TCS Daily

When Health Care Becomes Personal

By Arnold Kling - January 29, 2008 12:00 AM

"Despite a rapidly growing elderly population, the number of certified geriatricians fell by a third between 1998 and 2004. Applications to training programs in adult primary-care medicine are plummeting, while fields like plastic surgery and radiology receive applications in record numbers. Partly, this has to do with money—incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, most doctors don't like taking care of the elderly."
--Atul Gawande

Over the past eight weeks, I have been spending a lot of time with my father, who has developed some acute medical problems. For the most part, my focus is day-to-day (or hour-to-hour) on the issues and stresses that arise.

But I have also come around to some different points of view about our health care system. I no longer think of Medicare and health care regulation as inefficient. I now think of them as pure evil.

My Father's Case

My father has benefited from America's health care innovations and research. He had heart bypass surgery 17 years ago. His use of diet and medications to control blood pressure and an irregular heartbeat have enabled him to live to almost ninety, whereas his own father died of heart problems in his fifties. When told eight weeks ago that he had terminal cancer, thinking back on his heart issues my father said, "I'm lucky I've lasted this long."

In late November, my father started having episodes where he could not eat without throwing up in the middle of a meal. His doctor sent him for an endoscopy, which found an advanced malignant tumor in his esophagus. The survival rate for esophageal cancer tends to be extremely low, because it is rarely diagnosed early enough. In my father's case, the cancer is viewed as inoperable. Instead, he underwent a course of radiation.

On the evening of January 10, my father experienced severe pains near his right ankle. The next day, he went to see his internist, who diagnosed the problem as cellulitis, meaning an infection. He prescribed antibiotics, and also sent my father for a precautionary X-ray.

While standing near the entrance to the building for the X-ray, my father slipped and fell, fracturing his hip. He was taken nearby to the emergency room of BJC hospital in St. Louis, admitted to the hospital, and operated on that Monday. His hip required a reinforcement (screws) rather than replacement.

From an orthopedic perspective, he was supposed to begin rehabilitation the day after surgery. However, the operation had required stopping his heart medication, and his heart rate rose above safe levels. He spent more than a week as a cardiology patient, getting no rehab. Finally, he was transferred to the nearby St. Louis Rehabilitation Institute. I believe that he has the strength to eventually be mobile with a walker. However, statistically when people his age suffer hip fractures, 25 percent of them never make it out of the hospital, and with his cancer and heart problems he is probably not above average for his age in terms of overall health.

Health Care Complaints

I do not expect health care to be perfect. I do not expect someone with cancer to have an enjoyable experience. I am not threatening to sue anyone, or even to suggest that the care my father received was anything other than far above average. But I do think that there were serious flaws, and that these flaws are systemic.

When Atul Gawande says that "most doctors don't like taking care of the elderly," I think he is including my father's internist and virtually every other doctor that he saw at BJC. None of the doctors touched my father with their hands. Many of them used a stethoscope. The internist looked at the cellulitis. Otherwise, they never examined him. And each specialist was only concerned with his or her particular area--the heart doctors only worried about his heart, the orthopedists only cared that the screws were in correctly, the internist only worried about the cellulitis. Nobody noticed problems with my father's veins or his skin that were caused by having too many IV's and spending too much time on his back.

I do not blame my father's internist for failing to detect the esophogeal cancer earlier. However, it is a fact that for years my father had been coughing after meals, and he had asked the internist about this symptom. The internist treated it as an allergy.

I probably should not blame the internist for sending my father for an unnecessary X-ray, on the way to which he broke his hip. But the X-ray was unnecessary, because the internist already had made his diagnosis.

A Better Way

However, having seen the doctors at the Rehabilitation Institute, I know that there is a better way to practice geriactric medicine. The doctors there were hands-on. They changed dressings themselves. They looked at his entire body. They took their time. They found a number of problems that had slipped through the cracks of the specialists at BJC. And they figured out why my father has difficulty with balance.

It really was quite simple. The doctor at the Institute held each of my father's feet and asked him to make some specific motions. It was obvious to me just watching that my father has some neuromuscular deficits, which he has clearly had for at least a year. For example, he cannot feel his feet well enough to control whether his toes point up or down. These are issues that can be dealt with--but only if someone knows about them. And doctors who do not like to touch old people are not going to know.

The real key to preventing my father from falling and breaking his hip would have been to identify and treat his deficits. But it takes a hands-on doctor to do that.

Integrated Medicine

Our health care system is widely criticized for its fragmentation, specialization, and lack of incentives for quality. For example, Shannon Brownlee's highly-regarded book Overtreated makes a strong case that specialist-driven health care is more expensive and less effective than the best-of-breed integrated care systems. My guess is that the Saint Louis Rehabilitation Institute comes closer to this integrated care ideal than does its bigger BJC brother.

Atul Gawande points out the key issues with geriatrics. The elderly are particularly ill-served by narrow specialists who deal with issues piecemeal and in haste.

The Saint Louis Rehabilitation Institute offers a glimpse of a better way to care for the elderly. There, more of the care is driven by the needs of the patient than by the habits of specialists. However, best practices, whether at that Institute or elsewhere, are not going to spread to the medical profession as a whole. That is because our main policy objective in health care is to insulate people from having to pay for it.

Government is the Customer

When consumers are in the driver's seat, best practices tend to spread. In a market economy, if you fail your customers, you go out of business. BJC, which is regarded as one of the best hospitals in the country, should go out of business. It should be driven out by hospitals that function more like its subsidiary, the Rehabilitation Institute.

Internists and specialists who do not like to touch old people should be driven out of business. They should be driven out by hands-on doctors and by gerontologists who take a more holistic view of patients.

The reason that medical care works the way it does is that government is the customer. Government pays health care providers for time and materials. Shannon Brownlee and others believe that government could come up with better compensation schemes that would help promote quality. I doubt this.

