fit into the schedule sooner, as you say, rather than later.
And it’s not just now, not just in this profession. In my day I have worked as an insurance salesman, a carpenter, a factory worker – I have run a freelance business out of my house, I have worked for a big corporation. I have had Blue Cross insurance, I’ve had an HMO, I’ve had a COBRA extension insurance, and a PPO; I’ve lived in NJ, California, and New York, and I’ve received treatment in Connecticut, Pennsylvania, and Florida.
No matter what the circumstances, if I have been sick or injured, I have received treatment in a timely fashion and I have consistently been impressed with the level of care I have gotten. If I have needed an x-ray, I’ve been wheeled over to the radiology department. If I have been referred for an MRI, I am able to make the appointment from the receptionist’s desk, and it is scheduled based on the need that the doctor recommends. I have never had to wait for necessary treatment where time has been of the essence.
I know I have posted the anecdotes about my friend Steve, whom I picked up off his kitchen floor while he was having a heart attack. Steve had sustained himself for years by driving around wealthy neighborhoods, picking up trash and re-selling it at flea markets. He also used to bid for abandoned lots at storage facilities – and did not file tax returns or have health insurance. He was accepted to the hospital and immediately placed in the cardiac care unit. He was treated as a “charity case” (I filled out the paperwork for him); he has since had several stents implanted, has had cardiac-rehab on a weekly basis, has been treated for depression and has access to all the medications he could possibly need. Life has treated him like a pauper, but the healthcare system treats him like a king.
I don’t buy your premise that “If you have the money, you can have your own physician on call, otherwise, you get treated poorly”. Not by a longshot.
The fact is that there really was one time in my life when I was treated poorly by the “system” – it’s when I had an HMO that was run by bureaucrats. I went to an orthopedist because of a shoulder fracture – and while I was there I asked him about an issue I was having with my back. “I’m sorry”, said the doc, “But without prior authorization, I’m not allowed to talk to you about that”.
Other than that, I can say that when my wife was pregnant (both times), we got top-notch pre-natal care including sonograms, well visits, fetal heart monitoring, and were even treated to a romantic dinner-for-two in her hospital room before her release, while our new baby was being cared for in the nursery. Again, we’re not rich, we’re not “connected”, we are average Americans.
I can say that whenever either of our kids was sick, we got to see the pediatrician on the day we made the call. Was the waiting room crowded? You bet. Crowded with other families who had sick kids who were being seen on the same day. Did we have to wait a few weeks for a well visit? Of course – but one look at that sick-waiting-room was all the explanation we needed.
I can say that when my son was assaulted by a sledge-hammer-wielding psychopath who crushed his skull a few years ago, we were brought to the hospital and he had surgery the next day by a top maxillo-facial surgeon. I can say that two years ago, when I fell and tore my quad tendon (which is how I found this site), I had surgery the next day – my followup visits were all timely; I waited for nothing – meanwhile I had home-nursing and home-PT. That was a Workman’s Comp case.
I keep hearing horror stories like yours, but I don’t know anyone in my family, my extended family, in my circle of friends or in their circles of friends who have actually experienced it.
So yes, I will offer the “stock answer” that we have the best healthcare system in the world. I’ve experienced it.
I will agree that our insurance system is a mess – and I will write more about that in another post.
The Canadian system:
“…In other cases, the medical facility is a for-profit business first and a place of medicine second–the faster customers can be dealt with, the more customers can be seen, thus increasing profits.”
This is a common theme among many of your posts – a somewhat cynical, one-sided attitude towards the idea of profit. In your descriptions, “Profit” just means screwing the consumer in whatever way necessary to get as many people through the door as possible, without regard to customer experience or service.
There is a negative result to this, which is that given a choice, consumers will not patronize that business – whether it is a hardware store, a supermarket, a car dealership or a physician.
Physicians are rated on the Internet, just like restaurants. Anyone who runs a business knows that in order to encourage repeat business, they must provide excellent service at a reasonable cost. Of course, with the American healthcare system the cost factor is completely removed from the equation – but I choose my doctors carefully, and will not go back to a doctor for whom I have to wait, and who does not give me the time I deserve to get a complete examination, to answer my questions, and to spend some time trying to understand my situation.
