From: tjm@netcom.com (Thomas J. Merritt)
Subject: Re: The future of medicine
Organization: Code Generation Technology
Date: Tue, 12 Jan 1993 19:38:01 GMT

In article <1993Jan11.235321.3075@cnsvax.uwec.edu> nyeda@cnsvax.uwec.edu (David Nye) writes:
>[reply to tjm@netcom.com]
> 
>>It is easy to see that curbing health care costs in not in the
>>interests of physicians.
> 
>In the short term, perhaps.  In the long term, some of us realize that
>the system is going to collapse without radical modifications, and that
>we have an interest in helping modify the system so that it will survive
>and we can continue to be part of it.  Physicians would like to maintain
>their salaries (probably not possible) while trimming waste in the rest
>of the health care system -- overutilization of tests from which they do
>not profit and money leaving the system to lawyers, clerical workers and
>the insurance industry.  The physicians' fees actually constitute a
>rather small percentage of the health care dollar.

You can point the finger at attorneys and clerical workers but the ones
that are taking the big chunks out of the pie are physicians, insurance
companies, and pharmacutical companies.  (I known malpractic costs are
high, but it has less to do with lawyers than the business practices of
insurance companies that are designed to maximize profits.)  Physicians
do get a big chunk of the health care pie, this doesn't mean that all
physicians share equally.  You can certainly cite many dedicated physicians
that take only a modest salary.  However, it takes many of these folks
to make up for just one physician making a half million.

The insurance industry is in need of much reform.  Check out how much
of your malpractice dollar goes to pay for litigation expense and awards
and how much goes for administrative expenses, profits, AND recovery of
investment losses (or even worse recovery of investment underperformance). 
Don't take your insurers word for it or the industry as a wholes word.  
Part of you dollar does go to the lawyers but not the bulk of it like your
insurer would have you believe.

I have very mixed feelings about pharmacutical companies.  They have 
extremely high costs in bringing new medications to market.  On the other
hand their interests are not necessarily aligned with the ultimate consumers
of their products.  To maximize the return on their investment it is necessary
sell large quantities of a drug at rather high prices.  This leads 
companies to selling expensive medications that they have a patent monopoly
on and yet may not be the most effect treatment available.  Physicians are
likely to prescribe the medications these companies are pushing rather than
alternative treatments primarly because the advertising power of these
companies makes physicians more aware of these options.

I'm not saying that physicians are the bad guys, or that insurance companies
are the bad guys, or that pharmacutical companies are the bad guys.   Just
that thier interests are not necessarily aligned with the those of the 
patient and that it is often difficult for the patient to tell when this
is so.

>>However, providing suboptimal care is not so obvious.  At the extreme
>>if every member of the population was completely healthy and lived in
>>an environment where the stayed that way there would be no need for
>>physicians.  Ultimately this should be the goal of a national(global)
>>health care policy.  The problem with such a goal is that should we
>>actually make progress in achieving it we would reduce the power and
>>pretige of physician not increase it since there would be less demand
>>for medical care.  This goes counter to the interests of the AMA.
> 
>That's absurd.  I know of none of my colleagues who want to keep their
>patients sick.  It would be stupid to try to do so.  Patients will find
>out that Dr. X never seems to be able to help people and will stop going
>to him.  Furthermore, we get a great deal of satisfaction out of helping
>people.  Few physicians have holes in their appointment schedules.  If
>they did, they would move on to somewhere they could have a full
>practice.  There is no need to recycle old patients when there are
>plenty of new ones to see.

I suffer from allergies.  The common allergy treatments in this country
are not the most effective nor are they the least expensive treatments
available.  I would guess that most allergists providing these treatments
think that they are providing the best care possible to their patients but
they are not.  I'm fortunate to have stumbled upon an immunologist trained
in England that provides treatments not in common use in the USA but common
in England.  For me these have made a world of difference and saved my insurer
a lot of money.

My point is that the health care system is not optimized(incentivized) to
provide the best possible treatment at the least total cost to patients.
To understand the health care system though you must understand how
the incentives work.  To make reforms you must change the incentives.

>Preventative health care is generally not something the physician can do
>for you aside from periodic checkups.  Most patients already know how to
>keep themselves healthier but don't take the necessary steps.  If you
>don't smoke, drink in moderation, exercise, eat sensibly and maintain
>your ideal weight, wear your seatbelt, never drive after drinking, etc.,
>you are likely to be stay healthier and live longer.  Most patients find
>preventative medicine too much bother.

I guess that I and many others are in the minority then.  (A side question
is should smokers pay for the increased health care costs of smokers or
should the general public?)

>>Although the AMA doesn't not make a policy of injurying individuals
>>they do so indirectly by selectively supressing information that would
>>be helpful to the general population in pursuing more effective and
>>less costly treatments.
> 
>Examples, please.

I don't have any references handy at the moment.  But from what I've
read and seen on CSPAN the top folks in the AMA are not as ethical as
I would like.

>>Personaly the only way that I can see to curbing health care costs to
>>change the financial incentives that physicains receive.   When and if
>>we as a society provide a financial incentive for physician to have
>>healthy patients we will see a decline in health care costs.
> 
>You will likely get your wish under the Clinton administration.  It's
>called the HMO.  I like HMOs and feel they are a good way to hold costs
>down, but many patients don't, particularly when they are denied tests
>they think they should have or a visit to someone outside the plan the
>primary physician feels is unnecessary.

I'm not a big fan of HMO's either.  The HMO's incentive is to provide
the least care posible for the most money.  The sells pitch is that
they do this by providing preventive medicine and preventing major
expenses down the road.  The reality in some HMO's is that they do this
by limiting the care available to their members.  HMO's are maybe a step
in the right direction but still short of the goal of providing the best
care at the least expense.

>>MRI utilization in the USA is about one seventh our capacity.
> 
>Not here where I practice.  We have two MRIs in a town of 60K with a
>referral area of 250K.  They are full to capacity, running evenings and
>weekends.  I can't believe that the average MRI sits idle 6/7ths of the
>time.

My personal experience seems match the stats.  A year ago I broke my
colar bone and made regular visits to the radiology lab for X-rays.  On
only one occasion was the MRI machine in the lab in use while I was there.
There are many MRI machines in the SF Bay Area, nearly every hospital
has a least one and many clinics have them as well.  There are many
hospitals and clinics in the area.  This is in area with a population
of several million.

My personal take on the health care system is that it is not incentivized
to provide the best posible care for the least dollars.  The quality of
care varies widely from physician to physician and institution to
institution.  And that there is little correlation between the effectiveness
of treatment and its cost.  The bottom line is buyer beware.  The
federal government has done little to change this in all of its attempts
and I highly doubt that this will change anytime soon.

TJ Merritt
tjm@netcom.com