Trying to influence medical care from a government bureaucracy sets up a game between bureaucrats and doctors. The object of Medicare Administrators will be to get the largest change in behavior with the least increase in compensation to health care providers. The object of the health care providers will be to get the biggest increase in compensation for the least change in behavior. The health care providers are bound to win. They control the information flows ("you want to see reports that demonstrate quality? we'll give you reports that demonstrate quality.") More importantly, they have the most organized lobbyists, so that any "pay-for-performance" schemes that do not work in doctors' favor will be shut down.

Medicare is wonderful for relieving the elderly from the burden of worrying about health care expenses. By the same token, it is wonderful for relieving doctors of the burden of worrying about the elderly as customers. You get paid for understanding the billing system, not for understanding your patients.

State and local governments do their part to harm our health care system. Licensing regulations serve to entrench and protect the specialist system and fragmented health care. In other industries, business owners decide how to train their employees to do their jobs. Competition leads firms to adopt training methods that foster customer satisfaction. In health care, training methods are dictated by government licensing boards, and they foster high prices and inefficient staffing.

A recent story tells you which side the regulators are on.

Mayor Thomas M. Menino embarked on a highly public campaign yesterday to block CVS Corp. and other retailers from opening medical clinics inside their stores, an effort that exposed a rift between Menino and the state's public health commissioner, a longtime ally.

...The decision by the state Public Health Council, "jeopardizes patient safety," Menino said in a written statement. "Limited service medical clinics run by merchants in for-profit corporations will seriously compromise quality of care and hygiene. Allowing retailers to make money off of sick people is wrong."

In a separate letter, Menino urged members of the city's Public Health Commission to consider barring the clinics from Boston.

I believe that our health care system could be a lot better. Unfortunately, the politicians who claim to be our friends are in fact our worst enemies.

Arnold Kling is an adjunct scholar with the Cato Institute, and author of Crisis of Abundance: Re-thinking How We Pay for Health Care.



Elderly care(less)
Add three observations: (1) most seniors will not point out the deficiencies in the care they receive for fear of further antagonizing the reluctant "care givers." (2) this set of circumstances is exactly why we must continue to oppose all legislation that looks like "assisted suicide." (3) you make the perfect case for why family members must pay attention to their elderly--do not believe everything "the doctor said" including selected care and medications.

You're Right
That’s a fair analysis of the problem of government management directly or via regulation (as the latter is more common in this country.)

There are different levels of care within medically accepted practices with many institutions falling near the lower border of acceptable practice. Our family has changed doctors and institutions several times to get the level of care we desire. I’ve even gone out of network to do this.

With my mother’s illness and death last year, I found the specialists generally excellent but as you note they act independently. I often had to turn-up with the records or have them call her primary care physician.

At one point, I was running to the emergency room several whenever the nursing home sent her there. Even there I had to tell the staff what happened when she was last in that very emergency room! Otherwise they would repeat the check list of things to examine and do.

She was 86 when she died and it was clear the cancer weakened her other systems. There wasn't much that could have been done.

Dems want to nationalize health care
The Dems response to Bush's free market remedies to improve the health care told the tale.

They practically scowled at any free market solution.

Even the concept of exmpanding insurance pools across state lines and expanding insurance pools for self employed and others was frowned upon.

One cold get the impressing the Dems are in the bag for the HMOs and other health insurance companies.

Right on, but not entirely
The idea that doctors don't want to treat old people isn't correct. They don't want to treat people of any age who can't be treated, and old age is untreatable. There are lots of other demands on them beside us old people, and they'll naturally tend to those over tending to us. Sorry, but your dad is dying, unfortunately in little pieces, and there's little your doctor can do about it. What old people need is LESS doctoring...but that's not paid for by anybody.

I'm a retired surgeon, and now a patient. I know that the perverse incentives in the current system are the cause of all this. When doctors work for patients, their incentives are the same as the patient's, and doctors'll change their idea of what priorities to attend to. ANY administrative "fix" will fail, and will make the situation even worse.

We have a lifetime of experience with watching it get worse, and we've not learned from it. Government health care will be the final nail in the coffin of what once was a fine health care system, one in which doctors actually "cared for" patients. The "old days" are gone, forever. Forever. Sad, but true.

Good points
Its strange how Kling desires to blame Medicare and government for these woes, but the article offers little support of it. Problems with communication between doctors or institutions, having bad doctors, specialists, etc. doesn't indicate a problem with Medicare. Does it?

I agree government health care is a terrible idea. But there also is no mention of corporate control over our health care system. HMO's, anyone hear of them? Pharmaceutical reps lavishing doctors with "benefits" and free samples to get their patients "using". How many tv ads for prescription drugs do you see in an average day? Government health care is nowhere near the answer, but government has to be involved in solutions, in making changes to get our health care system corrected. As long as our government operates for the benefit of lobbyists and corporations over the interests of the people, there will be no solutions.

To receive a performance we wish to recieve, we need to establish incentives that motivate to that performance. Simple concept but complex to devise, in health care especially. Really, what does our system incentivise doctors to do?

Kudos to Kling for talking about integrative care and holistic care. A move more in that direction is a very good idea. Specialists provide a benefit, but they shouldn't be relied upon for primary care. Nutrition and exercise and stress and mental well-being are key factors to avoiding disease and having confidence when dealing with doctors.

I can't speak much to how the elderly are treated by doctors in general. But one thing I've experienced, is my primary care doctor bitching about elderly patients who come in with a cold and go nuts when he won't prescribe antibiotics. Is that a generational thing? An educational thing? I don't understand that, I thought it was common knowledge that antibiotics don't help with a virus. But maybe the same thing happens with younger people too. We should point the finger at ourselves first, before we point it at other people or government. Not that doctors or government or whatever are not at fault necessarily, but people are too quick to point fingers outward rather than examine our own behavior.

When you don't pay, why do you care?
The overall issue with health care is most personally don't pay and have no idea what anything costs.

The President's plan starts to address some of these issues by expanding medical savinings accounts and expanding insurance options.

The free market has proven, in the health care arena, that comepetition recuces costs and improves service.

