President Obama's speech to the AMA was a model of reason, clarity and vision. It raises the question of why the AMA needed to be lectured about the dilemma a doctor, particularly one in primary care, faces:
Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, and writing appeal letters; a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients.
The President's speech even quoted Newt Gingrich:
As Newt Gingrich has rightly pointed out, we do a better job tracking a FedEx package in this country than we do tracking a patient's health records.
The speech reminded me of a conversation a few days ago with a close friend who said casually, "Face it, Abraham, medicine is corrupt." I paused. I sputtered. I was about to say something. But I shut up. I shut up because (as the President explains) whether I like it or not, I am a beneficiary of a system of :
. . incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I'm talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can't spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it's not truly necessary. It is a model that has taken the pursuit of medicine from a profession - a calling - to a business.
We can quibble on the ways the President proposes to fund the changes he proposes, but I don't think we can quibble on the moral imperative to change the way we do business. As the President says,
"You entered this profession to be healers - and that's what our health care system should let you be."
(For another take on the speech from a thoughtful physician who also happens to be in New Hampshire, see KevinMD.com)
Comments (37)
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Abraham Verghese
"It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can't spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it's not truly necessary. It is a model that has taken the pursuit of medicine from a profession - a calling - to a business."
And who exactly is to blame for this?
Politicians as always.
HMO's were created by Democrats and Republicans alike.
In 1942 we moved away from individual insurance programs to employee based insurance programs when when employee health premiums were made tax deductible to employers--not to individuals.
Again, politicians.
Congress created Medicare in 1965, making individual insurance for those over 65 obsolete. As a result of government subsidized and unrestricted health care for seniors an unprecedented frenzy of spending by patients and doctors occured.
then things REALLY snowballed out of control.
As a result costs exploded which introduced an economic obstacle to individual health insurance. As a result those on the New Left, including then freshman Sen. Ted Kennedy, argued that the government ought to pay for everyone's health care and promoted the idea of a "health maintenance organization", a term coined by a left-wing college professor.
President Nixon appeased the left and proposed the HMO Act, which Congress passed in 1973. Combined with Medicare, the HMO Act eventually eliminated the market for affordable individual health insurance.
Government has been running healthcare for the past 4 decades.
Maybe it's past due that we tell the politicans where to go with their health help. I mean, it's not like they have anything to worry about. Congress has what can only be described as the best healthcare in the world and it's all paid for by us taxpayers.
Very nice outline of why we are where we are... Thanks for the history!
Yes, because ignoring a problem is always the best way to fix it. And it's not like the politicians back then were elected by us, right? We voted them in and we, as customers, gave the insurance companies the money for lobbying. If you want to play the blame game, it all goes back to us. Personally, I think throwing tantrums about who we should be mad at is a little juvenile and quite counter-productive. Let's learn from the past, not dwell on it.
I concur that there is plenty of blame to go around. Sure, politicians are partly responsible for the problems we face, and so are the American people, doctors, lobbyists, lawyers, employers, unions, ad infinitum. I agree with Jeremy: Let's learn from the past, not dwell on it.
I don't trust this president to do anything in the best interest of the United States.
What an annoying ass.
I suspect the depth and thoughtfulness of your response match your intelligence. "Waa waa. I don't like him. I don't like anything he does. I'm gonna tell my mommy." Thanks Newt.
A personal example might help. I went to a Podiatrist for a foot wound. He was very helpful and capable, but when I started to see his bills coming through my health insurance, it was clear that I was being bilked. He charged for two appointments on the initial visit - there actually was one that lasted less than 20 minutes but apparently the insurance company allows for this - I checked. He also charged for a boot to relieve the pressure on the wound - $500. And he charged to an X-Ray ($80)despite the fact that I already had one from Australia, where I was treated. Remember, this is simply wound care. The additional ghost appointment was $200, for what I don't know, as subsequent visits were exactly the same. The boot cost on the internet (there were several of exactly the same make and model) was $79. So I was bilked out of $421 on the boot, and $200 on the visit - the $80 for the X-Ray I'll ignore. How can you trust anyone that does that? I know Podiatrists are not MDs, but they really have a duty to honesty, and integrity. A really good idea is that patients and told costs and agree them upfront. The insurance company is complicit in that although they would not accept the boot cost, they settled at $370, which is still outrageous. They told me that despite paying for insurance, I have no say in what they pay on my behalf, nor is there any procedure to adjust.
As a physician I receive no "rewards" for ordering labs or x-rays. I do have and overhead that is $50,000 plus higher to deal with the vagaries of "managed care"
Why not return to the model of not for profit "Blues". Therre should be minimal profit in health care insurance and absolutely no concern about shareholder equity.