This is one of the huge problems with Obamacare and what has become known as “The Big Lie”, i.e., “If you like your doctor, you can keep him”. The ACA achieved many of its goals by expanding Medicaid, making it more widely available to a broader pool of individuals. However, Medicaid reimbursement rates for doctors are low, so only about a third of doctors accept Medicaid patients. Others limit the number of new patients they are able to take on. This is not because they are greedy, but because they are trying to run a business and keep their doors open. In addition to the low reimbursement rates, there is an increase in administrative requirements – which means more staff to deal with them – and doctors don’t want, or cannot afford, the hassles of that kind of bureaucracy associated with their business.
So even though there was no legal provision forcing a patient to switch doctors, if a patient obtained insurance through the ACA, and his or her doctor had a practical limit placed on how many new patients they could accept on Medicaid, there went the choice.
Those that do accept a large number of Medicaid patients are in the situation you describe – having to sacrifice the quality of care they are able to offer in exchange for being able to see an increased number of patients in order to cover their overhead. It’s not a matter of greed – but they are dealing with patients who truly have no choice.
“…Since part of the problem is the need for more medical professionals, steps should be taken to encourage and enable more people to enter the field.”
What do you suggest? When my father was alive, he was a surgeon. When it came time for me to start making decisions about my life and my career, he cautioned me against going into medicine. (This was back in the 1970’s). I remember him distinctly telling me that “Medicine isn’t what it used to be”, due to increased liability, legal requirements, insurance requirements, increased bureaucracy and an overwhelming amount of administrative record-keeping that crippled his ability to see patients. He told me that he kept files on every patient recording all kinds of tests that he felt he had to do as his own form of malpractice insurance – because he knew that if a patient had a bad result, a decent lawyer could swoop down and make it seem as though even the best physician were negligent and incompetent. As an orthopedist, he paid malpractice insurance at a rate that to this day I find staggering. I make a decent salary where I work – but my gross income does not reach the amount that he paid in malpractice insurance annually. In fact, my wife’s and my incomes together don’t.
Ultimately, he had to give up surgery before he was ready – because the insurance premium was an all-or-nothing rate. If he did one surgery or a hundred, it was the same. He gave up surgery because he was not able to cut back or slow down – the industry was forcing him to be a “mill”.
I had a friend in the same situation. His dad was an OB-GYN specialist, and had a similar experience to mine. My friend did go into medicine, but on his father’s advice, went into research and education. He is now a professor of medicine at a university, and does not have to deal with running a practice.
I think the “steps that should be taken” (and by this I think you refer to the government), would be for the government to do what it needs to do in so many areas of American life – just get out of the way.
correction – I said “only about a third of doctors accept Medicaid”. This should be “two-thirds”
Hello DH! Do you write any blog that I could follow?
The “ultimatum game” is a fiendish invention of economists to test people’s selfishness. One player is asked to share a windfall of cash with another player, but the entire windfall is cancelled if the second player rejects the offer. How much should you share? When people from the Machiguenga tribe in Peru were asked to play this game, they behaved selfishly, wanting to share little of the windfall. Not far away, the Achuar in Ecuador were much more generous, offering almost half the money to the other player — which is roughly how people in the developed world react.
What explains the difference? The Machiguenga are largely isolated from the world of markets and commerce. The Achuar are used to buying and selling to and from strangers at markets. The same pattern emerges throughout 15 small-state societies all over the world, in a fascinating study done by the Harvard anthropologist Joe Henrich and his colleagues. The more integrated into the commercial world people are, the more generous they are. As one of the authors, the economist Herb Gintis, summarises the results: “Societies that use markets extensively develop a culture of co-operation, fairness and respect for the individual.”
This would not have surprised Montesquieu, who spoke of “sweet commerce”, or Voltaire, who marvelled at the friendly collaboration of “the Jew, the Mahometan and the Christian” on the floor of the London stock exchange, or Adam Smith, David Ricardo and Richard Cobden, the radical champions of free trade in the early years of the industrial revolution.
Cobden said: “Free trade is God’s diplomacy and there is no other certain way of uniting people in the bonds of peace.” He was right. Recent studies have confirmed that commerce is the main cause of peace. “Within the developing world, economic development leads to interstate peace, whereas democracy does not,” concludes Faruk Ekmekci of Ipek University in Turkey. The evidence is overwhelming that markets do not just make people richer, they make people nicer too, less likely to fight and more likely to help each other.
The moral case for free markets is unassailable.
Glen Wallace says
It is clear we need a patient based medical system instead of the current market based system. Our current market based system of medicine ‘puts the cart before the horse’ insofar as it is designed to first find ways to bring revenue to the care providers, drug companies and device manufacturers and then, almost as an afterthought, try to find out how patients might also have a ‘trickle down’ benefit in health converted from the financial benefit to the people and entities bringing them the care and means of care.