Anti-market bias
Anti-market bias: a tendency to underestimate the economic benefits of the market mechanism. The public has severe doubts about how much it can count on profit-seeking business to produce socially beneficial outcomes. People focus on the motives of business and neglect the discipline imposed by competition. While economists admit that profit maximization plus market imperfections can yield bad results, noneconomists tend to view successful greed as socially harmful per se.

Democrats are really big on this, but so are too many Republicans.

Other economic biases systemic throughout the voter base and our politicians (and those of many posters on this forum):

Anti-foreign bias, a tendency to underestimate the economic benefits of interaction with foreigners.

Make-work bias, a tendency to underestimate the economic benefits of conserving labor. Where noneconomists see the destruction of jobs, economists see the essence of economic growth: the production of more with less.

Pessimistic bias, a tendency to overestimate the severity of economic problems and underestimate the economy’s performance in the recent past, the present, and the future.

From Byran Caplan's book, The Myth of the Rational Voter
Extract of it here:

Because we do pay
Whether its writing a check at the doc's office or through double digit premium increases, or increased taxes, we pay. But normal stupid people have to be hit over the head to think bigger than their self, so your question is not new. In fact, its a mainstream idiot-right-wing question on this issue. Its obvious you don't understand, simply by posing this question, that even if you don't personally pay the full bill, it still benefits you to keep the costs to your insurance as low as you can. Why is it so hard for people to take that into account? People are selfish and stupid, is the answer I offer.

This is not the only overall issue with health care. I'm not sure its the main issue. And keep in mind, sometimes we have no choice. When you are sick and need a drug, you will pay whatever the charge is to get the drug. For many drugs there is not competition to keep the price down.

"The President's plan starts to address some of these issues by expanding medical savinings accounts and expanding insurance options."

I support those two things. I have an HSA and I love it. I'm one of those people they've talked about in the media that has used it for investment and earning reasons more than relying on it to pay bills. It is a huge advantage for my situation, but its not an ideal option for everyone. Which is why expanding insurance options is a great idea also.

"The free market has proven, in the health care arena, that comepetition recuces costs and improves service."

How has it proven that? What are some examples? I just can't think of any. I don't think you can either.

Additionally, the health care system doesn't operate like a free market in all aspects. Drugs is the prime example. Patents are a protection that keep it from operating like a free market, but I'm not saying patents are wrong per se. But what a perfect situation for a corporation: they have someone who is sick and needs this drug that only this corporation can make, and they can charge whatever they want. The person is sick and NEEDS the drug, they will pay. And all drugs don't work the same. One may not work for you, but the one that does costs twice as much, you will pay.

Do you ever see your doctor's bill?
Eye surgury to correct vision has improved dramatically in the past few years. From actually cutting your eye to now using lasers to mold the lens.
All this was accomplished because people wanted it and insurance would not cover it.
Medical screening tests, mostly ultra sound, travel around the country and one can obtain several tests for about $200.00.
Wal Mart now has $4.00/mo prescriptions.

Walgreens, CVS and WalMart are opening clinics in their stores. The Boston mayor refuses to allow it in Boston.

Ever been to an orthodontist lately? They have top notch equipment, efficient staff and insurance usually does not cover all.

Any medical field that must compete in the open market is efficienct and effective.

PS: How MUCH do you pay?
What ARE all the hidden costs?

Even hospitals and doctors offices don't really know because they don't really care either. Not until they stop making money and have to shut down like emergency rooms throughout the SW USA and OB GYNs around the country.

"Its obvious you don't understand, simply by posing this question, that even if you don't personally pay the full bill, it still benefits you to keep the costs to your insurance as low as you can. Why is it so hard for people to take that into account? People are selfish and stupid, is the answer I offer."

Marjon understood perfectly what the problem is and quite clearly states so. As to what you write in the above, how can one keep their insurance low if they have no control over the situation anyway, as all the billing is handled between the doctor and the insurance company. Once you fork over the co-pay, neither one gives you a moment's thought.

If I buy a Blue Ray player the technology is patented. This argument is moot.

If I spend 500 million on a drug do I have the right to recover my investment?

This is a straw dog. The problem arises from other nations with socialized care negotiating lower costs from dug companies and spreading costs.

In a nutshell, we subsidize the world. The entire system is screwed up but a government run system is not the solution. The solution is a totally free market system.

The real issue is politics. Politicians, especially leftist democrats, want socialized medicine. Not because they actually care, no, they want it because it is a source of power.

You know you trade freedom for security you have less of both.

Show me one nation who has socialized medicine that actually has worked?

This is a sad story; I hope your father is doing better...
One remedy is to create a closer connection between the health care consumer and provider - by getting the employer and the government out of the picture. If deductibility of health care insurance by employers is precluded, a market that will service consumers will arise. Competition will set in and those providers that don't measure up will go by the wayside.

The drug would not exist without the incentive
Bobjones - you wrote "When you are sick and need a drug, you will pay whatever the charge is to get the drug. For many drugs there is not competition to keep the price down"

This is true only of drugs still on patent and the patent only lasts a few years after the final approval of the drug because of all the time spent in doing the clinical trials. Generic drugs (those that are off patent) are quite cheap - I just had a course of several days of penicillin for a few dollars per day, very cheap compared to the toothache.

It's a hard fact, but if someone invents a new drug that is better than older drugs and can keep someone alive it seems to me that the patient should be grateful to be able to buy the drug at any price.

Someone in one of the comments mentioned eye surgery. I recall a conversation I had with my aunt when she was decrying the $3,000 cost of cataract removal, especially the fact that it seemed the doctor did the operation in a half hour. I told her it seemed cheap and that the doctor should actually charge more. It was a bargain to be able to see again for less than one sixth of the price of a car.

Miracle drugs only seem expensive to spoiled and self indulgent people. A drug that can extend someone's life for years is literally priceless.

Priceless: Only to those who value life
Just another little incentive for the forces of darkness to promote abortion and euthanasia.

