From: jlove@ivrit.ra.itd.umich.edu (Jack Love)
Newsgroups: talk.politics.medicine
Subject: Re: The future of medicine
Date: 10 Jan 93 15:25:24 GMT
Organization: /usr/local/trn/lib/organization
NNTP-Posting-Host: ivrit.ra.itd.umich.edu

I found this to a remarkably well-reasoned brief article, and
I'd like to append a few comments.

In article <1993Jan9.230923.3060@cnsvax.uwec.edu> nyeda@cnsvax.uwec.edu (David Nye) writes:
>When the inevitable rationing
>begins, we are going to have many dissatisfied customers.  

My quibble here is that I think we already have rationing. My wife and
I (two kids) are well above the poverty line (supposedly we're in the
top 5 or 10% for income, but I have my doubts about that) and we have
not been able to afford anything other than HMOs for years. I think the
question is not whether we are going to have rationing, but what kind
of rationing will we have. As for dissatisfied customers, I think it is
also clear that there is an abundant reservoir of those. In a different
type of system, there might be more or fewer, the types of
dissatisfaction might be more or less serious, and it is even
conceivable that the dissatisfaction might have a different
distribution by class. How this all turns out will indeed be a function
of our public debate and political process.

>The folks in
>Washington seem to be fixing it so we will be the fall guys.

I think this is a little myopic. The only thing clear about Washington
is that they will seek to make *anyone* the "fall guys" as long as
doing so protects their own positions of power.

>The biggest problem with any proposed legislative solution is that
>lawmakers don't have the guts to cut the parasites out of the health
>care system, those who profit by but don't contribute to health care:
>insurance companies and lawyers.  

I agree 100% with the above.

>To cut out the former, we need to go
>to a single payer system with electronic claim submission simple enough
>that a solo physician doesn't need a full time insurance clerk.

I think this has merit, but there are many complexities that will need
consideration, such as a mechanism for controlling fraud. N.B. I am not
a fan of the notion that private insurance companies do well at this
task. My experience and study leads me to believe that as long as they
can pass the costs along to the consumer, they really don't care.  

>Regarding the latter, the cost of malpractice insurance, while not
>negligible, is nothing compared to the cost of practicing defensive
>medicine, estimated to be 40% of the cost of all diagnostic studies.

I have read a number of articles which claims that this argument
is exaggerated; that much of this "defensive medicine" constitutes
good medical practice. Perhaps someone else might want to provide
competent literature on this subject.

>Physicians who engage in this are not going to stop just because of
>award caps.  

I believe very strongly that the award caps are the wrong approach.
Before we rev up the flame-throwers, this does not mean that I support
the notion of business-as-usual in the malpractice business. My problem
with caps is that they are artificial and reward the victims who are in
the least need--namely the ones whose cases are fairly clear. As most
people reading this conference probably know, the "pain and suffering"
award actually represents the available "pot" for lawyer's fees. With a
cap, the attorney has less incentive to take the difficult cases.
Therefore, I believe that the best answer to this problem lies in the
area of general health system reform. If there is a general entitlement
(I know that's a bad word, but it belongs here) to essential health
care, this would hopefully mean that the legitimate victim of medical
malpractice will be able to receive appropriate treatment and will not
need to sue for funds for this purpose.  An arbitration board could be
empowered to deal with the issues of lost wages, etc, and a victim
should have a major incentive to accept the ruling of the arbitration
board. Lawyers could then be limited to appeals from this board.

One of the best books ever written about the insurance industry is "The
Invisible Bankers" by Andrew Tobias. I strongly recommend its chapters
on how to handle the medical aspects of automobile insurance. You would
probably like his solutions, since they essentially remove any
necessity for the insurance companies to have sales agents.

While my suggestions are not quite as radical as shooting all the
lawyers and destroying all the insurance companies, they would 
result in some additional unemployment in both professions. :-)

>quality control maintained by professional societies, not the
>courts.  I won't hold my breath waiting for this to happen, though.  

I don't agree that it should happen. I don't think there is a single
member of a profession of any sort who would not prefer to be judged by
peers. Cops want to be judged by cops, not "civilian review boards" and
ad infinitim. Every such group always insists that only peers can
understand the problems in sufficient depth to make valid decisions.
And I believe that there is some truth in these feelings. Nevertheless,
it is also true that the track records of virtually all such
organizations is abysmal. For one reason or another, the members are
never held to appropriate standards. No, the wolf cannot be allowed to
watch the henhouse.

I thought you prepared an excellent article, and I hope to see
more of the public discourse you are encouraging.
-- 
________________________________________
Jack F. Love	| 	Opinions expressed are mine alone.
		|	(Unless you happen to agree.)