Glen, the one thing we don’t have is a market based system of medicine.
Michael LaBossiere says
True; prices are not transparent and the insurance system deranges prices.
Glen Wallace says
And surely you have to admit you’re begging the question with the statement about the alleged dubious supplements and remedies. What I do think would help would be for naturopathic doctors to be fully authorized and legitimized to practice medicine so people wouldn’t be largely left to their own devices if they want to try an alternative naturopathic route. And just another thought on the matter — it is almost comical how often some law firm advertises on TV in search of victims of some mainstream medicine pharmaceutical that was supposed to be proven safe and had been recently been advertised on TV as well by the the drug manufacturer, but for potential customers to buy and take the drug. And usually it is the big drug companies marketing their product heavily on the big national network nightly news — so now the big network TV companies have a vested interest in keeping their clients happy by using confirmation bias to cherry pick any reports or evidence that some alternative medicine is either harmful or ineffective.
Like anything else, there are extremes- and the initial answer (to me, usually) lies somewhere in the middle. Today, there are PA’s and Nurse Practitioners of various levels who can handle all kinds of treatments without an MD looking over their shoulder – anything from the treatment of the common cold or flu to reducing dislocated shoulders and more. I myself had a cortisone injection for treatment of bursitis recently, where the bursa was located via sonogram and the injection went right in perfectly – all expertly handled by a PA.
The friend I mentioned in a different post, who became a research physician, paid for his medical school by serving in the Navy. I wonder why this kind of exchange needs to be military – I imagine low-cost, sliding scale clinics with fully trained PA’s and Nurse Practitioners, overseen by a physician as “community service” in exchange for some med-school tuition assistance. I think it’s high time that clinics like that become the norm. Perhaps there can be some tax incentives offered by the government for more experienced physicians to give back to their community by overseeing or even running a clinic.
I know that there are some issues with naturopathic medicine that need to be addressed. Cynics will, of course, charge that the so-called problems are due to the “system” wanting to protect itself, but there are also issues with some naturopaths reaching the limit of their expertise, yet keeping patients who are in need of traditional medical treatment from seeing a doctor who can help them. My father, an orthopedic surgeon, used to get very frustrated with some chiropractors who kept patients coming back over and over for adjustments, when the patient could easily be cured with a herniated disc reduction injection, or some other procedure. He used to say all the time that chiropractic medicine, like physical therapy, were wonderful tools and extremely helpful when used right – but there were some practitioners who simply did not accept the limitations of their profession.
It’s very hard for any of us to judge something as big and as complex as our own country’s health system, much less compare it to those of other countries.
Since I was a child, I have seen just two doctors in over 50 years, plus one specialist visit for a test, which did not need a follow up. Yes, I’ve been lucky. How can I judge what happens even at my local hospital 10 miles away, or in a town a hundred miles away, much less in another continent?
I often hear Americans says that they have the best healthcare in the world, and I wounder how they know, or think they know, that? This report judges the US healthcare system worst – 11th out of 11 developed countries: http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf – are they right? I don’t know, but they do at least “show their work” rather than basing it on anecdata.
Now, having said that, I think that Mike skips too rapidly from “too short appointments” to “problem with the for-profit system” without enough groundwork inbetween. I’ve tried to look up medical economics over the past couple of posts, but there there is a huge amount of information about a hugely complicated system comprising many, many parts. I’m not sure that anyone at all has a full handle on why US prices are so insanely high. I do know (anecdatally) that in any doctor’s practice, some patients will soak up all the time they are allowed to, so it’s not entirely a matter of cost, but of getting some (a minority, but a persistent minority) of patiente to leave the office at all!
I got caught up on the question of why people claim that US healthcare is best, and completely omitted the point more relevant to the article’s conclusion.
The average GP consultation in the British NHS also lasts 10 minutes (just over 11, to be precise) and no consideration of profit, in the American business model, is implicated. Any imputation that the consultation length in the US is cut short in the pursuit of profit needs to account for this.
Glen Wallace, TJB – I don’t know what criteria you are using to differentiate “patient-based” vs “market-based”; I’m not an economist and I agree with Coffee Time, that it’s very hard for us to judge and compare this system.
