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John and Jon I love you both!!

David --
Thanks for your thoughtful post.
I don't disagree with a thing you have said.
Nevertheless, medicine has become a utility -- not a luxury, as in the "old" days. As such, it has become a regulated monopoly.
And for whatever reason, young doctors out of training want NOTHING to do with running a practice.
In my town there is virtually no one who isn't on Medicare or Medicaid or some HMO/PPO plan -- the few that there are have no money.
So, I'm stuck, regardless of my personal philosophy.
I take them all, and swallow my lumps. No one around here -- doctors included -- seems to care about "private" medicine. They want it cheap, and they want it now.

Exactly.

I always find David's take in this area to be insightful and thought-provoking. I think his point is that when we make the calculation to participate with Medicare or Medicaid, we do a cost-benefit analysis. In the past, much of the discussion centered on the size of the benefit (e.g. was the fee schedule satisfactory). There was always a "cost" in the form of "the hassle factor". It seems that now the ante has been raised. Incentives increase the potential income, but the "costs" in terms of energy and time expended, as well as compliance with rules and regulations, have increased as well. We all need to re-think the analysis periodically. There is no right or wrong; each of us must reach their own answer.

And if 2 1/2 cents a box is a money loser...you can't make it up by increasing volume.

Thanks to you all. Tom, I pose to my students what I think is the central question of medicine today: "Is healthcare a right or a commodity?" I don't think our culture has decided this yet. Needless to say, that causes problems.

I am not eloquent enough to always be able to express my thoughts without sounding like Ted Kaczinski on an anti-government rant, and that is not my intention. It is easy to see choices as a binary A or B situation. I just want my friends to remember that the answer may not be A or B, but may include C, D, E, or even none of the above. I am certainly not critical of those who choose option A.

Healthcare is a pay-as-you-play service, not a right. Those who say it is a right are those who want something for free. Period.

If you have the money, you buy Healthcare. If you don't have the money, you don't.

If you have the money, you can go buy a new car. If you don't have the money, you don't.

End of line.

JamesNT

Healthcare is neither a right nor a commodity. It is a service which you can exchange for something else...another service, food or....money.

I will die without food and water. But Walmart does not have to give it to me for free. Some governments have elected to provide this for free for some persons...but they did not always do this.

Recently, we've had 3 patients in where I or Dr C discussed "socialized medicine." Interestingly, the 2 patients that had the most exposure to socialized medicine (one Canadian and one woman whose fiance was immigrating from Britian) liked it the least. The other American really had not encountered the people that, say, couldn't get a renewal on their medication because they could not get an appoinmtent with the doctor for a month or more (granted, they had missed an appointment, but they had given notice in advance. They were out of the country since they were here.) They just thought that being able to get an appointment within 3 or 4 days with a new doctor was just phenominal.

Health care is considered a right in most "first world" countries outside of the United States.

The reason healthcare is considered a right in most of the "first" world is that in order to control disease spread and to ensure equal ability to work (by having controlled disabling conditions) it makes sense to apply the services across the entire community.

Health care costs have skyrocketed in the last 20-30 years, going from about 5% to almost 20% of Gross Domestic Product.

This is true both in the US and in countries with socialized medicine, although the % GDP cost is not as great in other countries as in the US.

Some of this is due to defensive medicine and our litiginous society. Some of this is because we pay the bulk of costs for development in pharmaceuticals and equipment. We also train more physicians than many other countries.

Providers have not seen much of this increase as it is in hospitals, supplies, technology and pharmaceuticals. Mechanisms to control costs are primarily aimed at providers and hospitals.

We do not have the best statistics in many areas of health care. This is not only due to access to health care but certainly it plays a role in the care.

While it is true that availability of health care CAN be easier in the US (I bet it easier to get an appointment in the UK for a new patient than much of the US on Medicaid,) this is only available to about 50% of the population.

Great post. I am with you on 99% of it. And, I am only an "n" of 1, but a MaineCare patient could call at 8:15 am to be accepted to the practice and seen at 10:00 am for an ear infection.

Wendell, that was very well said.