Why not pass malparactice reform? Don't cap the judgement but cap the lawyers fee to one third of the first 1.5 million. Lawyers would stop suing for more...just ask them.
Why do we have the highest drug costs in the world? Lets make reform total don't just take on the physicians and hospitals or the best and brightest will no longer go into medicine. We are already 1500 primary care physicians short. If the hospitals sare forced to close wher will the sick people go?
There are a number of questions unanswered and the American people are not being given a true idea of cost or complexity.
I think the big problem should be insurance reform....set new standards and rules for insurance companies. They over charge the doctor, over charge the government and over charge the policy holders. Then they agree to be overcharged to avoid litigation. And it gets especially murky when the doctor's malpractice insurance is the same company as the patient's medical insurance.
FedEx is a private business and not run by the government. So there is nothing about "WE track packages..." it should be "FedEx tracks its packages..."
The US postal service has taken decades to catch up with FedEx and UPS, and still really aren't there, and they have been basically privatized to get where they are. Is this the route we want health care to take. Take a look at countries with universal health care for crying out loud!
Lets have some facts first. According to the CIA factbook:
*Canada (universal health insurance) is ranked 8th in terms of life expectancy
*United Kingdom (universal health insurance) is ranked 36th
*United States (private insurance) 50th.
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html
Matt, your post says it all. Believe in the free markets! Stop Socialized Medicine! Listen to the link I have posted.
http://www.youtube.com/watch?v=fRdLpem-AAs
Living in Canada, I've never been concerned about healthcare -- tho' I've had four "major" operations. Our taxes are higher and that's fine with me.
Also, in spite of reports that "Canadians wait forever to get admitted", I've never had to wait for more than a few days or (for emergencies) a few minutes.
It's always surprised me that the U.S., the richest country in the world, doesn't have "universal healthcare". Every other wealthy country does, like Brazil, India, Israel, Singapore, Taiwan etc. etc. ... and virtually all of Europe.
It's alright pjP. Not living here, you have no idea the lengths that the lawyers, doctors, insurance companies and politicians will go to to keep the status quo, perhaps even the status quo ante.
Lying and misrepresenting other country's situations is just part of the game.
Sigh...
pjP, We don't want to be like every other country. Being different is what has made us great. Why is it the government's job to do what the free market will do? Every step we take to expand our government is one step closer we get to having them control every decision we make in our lives. It is an individuals reposibility to take care of him/herself.
In the name of liberty!
1 - The "free market" has not been free for centuries.
2 - Does basing national policy on "being different" and nothing else really seem like a good idea to you?
3 - Being different is not what made us great, picking the best ideas from other governments and philosophers is what made us great.
Different and great are completely unrelated. FedEx, UPS, and DHL profitably coexist with the USPS, and the competition drives them to be better than the postal service in a lot of ways. Why should we deny Americans the benefit of competition in healthcare? It is the government's responsibility to give an individual the means to take care of him/herself.
http://www.youtube.com/watch?v=fRdLpem-AAs
Don't tell me, let me guess: "my country right or wrong."
Resigh...
Its going to be near impossible to alter the landscape of tx modalities for the middle of the USA's Dx bell curve. Look at the ten most prescribed drugs list . It will prove instructive. So... I think the sci fi outcome for the Obama health care model will be to decrease demand. Here's how it may end up. Legalizing all abortions thus allowing a propylactic abortion. Effect: a constraint on future demand. (the left wants 0 growth. Part of the new age world view; No?) Eliminate the older part of the population who use most of health cares services currently in the last 5 or 10 years of life. He will advocate legal suicide (assisted). It will be incentivised by extraordinary tax breaks(pehaps not so local GovTxCtrs can be made to look culturaly hip?) Maybe you could have the old useless person driven to the "going away center" in a guzler that gets only 30 mpg. (donated and gains a much bigger tax break then can be had under used car market forces.)Good Sci Fi is a natural horrific exageration of ordinary life No? We may be half the way there presently; No?
Have you dug your fallout shelter, yet?
I am an American now, but I grew up in Britain under the 'dreaded' so-called socialist National Health Service. Like our Canadian friend I had 3 major surgeries, one of which I had to wait almost an hour to get, and I could only pick one out of hundreds of thousands of doctors - i.e there are no restrictions whatever.
My total un-insured healthcare costs for the 40 years I lived in Britain - zero dollars. My insurance cost during the time - around $3000 a year, but that includes unemployment and retirement insurance too (all for LESS than US private medical insurance) - what a rip-off, eh?