The criteria used in any comparison will naturally skew the results, but I’m not sure that a comparison of our healthcare system to other developed countries is a fruitful endeavor, unless you’re a politician. Based on the care I have gotten over my life time, and that of my wife and my kids, it is completely meaningless to me whether we are first or last on that scale. I’m happy with it – extremely so.
I favor a free market approach; I don’t believe we have ever had such a thing. (more later). The involvement/interference by the government in this approach has caused a disconnect between consumers and any kind of value to what they are consuming; we are completely unaware of what our care costs us aside from whatever deductible or co-pay we have to pony up. Everything else is measured in billions and trillions of dollars, and we just have no clue how to reconcile that kind of number.
And just like with gun violence, hate crime, racism, and every other ill we deal with in this country, we are victims of the ubiquitous Facebook, Twitter, 24-hour Cable News, the Blog-o-sphere and every other “in your face” scrap of media telling us how awful everything is and how we should feel about it. I am much more inclined to judge our healthcare system by what I am able to see and touch – and in addition to my own family, I have seen indigent friends be treated very well, as I have detailed in previous posts.
When I talk about the “free market”, I am talking about the insurance industry, not medical care. I think it’s important to make that distinction. I also think it is important for at least *some* government involvement, but that would be more of a safety net for those who have no other recourse – not as a “top down” centralized plan for everyone to follow.
By analogy, I will talk a little about what happened in the car insurance industry in New Jersey during the 1980’s and 1990’s, when I lived there.
During that time, the State of New Jersey decided that there was too much variance in the insurance that was offered by different insurance companies, and were certain that people were not getting what they were paying for. They implemented a set of strict regulations as to what had to be covered, how much it was to be covered, and how much that coverage should cost the consumer. It was a perfect example of the “protection” offered by the government.
The only thing they could not regulate was who chose to do business in the state, and that number dwindled down to one or two companies. Because there was little to no competition, premiums absolutely skyrocketed. i paid more for insuring two cars in those days than I paid for my mortgage. It was unsustainable.
Over and over, I saw ads for competitive companies on TV (in the NY/NJ/PA market) – GEICO, State Farm, Prudential, and many others – offering things like fleet discounts, discounts for having your homeowner’s insurance bundled with the policy, discounts for safe driving records – everyone of them had something different, but every one of them had one thing in common – the tag line, “Not Available In New Jersey”.
Around 2003, these regulations were lifted, and companies flocked to NJ. The first thing that happened was a price war – everyone was lowering their premiums to get more business. After that came niche-marketing – some offered discounts for advanced degrees, others for fleets or bundles, others for high deductibles. Rather than the State of New Jersey deciding what risk consumers should take, the consumers decided for themselves. Around this time, both of my kids began to drive – yet I was able to insure four cars and two teen-age drivers for substantially less than I had with only two cars and two adults.
That’s what the free market can do.
As for the regulation – my thought is to take the indigent care OUT of the hands of the hospitals, OUT of the hands of the insurance companies, and put THAT in the hands of the Government. Instead of expanding Medicaid to ultimately overtake the system (or break it), those who need the assistance would trickle down and land where they do.
Rather than force everyone to buy or own insurance, and provide it for them at the expense of other taxpayers, enforce the law that everyone must pay for their own medical care. With the lifting of regulations, incentives for free market proliferation of a wide variety of coverage that covers a multiplicity of needs (high deductible catastrophic with HSAs, competition across state lines, low deductible “cadillac” plans, plans available for various groups not associated with the workplace; maternity; no maternity; birth control; no birth control – people would be able to obtain a policy that meets their individual needs based on actuarial risk analysis.
So what happens if someone does NOT have insurance? These people would fall into three categories – the very wealthy, who self-insure, the average middle class person who decides to roll the dice, and the indigent, who cannot afford it.
All of these people would be welcome at the hospitals and doctors’ offices. If their bills remained unpaid after say, six months, then the debt is sold – to the IRS. For the first two categories, that’s called a “Tax Lien”, which could be negotiated. For the last category, the debt could be forgiven and the people would go on Medicaid.
It’s not an overly well-thought-out plan, but the free market is self regulating. I believe that people will buy insurance based on quality and reputation – just like we buy everything else. As some are mistreated by their companies, the lucky ones will be able to choose different policies before an expensive disaster, and those that are not so lucky will drive the sham companies out of business with lawsuits or federal complaints. Companies that offer excellent service for a fair price will proliferate.
