The Hard Problem of Healthcare

[Miss_Kitt]

I'm not sure whether this needs to go into this area, or Politics, so I'll start here.

In all the discussions of the muddle which is the American healthcare system, I don't hear anyone talking about the real problem. Quite simply, there are more people who would like to see nurses / see doctors / get treatment / get diagnostics, than there are resources to provide these services.

No amount of insuring, legislating, posturing or good intentions is going to fix this. Only having more doctors and nurses in the needed fields is going to help. So why aren't any discussions going on about how to make primary care and family medicine more desirable career paths?

Further, in the absense of "enough" doctors, nurses, therapists and money to provide them, some form of rationing needs to occur. That's the bottom line, really. Some will have to do without, the only questions are, Who doesn't get? and, Who decides who gets what? By what method(s)?

When you factor in the increasing demands of much of the American public to have their health insurance cover chiropractic, homeopathy, herbal remedies, acupuncture, etc. what we have is an ever-increasing demand for services.

So, really, where should the lines be drawn? And by whom?

Some examples of places where the current methods seem to be misplacing resources:

A scary fraction of US healthcare dollars and ICU/CCU resources are spent on the last day or two days of life. (I'll have to look up the exact fraction, but memory says it's like 30 percent.) Ultimately, do we want to trade well-child immunizations for another day of life for a dying, unconscious cancer victim? Well, if it's your grandma and a stranger's child, you might see it differently than the mother of seven who sees a $30,000 expense and three units of blood, plus a day of an ICU bed and the nurses and doctor's time being used for someone who will die in a day or two anyway.

Premature babies: Oh, this one is an awful thing to contemplate, but it's part of the question. Very early, very small babies run huge risks of not living, or of only living with heroic interventions; and even larger risks of living with substantial disabilities that will require lifetime medical care. At what point do we want doctors to tell the parents, "Your child is not likely to live; and even if she does, won't have a normal life," before asking if they want to do that surgery? My daughter was premie, and so were my sister's kids (both of them). Would I want my niece to not have made it? Of course not! But...again, what was the cost, in not only dollars, but the time and focus of those medical practitioners, of coaxing that spina bifida premie to survive?

People who have been in horrific traumatic accidents (auto wrecks, fires, gunshot wounds) are airlifted to trauma centers and given every care to survive. They then need extensive rehabilitation and, again, may well need special care for the rest of their lives. What price do you put on a human life? What other human lives will you negatively impact by deciding to nurture this one?

I'm not trying to piss anyone off, I'm just raising very real questions about the issue of "healthcare reform" that aren't really dealt with.

Doctors are very frustrated with how much of their job has become dealing with insurance and facility bureaucracy, which takes time and energy away from working with patients. Any effective reform needs to take on that issue, perhaps even sooner than providing additional forms of public insurance.

I'm interested to hear what the fine minds in this Forum have to say on the subject. It makes me sad and angry when I think about it, but I think we do need to look at it.

Thanks for your thoughts on this, Miss Kitt

 

[Soapy Sam]

I would simply agree that much the same situation exists with social health care systems like the UK's, with the addition of longer queues as the consultations are (apparently) "free" at the point of supply.
Politically, this is a very hot potato. While doctors always have practised triage of various sorts, it's something nobody likes to talk about.

 

[Ivor the Engineer]

<snip>

I'm not trying to piss anyone off...

<snip>

Neither am I. I'm just naturally gifted.

End of life care is always going to be expensive because a patient has several medical professionals attending to their needs. In my experience I have not seen heroic measures being used on terminally ill patients, just high quality palliative care.

As for other places where you think resources are being misplaced, I think it depends on the value system you use to judge the medical interventions provided. If it is a utilitarian value system, then premature babies and severe trauma victims are inefficient uses of resources. But if your value system leads you to believe those with greater need should be given more care and those with similar needs a similar level of care, then spending more on premature babies and severe trauma victims becomes the right thing to do. Ultimately it comes down to what kind of healthcare system (and society) you want. The tragedy as far as the US healthcare system is concerned is that it falls far short of achieving either goal.