The great majority of Medicaid patients (let alone those with no insurance) do not have the access to care that Bert provides.

Well, I too accept Medicaid (about 66% of my practice) and am very liberal about walk ins. I know that Bert and I are NOT the norm.

I am obviously a believer in universal health coverage. This is a commodity much like sewage and water that is best done for the entire group rather than piecemeal.

It does not have to be run by the government directly. It could be Blue Cross of either the state or US. (Now BCBS of IL built a 2 BILLION dollar building in downtown Chicago WITH CASH 10 years ago and is now adding more floors for 3 BILLION in cash, but they are non profit ) They are still better than a FOR PROFIT insurance.

Much of the savings by deduplication of the 400 insurance companies administration systems and one consistent set of rules would pay for health coverage for those who do not have or have adequate coverage.

It would require government oversight, hopefully better than they have done with the FOR PROFIT companies.

The next question that comes up, if we accept that healthcare is a right, is how MUCH healthcare is a right? The answer is always "Well, basic healthcare..." So, I guess we can exclude cosmetic surgery. But what else? Does that mean you can get prednisone for your crohn's but not Remicade? We really quickly get into the issue of rationing and cost-effectiveness panels, which is a non-starter in our culture.

Partly this is true, of course, because whenever it is suggested that a service is maybe not cost effective, some medical specialist's income is threatened. Look what happens when it is suggested that mammograms maybe don't have to be done that often, or PSA screening does not improve life expectancy. This is because to a large extent, medicine IS viewed as a commodity. Everyone wants to think that he/she can drive a Lamborghini, and those that sell the product have every incentive to sell more.

I think that if healthcare is to be a right, we have to be willing to have it done all the way; personal provider's income must be disassociated from treatment recommendations. Just having Blue Cross foot the bills is not going to do a thing.

The average American wants the best healthcare that someone else's money can buy. As soon as you ask them to pay extra for brand name drugs, or have a higher copay for expensive procedures, they start examining whether they really want what they are asking for. My point -- making the patient pay a substantial portion of the cost is not a bad thing -- it keeps the doctor and patient both paying attention and sweating the details. If you look at the past 20 years, with physician panels and HMOs and fixed copays and wellness exams, you realize why costs are exploding. Which is exactly what is wrong with the present "reforms", more "Nanny government" givaways.

A "right" that impinges on some one else's freedom or property is not a right.
In order for a citizen to recieve healthcare, someone else must give up time, effort or money. That is NOT a right.
The unalienable rights, Life, Liberty and the Pursuit of Happiness are, as explained by the Declaration are self evident, and do not impinge on another citizen.
The rights conveyed by the Bill of Rights, property, Religion, speech, press, to keep and bear arms, etc. likewise do not impinge on others.
Once you start inventing "rights", then you cross a line, and SOMEONE suffers.
So healthcare can not be a right if my rights are infringed (by depriving me of property or freedom, e.g. working for free).
What other "rights" can we invent? Food is more crucial to life than healthcare, so why not free food?
The only rights in health care can only be tied to valid rights as granted by God or the Constitution.

Roger,

Another great post. I would have to say I lean toward your way of thinking. The only thing I disagree with is your analogy, although it is still a good one: "why not free food?"

There is free food.

I could argue that the right to "free speech" is limited, you can't yell Fire in a croweded theater, you can't defame people without consequences, so is it really Free.

You can bear arms, except in Chicago, but the right to use them and to obtain ammunition is limited, so is it really a free right?

Government exists to provide for a common basis of the populace. How much support the government provides is a never ending debate. It is a fundamental difference between several political parties and even within them.
Free is always a relative term. Most of our roads are "free" but they cost an inordinate amount of money to maintain, as does the cost for police patrols and court systems for fines, and the Department of Transportation. The system is set up for the betterment of the population.

Health care is another commodity that has been accepted in most countries as a necessary service for the support of the populace.

That has not been accepted in the US, and we pay the consequences. Because of overlapping bureaucracies and unequal availability of care, there are many duplicative services that cost a lot of money. For profit services for something that may sustain life and health would be better utilized as non profit with the care going to the populace.