All that said, I agree with Glen Wallace on the topic of TV ads for prescription medication. Pictures are worth a thousand words – it’s unconscionable for these companies to show soft-focus vignettes of happy people loving life while the voice-over talks about death, heart attacks, and other heinous side effects. Forget the voice over – I WANT that! Look how happy those people are! It’s especially disgraceful when they say, “Ask your prescriber for [insert name here].” ‘Nuff said.
I know my proposal will meet with all kinds of criticism, but it’s mostly a push-back from the overreach of the government – telling insurance companies what they have to cover, telling the consumers what they have to buy, not telling anyone what things cost, and lying about taxes, keeping your doctor, increasing the number of insured, and taking over a huge chunk of the economy.
This is how I would describe “patient-based” care. It is also “market-based.”
Today there’s a small but growing movement of doctors who are opting out of the traditional health care system by no longer accepting insurance. This new approach is is called “direct primary care,” but it’s essentially a throwback to an era before insurance companies were responsible for covering routine services like ear infections or strep cultures.
When companies like Aetna, Blue Cross, and Oxford started signing the checks for even minor health care expense, it had a destructive impact on the doctor-patient relationship. The direct primary care movement is an attempt to reverse the damage.
Dr. Ryan Neuhofel, who’s been running his own direct primary care practice in Lawrence, Kansas since 2011, has a page on his website that lists the cost of each procedure, which the patient, not the insurance company, actually pays.
Need an x-ray? That’s $25 to 40, along with a monthly subscription fee that runs from $35 for minors to $130 for a family of four.
Most direct primary care practices charge a monthly subscription fee. It allows them to offer other services, like answering patient phone calls, text messages, or even having appointments over Skype—services that our insurance-dominated system doesn’t allow for.
“Because I’m membership supported if someone calls me and says, ‘hey, I have a rash,’ they can send a picture,” Neuhofel says.
Removing the interference of third parties changes the dynamic between patients and their doctors.
“We’re able to be creative in meeting their needs,” Neuhofel says. “[We are] able to give them transparency in pricing, and redesign the entire health care experience around what patients really need.”
This is the way it used to be. I remember having a plan that was 100/500/1000 deductible, and 80/20 co pay until a 1,000/5,000/10,000 out of pocket maximum was reached, with a lifetime benefit in the millions. Bills came to me, I paid them, then submitted to my insurance company for reimbursement. Doctors would routinely wait a little extra time so that a patient could get reimbursed first – but either way, there was transparency in pricing and full disclosure on all sides.
Michael LaBossiere says
True; insurance should cover the unexpected and catastrophic. There is a pretty good analogy here to auto insurance: it does not pay for flat tires (usually), but the cost of fixing a flat is affordable. It is for those cases in which the car suffers a major wreck.
Not sure if it’s my analogy you’re addressing, but the point I was making wasn’t really about what was covered, rather, it was about what happens to prices when the government meddles with free markets.
The analogy about the auto insurance is a little disconnected, because insurance doesn’t pay for any maintenance at all – not oil changes or blown engines. In theory, your body, like a car engine, will perform better with regular routine maintenance – and catastrophic illnesses like diabetes and heart disease can be averted. Perhaps that approach might be better suited to “accident insurance” or double indemnity.
Anyway, “going to the doctor” isn’t enough – it’s like going to your mechanic and having a conversation about changing your oil. The conversation does nothing unless you actually change your oil. Likewise, your doctor can tell you to watch your diet, get some exercise, lose some weight, avoid cigarettes and alcohol – but unless you actually do those things you’re potentially headed for disaster. Heart disease is not an accident. Neither is diabetes or stroke. Both are preventable, and the cost is not much more than changing your oil every 5000 miles.
Although not a qualified, peer-reviewed study, I think there is some anecdotal validity to the conclusion that people don’t listen to their doctors – when you compare the number of people who have health insurance that pays for well visits to the number of people who are clinically obese in this country, it makes a pretty good case for wondering why the taxpayers should be footing the bill for all those visits. It’s like I told my kids – I’ll pay their tuition as long as they work hard and get good grades – but I’m not going to put more effort into their education than they do.
I realize that it’s a very Pollyanna point to make, but if we all took better care of ourselves and actually used the information at hand, our medical costs in this country would be far more manageable.
(I once sat next to an unbelievably obese man on an airplane – the fat on his hips took up both armrests. He complained bitterly about his knees – how they hurt all the time and how many doctors he has seen about them. His conclusion? “Doctors in this country don’t know anything!” I wonder how many people in this country have that same attitude.)