Another incentive
All of your medical records on a permanent storage media that you can give to any doctor.

There is NO reason why each and every one of us should not have our complete medical history availble to us, and under our control, on some sort of computer record.

Old age is not treatable - Medicare is the stupidest program imaginable!
My prayers are with as you go through what I expect to go through soon.

My mother (86 years old) has always had an attitude of trying to avoid doctors. For years we (the family) have tried to get her to go to regular doctors appointments. She resists saying that they always find something wrong. She will go if she is very sick. Once after much prodding she went to a doctor and asked about a symptom of having frequent bowel movements. She was diagnosed with Crohn's Disease. They gave her prescriptions for meds which she took for a while but the meds made her feel worse that the frequent bowel movements so she stopped taking them. Now she avoids certain foods and she says that the symptoms have lessened. She is now all the more determined to avoid doctors. After many years of trying to encourage her to get regular care I have begun to wonder if her way is not the better way. One thing that she fears is the medical establishment taking over her life at the end.

My mother has always said that doctors are fine if you have something that there is a cure for but there is no cure for the disease of old age. Some times it seems that it is better for old people to not know all the diseases that they have. If the symptoms can be treated great but the treatments should be balanced against the harm that they do.

BTW from talking to my parents and their friends all that most old people care about is the expense. In fact once their health makes them unable to care for themselves they often prefer to die so they do not much care about the quality of care. Often it is family and the medical establishment that give them care that they do not want.

Excactly right
" all the billing is handled between the doctor and the insurance company. Once you fork over the co-pay, neither one gives you a moment's thought."

What they do doesn't matter so much, I'm the patient, I'm the one getting the service, its up to me to know the cost and alternatives and act in my own interest and that of my insurance company. They will give me a moment's thought when I ask for information.

Regardless, I think I agree with you guys on this issue. I stated I like the HSA plans and creating more choices for people. I support the idea the cost of health care should be out front and open for patients to see. I do question how much it would lower costs, because we're talking about health care. Free market principles don't uniformly apply. Many times just finding a doctor you like and connect with and trust is hard enough, let alone shopping around for price. Sometimes with drugs you have zero choice, or limited choices that having nothing to do with price anyway. When you get referred to a specialist, in most cases there isn't much for choice. Those things won't change because patients pay the full bill. But that said, I'm still onboard, patients should be aware of the cost.

I think this argument point marjon raised is pointless. Its not marjon's talking point, its the most common lead point I've seen from the right. Its a spurrious simplification. It points the finger at everyone except the first place it should point- the patient and his responsbility to himself.

"Free market principles don't uniformly apply. "
Prove it.

I have given you examples where free market principles HAVE improved health care.

Even in the UK where they have nationalized medicine, and in Canada, they have had to 'resort' to the free market to meet the needs of their 'victims'.

"More and more people are turning to private GPs - paying about £50 for each consultation - as dissatisfaction with the National Health Service grows."

This will take a LOT of work.
Once again, Professor Kling, you have made some important points. But near the end, you reminded us why PROPER reform will not happen, or will take a LOT of work and time (and we are all too impatient as it is) to accomplish. Government agencies will claim that the medical profession is TOO IMPORTANT to leave to the doctors to control their standards and practices. And regulation is unfortunately a good way to look like you're "doing something". And as a public, we are too willing to accept even the wrong thing as "doing something". You also have to remember that doctors and other professionals will likely chase after the big money for being a specialist, instead of a "generalist", which is what integrated care would require. And I found this line from the part about CVS really interesting: " Allowing retailers to make money off of sick people is wrong". CVS already IS making money off of sick people, BECAUSE SOMEONE NEEDS TO MAKE SURE SICK PEOPLE GET WHAT THEY NEED. (A long time ago, I realized that we were better off with health care when we paid the doctor in chickens.)

My sympathies.
All my vitriol aside, I hope your father is doing better Mr. Kling. And it sounds like some people helping your father do care enough to do their jobs well, a rarity in this day and age. When they do their jobs right, we really do have the best medical care professionals in the world.

I wasn't arguing that patents are bad. I agree with what you're saying, but its also just a fact that patents create a monopoly protection. Its a fact drug companies can charge whatever they want for some drugs. They should be able to recover reearch costs, etc. And they do, and they profit handsomely on top of it. They profit on top of research costs AND the expense of lobbyists AND endless tv commercials. They need to be able to make a profit, but come on, this is an obvious abuse of the situation. And WE are paying for it! Its no different than being taxed, except its from corporations.

You're right we subsidize the world. It happens because lobbyists have power (money) over our politicians and so the benefits of collective negotiation isn't realized in our system. It is to a degree by insurance pools, but thats small potatoes. In the Medicare bill they passed a couple years ago, why wouldn't politicians allow administrators to utilize the power of their collective insureds and negotiate better drug prices?

And you whine about leftist democrats and socialized medicine. There was an opportunity to use free market principles in that Medicare bill and it was Republicans who stifled it. Besides, its not socialized medicine I see coming from Dems. Its health care made available independent of employment, provided by private companies. Well, SCHIP is socialized medicine and Dems are pushing for more of that, so thats a fair criticism.

"You know you trade freedom for security you have less of both."

Nice sounding talking point but its not very logical. If you raise security it means less freedom. The more freedom we have the more difficult it is to raise security. Unless you're specifically referring to Bush's incompetence- equating to less freedom and no change in security. But I disagree with that, I think security has improved some. Bush is doing a great job of monitoring his political opposition.

"Show me one nation who has socialized medicine that actually has worked?"

Britain is held as a good example we can learn from. But I'm not sure its defined as socialized medicine. I'm just not that familiar with it.

Spending for drugs is a small part of total medical spending...
Not much savings to be had there even if they were made free!

I agree, but
Patents last only a few years? Twenty years to be exact. Granted, that starts usually before clinical trials, but the average is still 7 to 12 years of patent protection while the drug is on the market. Thats from wikipedia.

"It's a hard fact, but if someone invents a new drug that is better than older drugs and can keep someone alive it seems to me that the patient should be grateful to be able to buy the drug at any price."