 

[Asolepius]

To some extent, this question has been addressed for many years by the specialism of health economics. Here in the UK the National Institute for Health and Clinical Excellence (NICE) decides which interventions are cost-effective, using a largely arbitrary benchmark of GBP30,000 for each quality-adjusted life year. This says that it is worth paying 30k to get another year of good quality life. The idea is that it works for both morbidity and mortality. It would be all very well but for political interference. The UK government has for 8 years refused to refer any sCAM interventions to NICE, despite agreeing to in response to a parliamentary report. The reason is that the political mantra called `patient choice' overrides science - basically it means give the voters what they want, and to hell with the truth.

You have though hit the nail on the head - medical technology will always advance faster than the resources available to deploy it. Just a fact of life.

 

[fls]

I'm not sure whether this needs to go into this area, or Politics, so I'll start here.

In all the discussions of the muddle which is the American healthcare system, I don't hear anyone talking about the real problem. Quite simply, there are more people who would like to see nurses / see doctors / get treatment / get diagnostics, than there are resources to provide these services.

It's difficult to find a way to measure 'need' without simply reflecting 'use' or 'want'. The US does have a lower number of some of these services than other countries, and Americans do tend to be less healthy than people in other countries, so I think it is reasonable to assume that there is unfullfilled need in the area of primary care.

No amount of insuring, legislating, posturing or good intentions is going to fix this. Only having more doctors and nurses in the needed fields is going to help. So why aren't any discussions going on about how to make primary care and family medicine more desirable career paths?

You mean here? Maybe it isn't sexy or interesting enough for the average forumite? Turn it into a conspiracy and see what sort of response you get.

Further, in the absense of "enough" doctors, nurses, therapists and money to provide them, some form of rationing needs to occur. That's the bottom line, really. Some will have to do without, the only questions are, Who doesn't get? and, Who decides who gets what? By what method(s)?

When you factor in the increasing demands of much of the American public to have their health insurance cover chiropractic, homeopathy, herbal remedies, acupuncture, etc. what we have is an ever-increasing demand for services.

So, really, where should the lines be drawn? And by whom?

I agree that there is an inefficient allocation of resources. I think it goes well beyond the number of providers. I also think that it is because the allocation is based on ability-to-pay rather than needs-based.

Some examples of places where the current methods seem to be misplacing resources:

A scary fraction of US healthcare dollars and ICU/CCU resources are spent on the last day or two days of life. (I'll have to look up the exact fraction, but memory says it's like 30 percent.) Ultimately, do we want to trade well-child immunizations for another day of life for a dying, unconscious cancer victim? Well, if it's your grandma and a stranger's child, you might see it differently than the mother of seven who sees a $30,000 expense and three units of blood, plus a day of an ICU bed and the nurses and doctor's time being used for someone who will die in a day or two anyway.

How do you determine this beforehand? Surely the three units of blood, the day of an ICU bed and the nurses' and doctors' time are directed toward the idea that the life can be saved?

Premature babies: Oh, this one is an awful thing to contemplate, but it's part of the question. Very early, very small babies run huge risks of not living, or of only living with heroic interventions; and even larger risks of living with substantial disabilities that will require lifetime medical care. At what point do we want doctors to tell the parents, "Your child is not likely to live; and even if she does, won't have a normal life," before asking if they want to do that surgery? My daughter was premie, and so were my sister's kids (both of them). Would I want my niece to not have made it? Of course not! But...again, what was the cost, in not only dollars, but the time and focus of those medical practitioners, of coaxing that spina bifida premie to survive?

Did you choose to withhold care from your daughter and attempt to persuade your sister to do the same? If not, why not?

