From: sworking@unixg.ubc.ca (Scott Workinger)
Subject: Re: Opting out.
Organization: University of British Columbia, Vancouver, B.C., Canada
Distribution: bc
Date: Fri, 2 Oct 1992 16:47:51 GMT

In article <1992Oct2.014026.10263@mikejag.wimsey.bc.ca> brent@mikejag.wimsey.bc.ca (Brent Kennedy) writes:

> One of the problems this all raises is the problem of what 'abuse by a doctor
>is.'  Part of the problem is how much should be done for each patient as what
>is called 'the standard of care.'  Wilson's disease could be picked up at an
>early age if we screened everyone, and there is treatment available for it.
>It can cause damage to the brain, liver, kidney and heart, if not picked up
>early enough.  The difficulty is that the disease has an incidence of 1 in
>100,000.  The test costs somewhere between $15 and $25 per person.  Should we
>screen everyone??  IS a doctor 'abusing the system' if he orders this test??
>How long should a doctor spend searching with investigations for the cause of
>a patient's problem??  If it costs the health system more money each week, and
>it may not affect the care given to the patient, or the prognosis for the
>patient, should a doctor keep looking??  The problem here is often the
>patients demand that they do, and keep going to more and more doctors until
>they get an answer.  Some of these people do eventually get a diagnosis, and
>it may even be treatable, but do we cut off the investigations at $1000 oe $1
>million dollars??  In the US, patients are given an MRI scan with much higher
>frequency than they are here, should we be doing more??  'Abuse' in this
>enviroment is difficult to define. 

You raise an important issue.  To expand upon your point, let us consider
economic consequences.  When health care is essentially free to individuals,
the demand will inevitably expand until it hits some sort of limit.  We
can see some evidence of this already.  It becomes difficult to book
certain types of 'elective' surgery.  (The news occaisionally reports
the deaths of people who waited to long for 'elective' surgery.)  We
see some areas doing other types of rationing.  (Washington State is 
experimenting with denying large classes of health benefits to people
who get state sponsored health care.)  There is a clogging of the system
in some areas that reduces everyone`s odds of getting timely care 
during an emergency.

Of course, holding down compensation inevitably reduces the incentive
for individuals to become M.D.'s.  However, compensation is not the 
greatest disincentive.  The prospect of spending your career subject 
to the arbitrary decisions of bureacrats and politicians in a daily
way is not appealing to many people.  Historically, one of the most
attractive aspects of being a doctor is the prospect of being
self-employed.  Remember, these people spend a LONG time preparing
to become doctors.  They give up a lot in the process.  For instance,
M.D.'s in North America have a life expectancy which is significantly
shorter than the general population.  

We can choose to ignore economics when we discuss these issues, but
we cannot evade the consequences of economics.  If we really want to
hold down health care costs, we must deal with the fundamental 
economic issues.  Let's look at preventable costs that drive up
these prices.  For instance, let's look at the cost of all the 
litigation that goes on.  Let's look at the cost of regulation
which dramatically increase the cost of medicines and medical
technology.  Finally, let's look at the fact that M.D.'s have an
effective monopoly on health care.  (If modern M.D.'s know so much
about health, why aren't they effectively applying their knowledge
to extend their own life spans?  Why should we be denied the access
to inexpensive alternatives?)

Overall, what I'm trying to suggest is that we expand the scope of
our vision a little bit.  There's a limit to what you can accomplish
by holding a gun to people's heads.  And the side effects frequently
cost you much more than you achieve.  Requlation is not the 
Philosopher's Stone of social policy.



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