Indeed, the patient should be very grateful, I agree. But does that absolve the drug company from gouging the insurance company, and possibly the patient?

"Miracle drugs only seem expensive to spoiled and self indulgent people. A drug that can extend someone's life for years is literally priceless."

Spoken like a person of sufficient ignorance. Agreed, it is priceless to the patient. The insurance company that pays the $2,000 a month or more for treatment, for one person, for example, may not feel the same way. Drug companies are gouging patients and insurance companies for some drugs. They are able to because its health care, its not a free market situation for the most part.

I think we're both right
You gave good examples, I agree, you're correct on that point.

Not all situations are like that.

Drug patents create a monopoly situation for specific drugs. I think patents are necessary, but this is a simple fact of the situation.
The existence of health insurance removes the potential of some free market competition among health care providers.
The fact that patients are challenged just to find a doctor that is right for them, independent of cost, is beyond the free market.

Your point is intriguing marjon. The reality is that the free market doesn't apply to all of health care in our system. But should it? Thats intriguing. I would argue that yes, it might lower costs AND improve quality. But I think reality is also that it will never happen, and maybe it shouldn't. Insurance is necessary in case of a catastrophic situation. Drug patents are necessary so companies can recover research costs, etc. But some proposals floating out there, and the advent of HSA coverage are moving in more of a free market direction. Thats a good thing. We need more choice.

NO free market in any medical insurance
There is no free market in any medical insurance. They are all controlled at the state level and prohibit individuals like business owners from pooling themselves or crossing state lines. The President mentioned that in his SoU speech.

"The fact that patients are challenged just to find a doctor that is right for them, independent of cost, is beyond the free market."

Ever hear of the internet? Or referrals? How do people find a good auto mechanic?
The AMA and states control doctor ratings. It is difficult to find out which doctors are bad let alone good because the free market of such information is controlled by the state medical boards and the doctors themselves.
If such retrictions were lifted, I would suspect some enterprising group would create a ratings for doctors along the lines of Consumer Reports.

Evidence is clear that free markets impove quality and reduce costs across the board in every industy.

Why do you oppose free markets?

Are you a socialist needing a power fix?

Looking like 'doing something'.
As I say in my comments elsewhere, the government (all levels) needs to look like it's "doing something" with regard to health care. But that is in terms of access, NOT quality of care, efficacy of practitioners, or the rest of the iceberg that's below the waterline. And I also noted that they see regulation of the medical professions to be "too important" to leave to the professionals themselves, or even the forces of the consumer market. (And the professionals will want to protect their own market to benefit themselves.) This is just one of those things that we need to quit tolerating in our governance: The illusion of controlling what they cannot and probably should not control. And also abrogating our own personal responsibility. But this is also going to take a long time AND a lot of work to reverse. I doubt we all are that patient anymore.

A Word of Doubt from the Uninsured
I’d just like to present a bit of a different view. I am currently reading Dr. Kling’s book, “Crisis of Abundance”, trying to remain open minded about a “free-market” approach to health care. My wife has MS and is uninsured, not by choice—even though she is healthy and hasn’t received treatment in 20 years, she remains an automatic industry wide permanent exclusion. Over the years, she has developed a fiscally sound, minimalist approach to health care—exactly the type of efficiency described above, yet she is consistently penalized by the system. She pays up to %60 more for provider services and medicines than insurers do—that is pure exploitation. The ultrasound she had the other day did not cost $200, but $500 and counting (at roughly $1200 an hour) In 1986, an MRI to confirm her diagnosis (at the time, brand new technology) cost $800. Two years ago, an ophthalmologist wanted her to get an MRI to make sure the loss of vision in her was MS related and not a brain tumor. The cost, now that you can find an MRI center on practically every street corner, was $4500 (not a few hundred as Dr. Kling describes in his book—she refused the test, by the way). If she needed to take current MS treatments, she couldn’t because we simply can’t afford the $2000 (and climbing) per month. So far, the marketplace has only proven it can and will bleed us dry.

While I understand the concept of a true market driven health care system, I’m afraid I don’t see the rosy picture many of you see. If we want to make health care like the other products we buy, we ought to take a look at the way we currently buy those other products. I look to examples that might seem silly or outside the realm of this discussion, yet they do represent the reality of choice the market currently gives the consumer. The current trend toward big box shopping often gives me less choice and less personal service. It seems the big players in the health care industry will only follow this model--more homogeneity of services, with the spoils going to those with the biggest advertising budget. No doubt a "boutique" medical industry will develop for those who can afford it, but the rest of us will probably be seeing a doctor at Walmart. I don't find that very comforting.

Of all things, I find shopping for household appliances to be a good example of the less than perfect marketplace. Have you ever tried to buy a counter depth refrigerator? Go to your nearest appliance store and take a look at the selection, you have maybe three styles to choose from, but they essentially all look the same, and none actually fit in your kitchen. You have to spend thousands for a counter depth model, though the technology is exactly the same. Given the choice, I’d bet most people would prefer a refrigerator that didn’t stick out into the middle of the kitchen and one where you could actually reach the stuff in the back, but unless you’ve got big bucks, you get no choice. I’d say this is just one case of a market driven by the manufacturers, the consumer has little or no say.

The same goes with televisions (an item most people probably care about more than health care). A few years ago, I tried to buy a TV with a black casing and could only find silver. We’re talking about the TV—a staple of American life—and you could only get it in one color! I bought a used black TV.

Of course the auto industry says we all wanted those SUVs. Really? Maybe after they numbed our brains with years of advertising. In the entertainment industry, we’re constantly force fed 20 bad clones of one successful concept...enough of us apparently pay attention because they just keep doing it. FCC deregulation of the radio airwaves has bought us less choice, as small independent radio stations are swallowed up by the Clear Channels of the world.