People who have been in horrific traumatic accidents (auto wrecks, fires, gunshot wounds) are airlifted to trauma centers and given every care to survive. They then need extensive rehabilitation and, again, may well need special care for the rest of their lives. What price do you put on a human life? What other human lives will you negatively impact by deciding to nurture this one?

I'm not trying to piss anyone off, I'm just raising very real questions about the issue of "healthcare reform" that aren't really dealt with.

Not to piss anyone off, but do you really expect the average person here to reliably identify what the real issues of healthcare reform are, and to find them of interest for discussion?

Doctors are very frustrated with how much of their job has become dealing with insurance and facility bureaucracy, which takes time and energy away from working with patients. Any effective reform needs to take on that issue, perhaps even sooner than providing additional forms of public insurance.

The bureaucracy comes about because the system requires that access be limited based on non-medical issues. If that was reduced, doctors could go back to the primary task of addressing needs.

I think resources could be freed up through tort reform, reducing bureaucracy aimed at limiting access, and the ability to negotiate better prices for some goods. Allocation of those resources could be made more efficient by equalizing access. This doesn't have to be done through public insurance, which seems to be unpalatable to Americans and would require removing the tight grip big business has on forming public policy (an impossible task as far as I can tell). It can take the form of what has been implemented in some European countries and what Obama has suggested as a solution - continuing to make use of private and public insurance but requiring that at a minimum the same basic, affordable plans be available to everyone.

But that doesn't address your question. Attempts have been made to develop a ranked list (the (in)famous Oregon Health Plan, for example) for allocation. But in a country that allocates far more resources to health care than any other country, is it really reasonable to talk about withholding life-saving treatments that other countries manage to provide with less? How ****ed-up is that?

Linda

 

[Almo]

An economist I know despises what he calls the medical profession's restriction of entry. He says the AMA restricts entry to the doctor profession to keep wages up by reducing supply. If this is in fact the case, then the assertion that there's not enough care to go around may be due (at least in part) to the actions of the AMA.

Just a comment. No numbers or data or anything.

 

[Tiktaalik]

...In all the discussions of the muddle which is the American healthcare system, I don't hear anyone talking about the real problem. Quite simply, there are more people who would like to see nurses / see doctors / get treatment / get diagnostics, than there are resources to provide these services.

No amount of insuring, legislating, posturing or good intentions is going to fix this. Only having more doctors and nurses in the needed fields is going to help...

Is there an actual lack of doctors & nurses or is part of it a "distribution" problem? By that I mean, how do we get doctors & nurses distributed to where they are needed? It's difficult to get many of them to come to rural areas - for example, there is only a single dermatologist within 2 1/2 hours of where I live (serving some 20,000 people as far as I can figure). As someone who has had skin cancer, that's pretty limiting. It's difficult to get an appointment and I have to drive an hour each way.

The clinic I go to for primary care has rotating doctors who come from cities & stay for a short period of time. This results in people not having primary care physicians & thus having to go to emergeny rooms for non-emergency problems, which jacks up the cost & eats up emergency room resources.

I think this is another part of the issue - I don't know how many doctors & nurses of various types we have, or how we would go about figuring out how many were "needed" (a per capita thing?) and getting them to move to rural areas & other undesirable locations...

 

[Ivor the Engineer]

An economist I know despises what he calls the medical profession's restriction of entry. He says the AMA restricts entry to the doctor profession to keep wages up by reducing supply. If this is in fact the case, then the assertion that there's not enough care to go around may be due (at least in part) to the actions of the AMA.

Just a comment. No numbers or data or anything.

That's an interesting point. How much medical education does someone need to be competent at diagnosing illness, or to know when to call for more assistance?

http://www.medicalnewstoday.com/articles/23495.php

Many primary care responsibilities can be safely transferred from doctors to appropriately trained nurses, says a new review of evidence. Yet there is little proof that such a shift reduces physician workload or health-care costs.