The Declaration of Independence does state unalienable rights include Life, Liberty and the Pursuit of Happiness. It could be presented that Life and the Pursuit of Happiness are directly impacted by the availability of health care.

Anyway, I will not change anyone's mind, but felt that I should exercise the right of mostly free speech to express my opinion. I understand that not everyone will agree but that's OK, not everyone can be right like me

Bert, I infer that your statement "there is free food" is a reference to government food give-aways or food stamps.
While the food is free to the recipient, it is not confiscated from the farmer or the grocer. It is purchased from the sources by State (and I include the Feds as part of the State, of course) and given to the recipients.
I once wrote a never-published op-ed piece describing "food maintenance organizations" as a continuation of the food simile, and then calling for "Medi-Stamps".

Wendell, I agree with much of what you say, and posit that we have more of a semantic difference than a philosophical one.
While the shout "FIRE!" example is oft presented as a limitation on free speech, I believe it is so only because of its impact on other individual's rights (e.g. right to be free of risk of harm).

Other countries who choose to provide health care services to the masses do so, I believe, without confiscating those services from the providers (as the several states and federal government does for many). They employ or pay for the services.

My point was there can not be an unfettered "right" to health care services without obliging SOME ONE to provide them. If the provider participation is voluntary for what ever compensation is provided for those services, then there is no compulsion to provide the services. But if a provider can choose NOT to provide services, then the "right" to health care cant' be enforced, and it really doesn't measure up to Life, Liberty and the Pursuit of Happiness.
My fear of accepting the position that health care services is a right can lead to providers being forced by the power of the State to provide those services, under what ever condition the State decides upon; after all it is a "right".

And Bert, while there is "Free Food" there is also "Free Healthcare" from the State. But do you think the State can afford to provide free food for everyone? I don't believe that even with better efficiencies that the government could pay for healthcare for everyone...not the way everyone would want it. Declaring things as "rights" is worse than a slippery slope...its more like an avalanch waiting to happen.

We used to accept Medicaid. Alice felt it was the proper and moral thing to do. I agree. But here in NYC, it can ruin you. Additionally, you get a gleam into what people consider their healthcare "right." So we had the 20 year old who was upset that we did not dispense free condoms for her. Or aspirin. Because Medicaid will pay for aspirin and other OTCs.

Whenever we hear about the wonderful system of these countries that have universal healthcare, we never hear about any of the costs associated with it. I mean cost in a general sense. What are the tradeoffs? Is there a higher tax rate? How are physicians rewarded? How long is a wait to get an appointment? And many other questions that I cannot even think of right now.

FREEDOM

I don?t know about you but it?s amazing to me how that the word Freedom has become corny, trite, and even ?unAmerican-like?. It is, or should be, the very fiber of our human existence and citizenship. And I feel corny just saying that, amazing.

For more than 40 years (peds and later allergist) I?ve always accepted Medicaid and Medicare without any restrictions. No insurance? Pay me ten bucks, okay? Now then, through the years I have turned down or ?fired? insurance plans (UHC a few years ago). At times I have informed patients that their lousy health plan should be brought to the attention of their employer. I have even called a couple employers and let them know what they?ve done to their employees! (How bout them apples?) You know what, changes for the better usually occurred. I have a choice and my patients have a choice. Yeah, that?s the corny freedom thing.

Single player medicine means no choice, nada, for the provider and the patient. You want the ?medical problem? to ?just be taken care of?? Be careful what you wish for.

Costly? If you think medical care is expensive now just wait till it?s free. That?s an indisputable fact and, come on, you know it. How's the government doing on the payment/cost side so far?

Poor outcome? A specious argument re providing more free health care. The false assumptions of infant mortality rates would be a good starting point. PM me if you?d like the real facts emanating from my days as a fellow in neonatology and the Great Plains Perinatal Organization.

Thinking about the government "efficiencies" and saving money. When was the last time you saw an article where docs had scammed a private medical insurer for a few million dollars?