Perhaps you can tell me otherwise, but I don’t believe the market is driven solely by the consumer. We like to think the marketplace affords us better choices, but so often we end up with inferior products we don’t really need or want…that is, unless you have an extra supply of cash hanging around. I see no reason why a market driven health care driven system will be any different. In any case, I’m sure my wife will still be pawned off to some government-sponsored program as she is seen as standing in the way of profit.

Free markets won't be denied
As the government squeezes in one area, it bulges in another.

Maybe the silver lining in government control of health care is that responsible people will try not to get sick in the first place. They will exercise, take supplements, follow nutrition plans not recommended by the government, like low carb diets, which I follow, with excellent blood pressure and cholesterol results.

Congress keeps trying to regulate the suplement industry , too , though.

Where I disagree with bobjones
Basically, I agree with you in principle. Where I disagree is in your apparent assumption that people WILL take responsibility when they really don't have to. People take the path of least resistance, as a rule. So, as a rule, they are not going to get more involved with the Third Party Payer mess than they already have to anymore than people get involved in jury duty any more than they have to.

They have to be placed into situations where they are forced to do so. That is what the free market does.

So far, the marketplace has only proven it can and will bleed us dry.
Yes, because you are one of the few players who participate in that manner. If EVERYONE or at least a significant amount of health care consumers were to pay providers directly, those costs would go down or alternative methods/treatments would appear.

Right now, why should the MRI scanner places accept any less when the bulk of their 'customers' are insurance companies they 'game the system' with? Your wife is standing in the way of how the providers have learned to profit from the insurance companies, not individuals who pay out of their own pocket.

That will all change if the systemic biases for third-party payments get reduced/eliminated.

Very good post
You hit the nail on the head with this. Generally I agree with market driven economic solutions, but that always bothered me when healthcare was the topic; and I never could put my finger on just why.

While I do wonder where you shop, or whether you shop around much, given you examples; overall that is the situation. You want the mass produced product of the day, no problem; you want something even a little different, pay through the nose. (However, I wish I had your problem on the TV, All I could find were Black cased units when I wanted a grey or silver one last year; finally did find it, and at a good price, but it took some looking.)

Healthcare would be even worse off than it is, if run that way. We do indeed live in a world where, if you want the best (or even reasonable) price, you accept what the manufacturer has available. If you want something even slightly different, be prepared to pay significantly more; sometimes as much as double. I went shopping for a new electric cook stove a few months ago and ran into this in spades. And we weren't talking 10% more; we were talking 70%-120% over the cost of the "industry standard". We ended up settling for a white stove in the median price range because we just couldn't afford the black and stainless unit with the same basic features.

We are looking at replacing our Refrigerator, we have shopped around and come to the same conclusion there already. I couldn't imagine shopping for healthcare that way. (having to take only what the provider whated us to have or pay twice as much or more to get the same thing done right.)

It might get so serious.
If it does, they might actually some of those foreign companies who operate private clinics and hospitals, all over asia, that have good service and prices and that many people already patronize and medical tourists. Apparently in America they don't want such competition in this sector. In fact I've read that you can't even buy medical insurance from out of state, muchless from out of country. And Americans try to call themselves a free country?

It might get so serious.
If it does, they might actually some of those foreign companies who operate private clinics and hospitals, all over asia, that have good service and prices and that many people already patronize and medical tourists. Apparently in America they don't want such competition in this sector. In fact I've read that you can't even buy medical insurance from out of state, muchless from out of country. And Americans try to call themselves a free country?

Man... people need to THINK!

First, market driven healthcare would not be similar to the appliance industry. Preparing an assembly line for making widgets is expensive, which is why manufacturers like referigerators that fit a common profile. It's NOT that they reject what the market wants, but that they are focusing on exactly what most people demand! Most people do NOT want a fridge that is as narrow as their counter, becuase that means it must be WIDER to hold the same amount of food, and that takes up MORE space (it is counter space that is typically at a premium). The market is giving MOST people EXACTLY what they demand. Plus, if you want something different, you CAN get it, you just pay more. So what? That is your choice. You can get a REALLY CHEAP fridge that is mass produced, or a custom one that is to your exact specifications.

So even if healthcare worked that way, so what? Most people would demand similar types of care, and thus would be happy to get it at a discount if they can, and those who want customized care could get it for more.

But healtcare is NOT like manufacturing. It is personalized because it is, for the most part, a service. It is more like auto repair. You can choose what to replace on a car, and let it leak oil if you can live with it, but have them replace those bald tires for safety. There is plenty of variety in auto repair.

But regardless, the health care market is distorted by the government, and thus is NOT market driven. Imagine if the government decided to order 10 billion refrigerators of a specific specification to give away to the poor, who would take the freebees and no longer participate in the free market. That would make the rest of us nitch markets (even if we want the normal fridge), and thus more like the counter-depth fridge. It might also prevent the manufacturer from being able to offer other types, because it is focused on supplying the larger market provided by the gov't. and limited resources might even raise the price of fridges for the rest of us (the cost of freon would skyrocket--if freon were still used, that is). In essence, the gov't becomes the mass market, and we all become nitch markets.

Health care is similar, in that most of the rules are fomred by the gov't, and most of the market serves people under government or insurance plans under fixed rules. Thus, the true free market in medicine is too small to really effect us.

Until the medical market is truly freed, these problems will continue.


Free market rewards and punishes
The free market penalizes those who are stupid or ignore the market.

If you don't like a free market, then you are stupid or ignorant.

Or most likely, you want to have power over others and force them to your will.

Lasik surgery has dropped in cost and risen in quality.
Cosmetic surgeons are doing gang buster business around the world.

And they all have payment plans and financing.

Would you do away with patents too?
You addressed medical insurance, what about patents?

"Congress keeps trying to regulate the suplement industry , too , though."

So do you think supplement makers should be free to market any benefit they can come up with for their products?

Thats the only regulation of supplements I'm aware of, maybe you're referring to something else...

There is no patent for Coca-Cola
It is a secret recipe. If they did try to patent Coca-Cola, they would loose their exclusivity after so many years.