"The findings may be considered controversial by health care professionals and policymakers, as there is a widely held belief that nurses can save physicians' time and reduce costs," says lead reviewer Miranda Laurant of Radboud University, Nijmegen in the Netherlands.

Demand for primary care services has increased in many countries due to aging populations, rising patient expectations and changing health-care approaches. At the same time, availability of general practitioners may be limited, and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges.

...

Overall, the review findings suggest that appropriately trained nurses can produce the same high-quality primary care as doctors and achieve similar health outcomes for patients. Laurant cautions, however, that many of the studies had methodological limitations, and follow-ups of less than one year left long-term health outcomes unclear. In addition, most studies included only a few nurses, so the findings may reflect personal variations rather than broad trends.

 

[Miss_Kitt]

To respond first to my British correspondents: Yes, it's different over here. We don't have any centralized health care, and the level of care available varies greatly depending on: Where you are, geographically; What kind(s) of insurance you have; How aggressive you, your doctor, and/or your designated advocate (next of kin, etc.) are in pushing for more care; and a lot of pill-pushing by both pharmaceutical companies and some providers.

On the issue of ICU care, my sister is a career ICU/CCU nurse, and yes, they do provide ongoing care to people so far gone that they have no gag reflex, pupil response, etc. The devil in the details is that some people are in temporary failure, and some can be expected to not recover. (The multiple-system failure long-time drug addict (needle marks in his p**is, since his arm and leg veins were so bad) who was kept "alive" for days with no response is one time where I think even the doctors wanted to pull the plug--but his mother was sure he would recover soon.)

The issue I am raising here is that there does need to be some form of control on who gets access -- as fls so brilliantly pointed out, the spectrum of "need" versus "want" is wide -- and I hear a lot of people talking about healthcare reform in terms of We Just Need More Insurance. That's not going to do it, and I hope to get some smart people thinking about the subject. Hence, this thread.

On the personal issues: My daughter, thankfully she was so healthy she never spent a minute in NICU; she just stayed in my room with me. I, however, was quite ill and spent a week in the hospital--she was induced to protect me from the imminent eclasmpsia. My sister's daughter received all manner of care and surgery, and is still getting care; my sister, as a doctor, is able to afford what is not covered by insurance. But...a poorer family would probably have lost their child. If we go to a nationally mandated health policy, the question of whose child gets care is not going to go away.

Right now, we 'ration' healthcare primarily on the basis of money and insurance. When there are more people who have money/insurance, there's going to be a shortfall of resources. Yes, we will have some ER visits missed because people will get care earlier in the course of their illness or injury, and that's all to the good; but when everyone starts getting seen regularly for their chronic issues, where are the triage decisions going to be made?

I don't pretend to have any answers here; I have some ideas, half-formed, that I want to discuss. And I really, really want to hear from people who are more informed than I am on these issues.

A few things I am clear on: I think that spending tax dollars on CAM is bunk, and there should be requirements for evidence-based medicine. I think the lawsuits requiring that various private health plans pay for acupressure and chiropractic are a shame and a vast waste of resources. I think that there is national issue with unnecessary drug use; even in our own "family clinic," one of the nurse-practictioners is a "writer" who will always give you a prescription even if (IMHO) an over-the-counter drug would work, and/or no intervention is needed. (We don't see her anymore, we ask to see someone else and sometimes wait the extra day.)

There is a lot of "defensive medicine" practiced, too, where if the patient is insured, then extra diagnostics are performed to protect the doctor in case of a rare issue...that's wasteful, but necessary given the current lawsuit-happy climate. Again, we saw this in person when my husband developed appendicitis, and the decision was made--since he was very early in the process--to have him have some imaging done to confirm that was the case before surgery. Well, given that he had rebound tenderness, a rising fever, prior generalized abdominal discomfort changing to localized pain in the typical location, etc. I think they could either have just watched him for a few hours, or gone for the surgery. But that imaging did protect them if he had some other odd condition that presented like appendicitis, but wasn't--and if we'd sued, they were covered. Did we really need that MRI? (I'm not a doctor, but *I* told Himself it was appendicitis just from the way he was reacting...and made him see a doctor instead of driving to work.) The time for the contrast material to reach his bowel was spent watching him get sicker and sicker and sorer and sorer, by the time they did the scan they took him straight to Admissions in a wheelchair after.