Every month we learn of a new multimillion dollar Medicare fraud perpetrated over some years. This month it was mail order "penis helpers" for Medicare. Last month it was orthopaedic appliances for elderly, a scam which finally came to light when one individual was billed for four artificial right legs. I suspect if they would have billed two right and two left it would still be going on.

Private insurers may drive us nuts but they don't get scammed as easily.

(Okay, I'll get off my soapbox...Sorry for the rants but...)

I have this recurring dream...


The day comes when our current healthcare system finally implodes... and by that, I mean really implodes, to where a huge block of people really could not get any care even dire circumstances... I would see it going down like this:

The army would draft us. It alone has the infrastructure to manage large groups of unwilling employees, knows how to run hospitals and clinics, and operate supply lines. It is good at triage.

Medical schools and training would be taken over. Medical education would be free. Specialty training would be based on 1)need, 2) ability, and 3) (last) preference. "Sorry, we don't need any more interventional cardiologists. You can have a general medical slot". Similarly, assignments would be based on need. "no, you don't get Manhattan; you are needed in Mason City, Iowa."

Care would be inconvenient, impersonal, cost-effective, totally science based, hateful and universally available. "No, you don't get proton beam therapy for your prostate.. Come back in 6 months for a repeat digital exam." "No, you don't get antibiotics for your sinusitis. Use nasal washes".

Physicians would be generously but not irrationally reimbursed. ( a quick aside; is there someone who is not somewhat offended by the fact that an interventional cardiologist at the 75th percentile of income makes $800,000 a year? Was medicine really supposed to be a pathway to great wealth, or were we supposed to do good work first and hope for a reasonable lifestyle?) Pay would be according to rank, maybe plus years of training. The colonel would get paid more than the Major because she is a colonel, not because she is a thoracic surgeon. At the top of the heap is some general who says "no" a lot when pressured by patients or politicians to make exceptions to care. He is outside the civilian judicial system.

Those of us who could retire or change jobs probably would, once our enlistment was up. Those who refused would be treated as deserters. There would be plenty of new applicants waiting to take our place.

I forsee that we will continue to try to keep the current system going with more and more patches and Bondo, until one day it just totally collapses, and not even the slightest vestige of care can be found. This might be our future.

David,
I vowed to stay out of this, but you drew me in.
Your dystopian view may come to pass. I think a simpler version is much more likely, and fits with many ideas that are floating around at very high levels in government now.
Step one: Congress passes a law that Medicare participation is a pre-requisite for a medical license. This has been bandied about on a state level, too, and really might happen.
Step two: A revision to the Medicare fee schedule: no more RBRVS, just a salary payment, with reductions or incentives based on your (perceived) quality of care. Payment is no longer based on volume, which is just what is being discussed now.

David,
I also have been biting my tongue trying to stay out of this. But, you know what, your scenario sounds appealing to me. Am I daffy or just unimpressed with the current state of affairs?

David,

Don't push the rank (major, colonel, etc.) comparison too hard. I spent 4 years as an Army doctor, paying back for college tuition. It is clearly (as far as the Medical Corps) not a merit based system. The only reason for rank is longevity. I earned Board Certification, ACLS, ATLS and volunteered for field stations, and never earned a single decoration or speedier promotion. In a sense, it is what you would expect if Uncle Sam ran the medical system, top to bottom. Since we weren't at war, I didn't do much work, however. I imagine that is different now.

John. Agree that rank is a far from perfect system, just as is seniority for an airline. But, it is better than basing it on how many procedures you can justify. Jon's vision might be closer. I am just sure that personal income has to be separate from procedures and drama, and seniority is less onerous to me than the schemes that are based on how many checkboxes you can tick off during a visit.

I was just saying there is free food. No opinion.

The only thing that currently remains truly "free" is sunshine and air.
But some people still chose to pay for these items at the tanning booth and the Oxygen bars. How weird are humans? We want stuff for free that cannot be free. We want to pay for stuff that is totally free.

The monopoly exist in the medicine market.Yes,I agreed thanks for sharing such an interesting idea.Similarly the rights conveyed by the Bill of Rights, Intellectual property rights , Religion, speech, press, to keep and bear arms, etc.Every one should be treated equally.