When politicians talk about the Health Care Crisis, they focus on the lack of insurance for the poor, the insecurity felt by the middle class who fear a medical emergency will bankrupt them, and the more general sense that health care expenses are becoming an increasingly problematic part of our personal and societal economies. Essentially, all the proposed solutions focus on making health care more affordable and more available.
Most of the proposals for dealing with the Health Care Crisis involve finding ways to disguise the costs of health care and even more significantly, disguise the sad reality that health care is not an unlimited resource but a very limited resource which must be rationed. In countries with Universal Health Care such rationing is effected by limiting the health care of all (or almost all) the members of the community.
[If anyone knows of any Universal Health Care system in which politicians are required to suffer the same level of care as the masses they represent, I would be surprised and interested to hear of it.]
The American model has been to ration heath care by financial ability. Those who can afford good insurance or can pay for premium health care out of pocket have access to the best health care available in the world. This system worked adequately until trends from the post-war era came to fruition in the 1980s. In the post-war period, health care expenses for the vast majority became decoupled from availability (via employer supplied insurance); the problem worsened when Medicare further decoupled health care from its true cost for every senior citizen in America. For a time, a fantasy of almost free, almost universal, health care held sway, until the true costs of health care began to spin out of control (in large part because "no one" had to pay for health care and because of the burgeoning of Medical knowledge and treatment options.)
Now the system is breaking down under the pressure of a burgeoning elderly population and expensive new technology. The political response, never particularly open about the fundamental reason for the crisis and the ongoing need to ration access to expensive health care, remains trapped in an archaic model of shifting and disguising the costs in order to give people the illusion they are receiving the best health care available.
Once our politicians attack the Health Care Crisis, they are likely to make an already difficult situation worse in ways that will be completely unexpected, at least to the proponents of Universal Health Care.
[First, a digression:
When I entered Medical School in 1974, I had already concluded that Psychiatry was my most likely destination. I was always extremely interested in how the mind works and imagined that the combination of the Psychiatric approach, based on the biology of behavior, and the psychodynamic approach of Psychoanalysis, would offer an ideal synthetic approach for understanding the brain an the mind. I assumed that I would be able to make a good living but financial renumeration was not a particularly important part of my decision. (Psychiatrists and Pediatricians have traditionally been the lowest paid sub-specialties in Medicine and those of us who entered those fields knew this going in.) I have not been disappointed in my choice, though the financial aspects of Medicine and Psychiatry have changed in unfortunate ways since I was in school.
My closest friend from my time in training became a surgeon. He thoroughly enjoyed the entire process of diagnosis and, usually, definitive treatment that was the province of the surgeon. When he finished his Residency, with minimal ties to the New York area, he decided to relocate to Florida, an optimal environment for the type of surgery in which he specialized. At the time there was a relative dearth of Doctors, his specialty was an important part of the care of the elderly, almost all the patients had insurance (primarily Medicare), and he found the combination of a ready patient supply and guaranteed reimbursement an irresistible combination. Since that time, the entire field of Medicine in Florida has shifted and it is no longer the business model he built his career upon.
Digression over.]
Here is what is happening today in Florida:
Physician Shortages Forecast for Palm Beach County by 2011:
Gaps of 48 Percent of Needed General and Family Practice
Doctors: 66 Percent of General Surgeons; 39 Percent of OB/GYNs
Many patients in Palm Beach County – who are already having difficulties scheduling appointments with certain types of medical specialists – will face even greater challenges locating a specialist in the coming years, according to the firstever Palm Beach County physician census. The census was conducted by the Palm Beach County Medical Society (PBCMS) on behalf of the Emergency Department Management Group (EDMG).
Within five years, it will be increasingly difficult to locate certain medical specialists in Palm Beach County. For example, the census forecasts that by 2011:
• Only 70 general surgeons will service the entire county, whereas an estimated 208 are needed for the forecasted population of just over 1.4 million residents. That represents just 34 percent of the needed general surgeons.
• Just 194 general and family practice doctors will be active; 373 are needed. That meets just 52 percent of the demand in the county.
• Physician shortages of at least one-third will exist among the following specialties: allergy/immunology; colon and rectal surgery; obstetrics and gynecology; pathology; psychiatry; radiation oncology; and thoracic surgery.
The census revealed that physician shortages already exist. There are 39 percent too few general surgeons in Palm Beach County today and eight percent too few general and family practice physicians.