But, again, how do you decide what is 'necessary'?

I look forward to a continuing discussion, thanks for the input, MK

 

[blutoski]

An economist I know despises what he calls the medical profession's restriction of entry. He says the AMA restricts entry to the doctor profession to keep wages up by reducing supply. If this is in fact the case, then the assertion that there's not enough care to go around may be due (at least in part) to the actions of the AMA.

Just a comment. No numbers or data or anything.

I'm pretty sure he's misguided about the AMA... does he mean the College of Physicians and Surgeons?

FWIW, the College does not control how many MDs can be licensed: only the standards for licensure. I'm sure they'd love to boost their paying membership ranks if they could find a way without destroying the self-regulating purpose of the College. They are perfectly aware that if they fail to fulfil their role as profession disciplinarian in good faith they will be dissolved and replaced by conventional government regulation, as have many other professions.

Lots of people are angry about it; none have come up with a good reason from what I can hear.

In any case, this is certainly not a 'science, medicine, and technology' issue - it's squarely politics, and I suggest a migration to the other forum.

 

[Ziggurat]

In all the discussions of the muddle which is the American healthcare system, I don't hear anyone talking about the real problem. Quite simply, there are more people who would like to see nurses / see doctors / get treatment / get diagnostics, than there are resources to provide these services.

No amount of insuring, legislating, posturing or good intentions is going to fix this. Only having more doctors and nurses in the needed fields is going to help. So why aren't any discussions going on about how to make primary care and family medicine more desirable career paths?

Because the best way to do that is with a market for medical services, but that's exactly what so many people are trying so hard to prevent.

Note, though, that while an increased supply of doctors in certain fields may help, the fundamental problem of scarcity (namely, people want more medical services than are available) will ALWAYS exist. There is no way around it. Any and every possible medical system we could establish must institute rationing of some sort. Either consumers ration healthcare themselves through price incentives, or someone else (be it an insurance company or the government) is going to ration it for them.

 

[Ivor the Engineer]

Because the best way to do that is with a market for medical services, but that's exactly what so many people are trying so hard to prevent.

<snip>

No, it isn't. Market failure is inevitable.

Physicians are not going to push too hard for the US system to change (except those aspects which cost them money, such as being sued), since they're doing very nicely out of unnecessary MRI scans and other treatments.

 

[blutoski]

Because the best way to do that is with a market for medical services, but that's exactly what so many people are trying so hard to prevent.

Obviously, it's because they disagree with it being the best way. I think the outcomes of different approaches make the above claim very questionable.

Note, though, that while an increased supply of doctors in certain fields may help, the fundamental problem of scarcity (namely, people want more medical services than are available) will ALWAYS exist. There is no way around it. Any and every possible medical system we could establish must institute rationing of some sort. Either consumers ration healthcare themselves through price incentives, or someone else (be it an insurance company or the government) is going to ration it for them.

Everything is rationed. Period. That's the nature of human existence.

The question is complex because people have different values. Some people are very willing to die and see their families die as long as it was their choice. We see this in all sorts of religions, and freemarket libertarians aren't any different. Others feel that they have limitations and would like to delegate these decisions to people with vetted qualifications. Trust of public institutions is involved, and that's a value judgement.

There are no 'facts' that will change a person from valuing choice to valuing life if he's already decided choice is more important than living. In my day, it was 'Better dead than red'. Same applies to healthcare for people. Personally, I don't get it, but hey.