Drug companies have been trying to regulate the suplement industry for some time because many supplements are the precusors to some drugs. White willow bark is unrefined aspirin. Which would be a prescription drug if discovered today, BTW.

Drug companies have the right to their patents if they want them.

If a drug company can create a proprietary supplement that does what it claims, why should they patent it and give away their secrets (but they must give their secrets to the FDA for approval, no?) So the government forces them to patent their products to protect their rights.

True that Zyndryl. I think we actually agree.
"Where I disagree is in your apparent assumption that people WILL take responsibility when they really don't have to."

I do agree with that. Replace the word WILL with SHOULD, is really what I'm thinking. But reality is what it is.

"They have to be placed into situations where they are forced to do so. That is what the free market does."

I agree with that too to an extent. But I think a free market can go in the other direction too. People are shallow and prone to groupthink. A new product that is harmful, without regulation can cause much more damage than if regulation stops the damage early or limits the damage. The company that produces that product would survive fine with the utilization of good marketing people. Or simply change the company name.

I'm a free market supporter, but I don't think free markets are infallible. I still ask questions and insist on examination to confirm its a good idea. Free markets are a harsh system, its much closer to "survival of the fittest" than how our society currently operates. The opportunity for corruption and fraud are greater, easier to execute, in free markets. I just don't think its realistic that a system depends solely on consumers to regulate it. Not in all cases.

No direct arguement
And I agree that there are areas where the "free-market" has been tried and shows promise. In fact, some are going to a pay-as-you-go system on their own at significantly reduced prices. And it does work, for general check-ups, colds, mild infections and other quick work.

But, as I said above, I've always felt that, in spite of this, something is out of whack with a fully unregulated. uninterfered-with medical system.

This is just part of it, put in a way we can all understand.

The other is insurance; it must be changed. The idea that everyone has, and must have, insurance is a very new one. My parents never had medical insurance until around 1980 or so. Prior to that they paid out-of-pocket for all their medical. They had four kids, which means a couple of operations and medical proceedures, hospital stays, ER vists, physicals, etc. They paid for all of it and a lower-middle class income.

What has happened to medicine that this is no longer possible? I have a wife and four kids, no way I could have paid for their delivery, pre-natal, well-child check-ups, setting of a multiple fracture in my oldest, gall blader surgery, adhesions surgery, appenix surgery and physicals, doctor's visits, etc. without insurance. Worse, I'm in a comparably higher income bracket than my parents were!

Then, a couple of years or so, I sat down with my mom and went over the "big item" costs. We had both paid for about the same number of hospital stays, kids and surgeries. My families big-item medical bills alone were about $110,000; my moms (1961-1978) were about $18,000. In that time (median to median say 1970-2000), base wages have quadrupled as has the general base cost of living; yet the cost of comparable medical proceedures has goe up 6-10 (median to median it is 8.5) times.


Certainly government regulations and programs have been a big part, but they aren't the whole reason or the real reason. The real reason is malpractice insurance and medical insurance. They are sucking 10% to 35% of the total cost for doctors and hospitals to do business.

Insurance and government programs have created a paperwork blizzard, they do not pay "in a timely fashion" and use numerous tactics to delay payment. to improve the timeliness of payments, hospitals and clinics have to have more administrative staff to handle claims a reduce filing errors (even the most miniscule of which can hold up payment 60-120 days beyond the normal 45-60 days these two groups tend to take to begin with).

Talking to our hospital, they lay the blame for this more on the insurance industry then on the Government.

Medicare/Medicaid tends to pay unless their is a notable error, many insurance companies don't. Worse, it isn't just the "poor" who we all pay for through higher fees(Due to non-payment of any kind). Did you know that between 3% and 10% of all insurance claims are never paid?

That's right, through hook or crook, insurance companies manage to "time out" or otherwise deny payment on these bills and, almost all of the time, the medical facility ends up eating these losses. Medicare/medicaid is a different problem; in some cases the Government won't pay enough for a procedure to cover the base costs of the proceedure to the facility. But, the loss to them on legitimate claims is less than 1%; they do tend to pay.

So insurance is not the answer, in fact it is a big part of the problem.

So what is the fix?

Ideally it would be to make sure we can get prices in line with what should be affordable. Then have most people with nothing more than a realatively inexpensive "catestrophic care" insurance, and have the government pay only in genuine cases of inability to pay (present day emergency medicaid type set up).

At least that would be a step in the right direction; but I'm not sure how you get there.

Firestone tires and Ford
Numerous government regulations were involved with tire and auto safety yet there were many victims of Firestone tires blowing out at highways speeds in Ford SUVs.

After many secret out of court settlements, the issue finally became public and the product was changed.

Free and open markets, with the free flow of product information will quickly judge product quality.

What is very dangerous are those products deemed safe by the government and later found not to be, or when say something like Tylenol is overdosed and people die from liver damage.

That pet food company that imported bad stuff from China responded much more quickly than any government did because they have an real incentive.

Abuse in free markets can only occur when the free flow of that product's information is restricted. Which is usually done with the help of the government.

You agree it is not a free market, but
"They are able to because its health care, its not a free market situation for the most part."

You don't think the free market will work?

BTW, I think I have asked you many times to prove that a free market does NOT improve price and quality of products and I don't believe you have ever proven that.

If there is a market a way will be found to provide the service.
Lifeline screening seems like it could be a reasonable idea.

Lasers for eye surgery have been developed rather quickly. And that is all 'out of pocket'.

"Cost cutting has been the key to staying competitive, which means fees have dropped significantly in recent years. The Lasik Vision Corp. now charges Canadian patients (Cdn.)$999 for LASIK (laser in situ keratomileusis) surgery for both eyes, down from $4800 in 1997 and $2995 in 1998. For American patients, the price is (US)$999. When the company first cut its price to $1498 last year, says James Watson, the vice-president of marketing, business "doubled overnight." Many clinics now offer bank-supported financing plans to help patients cover the cost."