It is the reasons for the shortages that are most troubling. Some of the problem is the skyrocketing cost of Malpractice insurance (and that is the focus of the linked article.) My friend, an excellent Doctor, but like all of us, an imperfect human being, has decided to "go naked", ie he has dropped his astronomically expensive Malpractice, which was eating up a quarter of his income, and has put most of his assets in his wife's name to protect himself. Needless to say, if he is sued, not only will it be incredibly unpleasant on an emotional level but will leave him in a difficult financial position. He informs all of his patients of his status and the evidence state-wide from the many Doctors doing the same is that it leaves patients significantly less likely to sue for untoward outcomes.
However, there are additional problems which have discouraged Physicians from establishing their practices in Florida. When I finished my Residency, it was universal for all young Physicians to apply for a Medicare number. While Medicare did pay ~10% less that usual fees, the premium was worth the assurance of payment and the ready supply of patients. Private Insurers ranged from covering 80% of fees, without the "usual and customary" proviso, to those that covered less significant fractions. As well, the Insurers and Medicare were relatively non-intrusive, demanding little of the voluminous paperwork, documentation, and phone time necessary to work with managed care today. While there were some who abused the system, in fact it was the inherent disconnect between fees for service and patient costs that led to the over-utilization and inflationary effects of the system at the time; this led directly to the Hillary Clinton debacle in the 90s, trying to increase government control over the entire system. Sadly her failure ushered in a system which while not quite so onerous has had very significant effects on the practice of Medicine, none of them salutary.
The 10% cost sacrifice between usual fees and Medicare reimbursement is now closer to 50-60%; worse, private insurance companies have followed Medicare's lead and have slowly eroded their fees for services in parallel with Medicare (and often substantially worse than Medicare.) Furthermore, in an effort to cut costs by an apparent policy of attrition, both Medicare and private insurers have become slower to pay and more capricious in their policies on non-payment. (If a form is missing a single, minor piece of data, it is subject to refusal; attempting to find out what information on the form was missing or incorrect can be an all day affair, and even properly filled out forms are subject to denial for no apparent reason; and in my experience, up to 20% of all forms submitted are simply never acknowledged and require resubmission.)
Most Doctors have responded either by increasing the quantity of patients they see (which inevitably decreases the quality of their interactions with their patients) or by refusing to participate in a system which serves them so poorly. I do not know any Psychiatrists in New York who remain on Managed Care panels and only very, very few who will accept Medicare. I have not yet dropped out as a Medicare provider but have not taken on a new Medicare patient in many years.
I do not expect or desire any sympathy for the predicament Medical Doctors now find themselves mired in (a quagmire partially of their own design, perhaps?) but I would suggest that there is a confluence of trends which make America's near term health rather parlous.
Medicine is on its way to becoming an information technology. Just as with other parts of our economy that have become IT driven, such a change will cause significant dislocations. Eventually, as with all IT, costs will come down and once extremely rare, cutting-edge, treatments will become routine. I have no problem with that. However, it is going to be a very long time before Medicine matures as an IT industry and thus a very long time before Doctors become, essentially, technicians. It will occur, but during the transition Medical Doctors will be placed in the role of understanding and manipulating exponentially increasing amounts of information and translating such understanding in ways which can benefit the health of their patients. If the baby boomer generation was smart and able to see past their most narrow, short term, financial interests, we would recognize that we want the best and brightest of our children and grandchildren to enter the medical field. We need our brightest to be at the front of the biotech revolution, developing and applying the break-throughs that cannot come fast enough for aging boomers. By attempting to control costs above all other considerations, we are doing exactly what we should not do if we want new life saving and life extending treatments and techniques to continue, and accelerate, their appearance.
A smart health care system would offer powerful financial inducements and rewards to those of our children who enter Medicine. Instead, we are conveying the message to our young and future Doctors that they can expect to leave school with loans in the six figures and with increasingly onerous limitations on their ability to do good work and receive substantial compensation for their time, energy, and emotional investment. Treating Doctors and allied health professionals as the enemy to be attacked and controlled is short sighted in the most egregious way. (Are drug companies only rapacious capitalists to be attacked and dunned, or the font of life saving and life extending, not to mention extremely costly, drugs?)
One of the Democrat's core differentiations with the Republicans thus far has been the promise by every candidate to fix the Health Care System and extent its benefits to all. Can anyone reasonably expect that the plans to be put forward will do anything but exacerbate the problem of encouraging potential future Doctors to become Hedge fund managers instead?
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