The problem I see all to often here is that far too many people are so gullible they'll believe the lies told to them by the very people and corporations who stand to profit if we believe their lies. Wake up, people, corporations all (legally) tell whoppers and hope you're dumb enough to believe them so they can make obscene profits out of your misfortune.
You really want to compare a population of 59 million with the USA and its wildly disparate issues? Cant speak too much to your tax situation but Im thinkin' you're not completely and fairly accounting for the true costs. Oversimplification ie; apples and oranges.
Are you really gonna pretend that 59 million people is insignificant? What are these medical problems that are exclusive to Americans? Please, do share.
C'mon, dont put words in my mouth. Setting up the straw man by tryng to defuse my central argument pretending I said 59 million humans is insignificant is really going out on a limb. Allow me to saw off your thin branch. Demographic , ethnicity and any number of catagories inherant in our much larger population and geographic spread makes planning for disease control ie social health care concerns and programs differ greatly from GB's. Complex for one sentance but significant. Thats what I was getting at. A one-size-fits-all for the motherland we Yanks broke away from (but are now lately re-inventing ie: "what we came here to do") wont work well, here, as 'its' presently practiced in europe.
Have you looked at the financal mess the UK is in? 50% income taxes etc. Sounds fun.
I'll play like you don't know that you're repeating an easily-checkable lie, and that you just spout talking points without thought. The alternative would be much worse.
http://www.hmrc.gov.uk/rates/it.htm
I am mistaken then.
Wow, my father is a retired surgeon. There are many factors which effect the cost of healthcare among which are malpractice insurance (in 1979, $350,000/yr for a high risk specialty surgeon), and the cost, which is passed on to paying consumers, of those with no insurance. They get surgery and hospitalization just like everyone else. Guess what, we are ALREADY paying for it. Canada? I have many consultants through my company that work there and ALL of them carry their own private health insurance. UK? My friend's father was on a LIST to get a heart test done for three months. He came here to visit his daughter and had a heart episode. Test was performed immediately showing emergency heart surgery was required. Would have probably died in the UK waiting for the test. I am sure there are examples of systems that work, but tort reform is going to need to be a huge part of the solution. Last I checked, most politicians were previously attorneys. I just don;t see it happening. My solution: vote against every single incumbent for the next four years. Throw the bums out. Make them use Medicare for their own healthcare. End the reign of idiocracy.
Something interesting to read (from the point of view of a Canuck):
http://www.gummy-stuff.org/health.htm
Obama is NOT telling it as it is. Not only is he going to cut reimbursements to Doctors and Hospitals, but he will also, of course, control Doctor's compensation. If he does this for bankers, insurance and auto executives how can an intelligent Doctor not realize this is in his future too.
Obama is putting the whole medical services industry through the "sucker" phase: 1) Rosy promises, 2) Government money 3) So called needed controls, and 4) Total government dictation of virtually everything.
Doctors and other medical services executives should realize they are dealing with the devil who acts illegally, steals billions (like he did when he extorted Chrysler and GM bondholder's money), and who has the morals of a street thug. Well, he is a street thug -- and Doctors and Hospitals need to know they need to protest, fight, and denounce the Government programs -- unless they want to be told what to do, how to do it, and how much money they can make.
As a physician in the trenches, Obama is NOT "telling it like it is". First of all there are NOT 47 million uninsured Americans but rather 47 million consumers of American healthcare...big difference.. and the media keeps repeating the inaccuracy. At least a third of the uninsured are illegal aliens who are bankrupting many medical centers. This figure does not even include all of the anchor babies who become defacto American citizens eligible for Medicaid and multiple other subsidies as Americans. There has been a blanket refusal by administation officials to tell the truth about this issue and where the real costs are coming from. Many uninsured Americans are also young and healthy and don't consume healtcare services. Those of us that work in Emergency rooms see it every day...from translators to social services on top of "free" healthcare. Lets face it, when the door is wide open (still no fence) and the Third World is flooding American hospitals for free healthcare, it is no wonder why we are going bankrupt. But lets just tell the truth about why the number of uninsured is growing and wont be fixed with data availability and electronic medical records. No one with any intelligence believes that you can give healthcare to everyone at lower cost and high quality....something has got to give....a good start would be to think about Americans first and not the rest of the world.
