The Perfect Storm for Physicians in America

I take the title for this blog from an article in the Journal of the American Medical Association June 18 2008 p. 2789 "The Perfect Storm of Overutilization".

Two Ph.D's in "bioethics" (one with an MD) employed by the government, paid for by your tax dollars, working for the National Institutes of Health wrote an article about what insiders in the drive for socialized health care see as "problems". This paper will hardly be noticed. Most doctors will poo-poo its implications. Many will actually gladly trumpet it as an advance, even though it calls for cutting their pay in half and submitting themselves to total government control.

First of all, as an aside, what the hell is the government doing paying my tax dollars for doctors to sit around thinking about how to limit my freedom? Why should the government be involved in this activity at all? The answer is that since the government provides welfare via medicare and medicaid, then it can decide how to provide this welfare. And you really have no moral standing if you think the government should steal from some to give unearned benefits to others and at the same time say that while the theft is just fine, what you really object to is cutting your pay.

The article notes that the US spends 2.4 times more than the average of other developed countries. The article notes that one reason is that a huge part of this is siphoned off to a massive, government subsidized and created, health insurance system. This industry (medical costs eat up 15% and more of our total GNP if you include insurance skimming) provides no useful service whatsoever other than enriching the elite owners and managers and making care more expensive through direct costs and indirect costs of bureaucracy that make your doctor charge more and have less time because of activities such as filling out forms and electronic medical records that have no use and actually harm patient care.

And by the way, isn't it amazing that these two bright authors never even pointed out that by getting government and insurers out of the way, the administrative costs could be kept by the patient and doctor? Wouldn't you like to take home an extra 800 to 1600 dollars a month that your company sends to rich executives at the insurance company so they can deny payment for your diabetes medications?

Another listed reason was that US doctors make twice what European doctors make. (And if you don't think that isn't a call to cut our pay, you deserve what's coming) They also note our drug prices our a little (10-30%) higher. Realize that these guys are trying their best to make our drugs look expensive and this is the best they could improvise. I note that there are a long list of un-subsidized drugs available for four bucks a month at many pharmacies, a price unable to be matched in any socialized paradise when you realize how much the government subsidizes medicines. Also, in other countries, you simply can't get many drugs and especially many newer drugs. For example, an expensive drug like erythropoetin to boost blood counts, would simply not be given in most of the world.

A third factor was the abundance of amenities in the US making getting health care actually comfortable and pleasant in the US. (OH, THE HORROR!) The authors note we have "more privacy, comfort and auxiliary services" in our hospitals. Damned Americans, why can't they just lie quietly in threadbare sheets on hard beds lined up like criminals like they do in Europe? The nerve of those Americans! Along these same lines the authors note that in decadent America "offices are typically more conveniently located and have parking nearby and more attractive waiting rooms". Damn those Americans again!

Another aside, my parents were Canadian immigrants and when my mother went to a hospital, there was only one wheelchair on the whole orthopedic floor and it was willed from patient to patient when they left and guarded like glittering treasure.

Then the authors get to the "most important contributor" - overutilization. The authors note that our hospitalization rate is lower than anywhere but Japan. France has more than double our rate. And we see doctors half as much as the average in other developed countries. (You might be shaking your head and wondering out loud, "Isn't that a good thing?" Not in socialized medicine world.) But we do more MRI's, heart procedures, dialysis, and use more newer drugs, and these cost money. (Implicit in this, is that if we would just quit whining and die with our heart attacks and kidney failure like a proper EU slave does, we could save a lot of money that could be spent on the survivors, especially those hard-working government workers at the NIH.)

Now a rational individual might look at this and think "so by using better drugs and tests, we get sick a lot less and survive things like heart and kidney disease a lot better than in the socialist EU", and think that that is probably a good trade-off for money. But you would be wrong. Health isn't the point of socialcare - saving money and forcing everyone to get exactly the same inconvenient, sub-standard, cheap care is the point. Damned Americans.

The authors then note "at least 7 factors" that drive overutilization. One is that American Doctors try really hard to get their patient's diagnosis right the first time. You might again be thinking unauthorized thoughts like "Why the hell would I not want my doctor to get the diagnosis right the first time for?" Idiot. Because it costs more. It's much cheaper to assume every infection is viral, give a patient a few "free" government-subsidized aspirin and send them home to die or get better. Most will get better and the odd brain-damaged meningitis patient is just the price we all have to pay for lowering costs. Idiot.

You might think I'm exaggerating. "Medical school education and postgraduate training emphasize thoroughness." Damn those American medical schools!

Secondly, we get paid for working - in the lingo of medicine "fee-for-service". That means that you pay me each time you see me. That means I even like to see patients. That means I treat them well because I want them to come back. According to the authors, this "misaligns incentives." If I got paid the same low salary whether I saw you and sucked up to you or not, I would rip the carpet out my waiting room, work reduced hours, make you wait for hours in metal chairs, and treat you like crap, which is good because this would keep you away from the doctor and save money. We also get paid more if we take your bad appendix out than if we send you home with aspirin. This "reduces physician's inclinations to watch, wait, and communicate". You might again selfishly think, "But I don't want to wait to have my appendectomy until after it gets worse and bursts. That will really hurt, and might kill me". Selfish bastards. Damned Americans, go home and writhe in pain like the rest of the world!

Reason three was that our system is making so many advances that I might occasionally talk to a drug rep who is trained in what the new drug or device can do to save time. I might even take a bright purple pen with writing on it! And that would make me - I don't know what that would make me, but it would be very, very bad. It would be much better if we closed down most of the research so we would stop making drugs to manage diseases like diabetes. Then we wouldn't need a drug rep. And that 10,000 dollars that the pharmaceutical companies spend on educating doctors on new advances wouldn't be spent because there would be less advances. And while that new drug might have saved your life or made you feel better, quit being a selfish pig!

So how to fix these horrendous things like caring, "thorough", doctors with nice waiting rooms, convenient parking, and pleasant manners, who stay open late and take out our appendixes before they burst? The authors despaired at getting us to act like jerks. "Calls for changing physician training and culture are usually ignored." Damn those independent doctors who want to provide the best possible medical care for their patients. Scumbags.

"Realistically, the most effective change would be to alter how insurance pays." Wait, you mean like let patients keep their own money rather than letting insurance companies take a big cut before denying you care? You mean like negotiating price with the doctor? Things like allowing the doctor not to make me pay the co-pay? (Amazingly, this is strictly illegal under current US law and punishable by fine and imprisonment as a racketeering violation. Look it up if you don't believe me.) Wow, that sounds too good to be true.

And you would be right. Rather than the obvious solution of allowing free men to make free choices and contracts without government regulation and government-sponsored skimming by corrupt insurance companies, the authors suggest that we have a lower co-pay if we agree to accept lower quality irradiation of our prostate cancer that will leave us sterile and incontinent. Don't be so selfish! You could pay a lower co-pay!

Now you may think that I'm exaggerating this last part. "For instance, men with early stage prostate cancer who choose radiation therapy might have no co-payment for 3-d conformal radiation but might have to cover the marginal cost if they want more expensive (and safer and better) intensity-modulated radiation". Come on, diapers are cheap and Viagra is expensive anyway! Egomaniac.

Well, since most of us are too lazy to care or shoot our politicians like they deserve, welcome to the future of American Medicine. I note that we are being assaulted on every side. Medicare pay cuts of over 10% go in effect in 10 days. The US medical graduate average debt of over 150k can no longer be put off until after residency. Etc., etc., etc.

All I can say is you were warned, and you deserve exactly what you are going to get. Bend over and quit complaining. The doctor will see you now.