"Who wants laser eye surgery? The market is driven by a diverse mixture of Canadians and foreign visitors, especially Americans and Asians. Forty percent of Lin's patients come from outside Canada, while most of Maerov's are Canadians. In some months, more than 50% of Sutton's patients are Americans; most are from Washington state, but some come from as far as California, Oregon and Idaho. They are lured across the border by the attractive exchange rate and cheaper surgical fees, as well as by the fact that the Vancouver doctors have more experience with the surgery than their American counterparts. Sutton says the high volume of surgery in Vancouver allows clinics to charge less, and "we have more advanced equipment than [is allowed in the US].""

U.S. patients choosing Mexican hospitals for price, quality

" "All around I was very impressed, and the experience surpassed any expectation I had," Mr. Woods said. "I could have been in Zurich, Switzerland, but it was Mexico. I found the care to be top quality, what you would expect at a U.S. hospital and more."

Like vacations in sparkling Cancún or Cabo San Lucas, health care in Mexico is becoming high-quality, cheap and convenient, advocates say. As more Americans go without heath insurance or feel the pinch of managed care, some are making a run for the border for treatment ranging from routine care to live-saving procedures. "

" Two North Texas-based hospital chains, Christus Health of Irving and International Hospital Corp. of Dallas, are tapping into a need and an opportunity by providing in their hospitals in Mexico what their executives say are the best of both worlds – U.S.-quality health care and relatively low Mexican prices.

"Our goal is to have the safest hospitals in the international market," said Cliff Orme, CEO of International Hospital Corp. "We're implementing U.S. standards into these hospitals so you won't notice the difference going to a hospital in Dallas than one in a Latin American country."

Some experts, including Peter Maddox of Christus Health, see Mexico as an answer to the complex question of how to treat aging and underinsured Americans at a time when the retirement of baby boomers will further tax the U.S. health care system. An estimated 43 million Americans, about 15 percent of the population, are uninsured, according to a Census Bureau study.

"Our country will go broke unless we find a health care alternative," said Mr. Maddox, Christus' senior vice president for business, strategy and corporate development. "Mexico is a wonderful alternative with incredible potential." "

We take Mexico's 'manuel' labor and send them our baby boomers.

The AMA and foreign competition
The AMA has long done its best to keep foreign doctors from easily practicing in the US. They do this by applying double-standard examination processes and refuse to offer ESL versions of their tests. Now, insurers are finding it cheaper to send Joe Lunchbucket to Thailand, have him operated there and recover there (many of those hospitals are right on the beach, like resorts) than to try to do it as outpatient as possible here at home. A lot more and more people are happy to go, too.

but it could work
"You don't think the free market will work?"

Actually, I'm starting to think more and more that a move closer to a free market in health care would work. I still think there are exceptions and aspects that might not be applicable, but the more I think about it, the more I think it could cause positive changes.

"BTW, I think I have asked you many times to prove that a free market does NOT improve price and quality of products and I don't believe you have ever proven that."

Or perhaps such proof is impossible for you to accept.

Regardless, thats not my position. I do think a free market can improve price and quality of products and services. It wouldn't in all cases, is my point. I don't think free markets are infallible, they are not a good idea in every situation. I think you need to look at the circumstances, ask questions, before its wise to make a change like that.

You're way off base
"Numerous government regulations were involved with tire and auto safety yet there were many victims of Firestone tires blowing out at highways speeds in Ford SUVs."

And there would have been many more in that Firestone situation, and other situations over the decades, if there were not safety regulations in place.

"After many secret out of court settlements, the issue finally became public and the product was changed."

Is that even true? Were there secret settlements? How did it become public? The circumstances matter. Given how often you're wrong marjon, I can't trust you're accurate with this statement.

"Free and open markets, with the free flow of product information will quickly judge product quality."

Thats an ideal situation, but its not reality. There would not be a free flow of product information. Firestone would try to hide it, and they could be more successful doing so in a free market. Product quality would be judged no differently than it is now. People would be killed or injured in the process of making a judgement. Even moreso with safety regulations.

"What is very dangerous are those products deemed safe by the government and later found not to be, or when say something like Tylenol is overdosed and people die from liver damage."

Overdose on Tylenol? I think thats called suicide. In a free market we wouldn't know Tylenol causes liver damage, not until enough people died from it. But its very tough to prove they died from taking Tylenol, even tougher without safety regulations. Thanks to regulation Tylenol is required to inform us of side effects up front.

"That pet food company that imported bad stuff from China responded much more quickly than any government did because they have an real incentive."

Yeah, they lose market share AND get nailed with fines from the government. Thats extra incentive. In a free market the pet food company could quickly recall the products, pay off the people affected and otherwise hide the episode. Because they violated safety regulations it wasn't as easy to keep it hidden.

"Abuse in free markets can only occur when the free flow of that product's information is restricted. Which is usually done with the help of the government."

Are you serious? Maybe so during the Bush years, its a fact our government now sides with corporations in lawsuits, versus traditionally siding with the interests of the environment and people. But you're still dead wrong. Did the government help hide the poison the pet food company put in its pet food? Did the government help hide the Firestone tires? Do government regulations restrict information on harmful side effects of products?

Abuse of markets occurs even when they're not free. It would be worse if there were no safety regulations.

You really need to educate yourself before you talk marjon. Its disappointing the things you offer sometimes. It dilutes good discussions and wastes time. Go to Daily Kos or Rush Limbaugh's site if you insist on posting such moronic musings.

"The U.S. National Highway Traffic Safety Administration is investigating at least 203 deaths linked to Firestone tire blow-outs caused by tread separation and roll over accidents."

"Both Ford and Firestone have settled dozens of lawsuits out of court. Several class action lawsuits have also been filed.

Ford has continued to deny any responsibility for the tires. The automaker ended its 95-year corporate relationship with Firestone. "

The court system is the third branch of the government. It allow out of court settlements in which the parties are not allowed to discuss the details of the case.

When did the NTSB demand a recall?

Firestone recalled 6.5 million tires in August 2000. Who was president in 2000?

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