MW:
I was curious about you're comments here, so I did a bit of reading. You say, "there are NOT 47 million uninsured Americans but rather 47 million consumers of American healthcare." If I understand your meaning, it's both. You're right to point out that everyone living in the U.S. is a healthcare consumer at some point, whether they are insured or not. But there are genuinely 47 million uninsured Americans, at least according to the U.S. Census Bureau. The Census Bureau is calculating based on the number of U.S. citizens without employer-based insurance, not on the number of patients seen in hospitals. For this number, see Dr. Newton, et al in the Journal of the American Medical Association, who report 17% of ER patients in the U.S. being uninsured last year (JAMA 2008;300(16):1914-1924). In 2008 this was about 19.5 million people and the percentage has risen sharply since. Of this number, the U.S. General Accounting Office has reported that about 5% are undocumented. This is a median percentage from 198 hospitals around the country, so obviously hospitals will have different experiences; presumably, those near the Mexican border will see more uncompensated care. In general, however, and with all respect to your work, your experience that "a third of the uninsured are illegal aliens" does not match the norm.
I'm an American who grew up in the US, spent more than a decade living in England until a few years ago, and is married to a Belgian, so I feel capable to talk about both sides here. Broadly, the difference between European-style and American health care is this: the US has among the top health care in the world and so long as you're insured you get it when, where, and how you want it. BUT, you pay through the nose for it and not everyone can get it, or keep it once they've got it. On the other hand, countries with nationalized health care provide that care to everyone, all the time, for free (or nearly). BUT, the quality of care is sometimes a bit less and you do occasionally have to wait. However, for 95% of people 95% of the time, it works out and its brilliant. It's the 5% that make headlines, and not just in the US, because the British and Europeans compare themselves to the U.S. too, especially when things go bad. See, for example, wg's comment above.
So basically, it really depends on your perspective on social needs. If you're more interested in the good of the (relatively wealthy) individual vs society, the US system is clearly better. If, on the other hand, the good of society trumps the good of the individual than the Brits (and Canadians, and French, and...) have the better idea. Personally, I lean toward the latter.
And incidentally, the United States DOES have universal, nationalized health care, at least for a small segment of its society. It's called the Armed Forces, of which I was a member for many years, and overall it was excellent. We CAN have that if we find the will and the sky will not fall. I promise.
What continually surprises me is that the U.S. COULD have the best healthcare system in the world ... if it were a top priority of the medical community and the government (as seems to be the case, these days).
Indeed, the U.S. SHOULD be the best place in the world to live -- for (almost) any measure of "best".
However, see this recent U.N. report: Best Countries
This is a thoughtful analysis and an interesting perspective. Thank you for contributing it. I might add another small segment to the list of Americans with universal health care: those over 65. It is very difficult for one over 65 not to be covered by Medicare. I don't know the exact percentage of the over-65 set who lack Medicare, but I suspect it's so small that we can essentially call that segment of the population universally insured.
I watched the President's speech to the AMA at work, during lunch, streaming on BBC news. I was stunned by how well informed he was about the issues of medicine. It was as if he was a doctor himself who faced these problems. As a physician myself practicing critical care medicine, I can attest that everything he has mentioned is correct. The reimbursement system from insurance, whether it's private or public (ie. Medicare), is so dysfunctional that it rewards mindless action for its own sake, not for the sake of actual effective care. As a personal example, the more procedures I perform, the more diagnoses I come up with, and the longer time I say I spend with a patient, the more I can charge. Another doctor might spend twice the time with the same patient and achieve half the results, but charge for more. There is a great motivation to exaggerate, as there is no consequence.
Those who would cite the market as a self-regulator forget that certain conditions have to be met for the market to function in perfect competition and minimize costs.
1. There have to be so many insurers, furiously competing against each other for business, that they cannot manipulate the market to their benefit. In the US, there are only a handful of insurance conglomerates, so that the net effect is an oligopoly. Although it is illegal for them to collude, I'm sure they do it at least some of the time, to protect their interests as a whole.
2. Both the buyers and sellers of insurance have to have equal access to information. In today's market, the insurance company has no idea if I'm lying through my teeth when I submit a medical record, and has no way to figure it out that is not cost-prohibitive. So everyone's premiums go up, and everyone's reimbursements go down. What's worse is that the insurers have a mentally retarded scheme for determining reimbursement that has no basis in the utility of those services. As I've mentioned before, the time that a doctor spends on a patient has no utility whatsoever if nothing gets accomplished as a result. Likewise, any diagnostic test ordered, whether it is the correct one or not, is reimbursed.
3. A market system has to properly take into account all costs of services. Right now, a disproportionate share of costs is diverted to largely non-utilitarian tasks, such as bureaucracy (an attempt to compensate for asymmetry of information), malpractice insurance, and charity. These are completely out of the hands of the patients because the legal system has been set up in such a way as to dysfunctionally reward 3 behaviors:
a: costly paperwork to get reimbursed with next to nothing
b: sue
c: plunder the Emergency Room for free medical care, knowing that EMTALA will force care to be provided regardless of ability to pay
If the market is to function properly, the laws have to be altered so that these non-utilitarian incentives do not exist.