It's important to also recognize that medicine is not a typical product or service. It is literally the only profession where you are legally allowed to use the salespitch: "Your money or your life." It is because of this that I believe it is very misguided to believe that conventional market models for price optimization would apply. To the point of being wilfully blind.

 

[Ziggurat]

No, it isn't. Market failure is inevitable.

Perhaps you read more into my reply than was actually there. I meant nothing more by "that" than attacting more doctors to particular fields of high need. Markets work for that, and they work rather well. Perhaps you do not want to pay the cost for that, and there are arguments to be made in that regard, but that's a separate issue.

Physicians are not going to push too hard for the US system to change (except those aspects which cost them money, such as being sued), since they're doing very nicely out of unnecessary MRI scans and other treatments.

Funny you should mention something like this just after mentioning free market failures (without mentioning what those failures are). What you mention here is a failure of a controlled market. In a free market, consumers would have rather high incentives to figure out whether or not the MRI was necessary, and would be much less likely to agree to one when it was either unneeded or when cheaper alternatives were available. As it is, they've got very little incentive so long as the insurance will pick it up, so they're happy to play along with the doctors. After all, an unnecessary MRI won't hurt them.

 

[a_unique_person]

It's a simple matter of the advance of technology and the growth in population, as well as restrictive trade.

The range and effectiveness of medical treatments has exploded. Diseases that were untreatable are now treatable, and everyone with those diseases wants them treated. (not surprisingly). The cost of most of these treatments, however, is quite expensive, or very expensive, or hideously expensive. This process is not going to stop.

 

[Ivor the Engineer]

The two most important causes of market failure are the gross disparity in knowledge/information between physicians and their patients and that physicians often have an incentive to provide as much treatment as possible to maximise their remuneration.

Until a solution is proposed which addresses these problems, forget about having healthcare system which does not have exploding costs.

 

[Ivor the Engineer]

http://content.nejm.org/cgi/content/full/358/6/549

Relentless medical inflation has been attributed to many factors — the aging population, the proliferation of new technologies, poor diet and lack of exercise, the tendency of supply (physicians, hospitals, tests, pharmaceuticals, medical devices, and novel treatments) to generate its own demand, excessive litigation and defensive medicine, and tax-favored insurance coverage.

Here is a second opinion. Changing demographics and medical technology pose a cost challenge for every nation's system, but ours is the outlier. The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization. The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system.

 

[fls]

On the issue of ICU care, my sister is a career ICU/CCU nurse, and yes, they do provide ongoing care to people so far gone that they have no gag reflex, pupil response, etc. The devil in the details is that some people are in temporary failure, and some can be expected to not recover. (The multiple-system failure long-time drug addict (needle marks in his p**is, since his arm and leg veins were so bad) who was kept "alive" for days with no response is one time where I think even the doctors wanted to pull the plug--but his mother was sure he would recover soon.)

That was a difference I noticed between the United States and Canada - that physicians were more reluctant to withhold or stop futile treatment. This seems to be gradually changing as the legal issues are clarified and there is support for the idea that physicians are not only not obliged to provide futile treatment, but have a duty to discourage it.

The issue I am raising here is that there does need to be some form of control on who gets access -- as fls so brilliantly pointed out, the spectrum of "need" versus "want" is wide -- and I hear a lot of people talking about healthcare reform in terms of We Just Need More Insurance. That's not going to do it, and I hope to get some smart people thinking about the subject. Hence, this thread.

On the personal issues: My daughter, thankfully she was so healthy she never spent a minute in NICU; she just stayed in my room with me. I, however, was quite ill and spent a week in the hospital--she was induced to protect me from the imminent eclasmpsia. My sister's daughter received all manner of care and surgery, and is still getting care; my sister, as a doctor, is able to afford what is not covered by insurance. But...a poorer family would probably have lost their child. If we go to a nationally mandated health policy, the question of whose child gets care is not going to go away.

Right now, we 'ration' healthcare primarily on the basis of money and insurance. When there are more people who have money/insurance, there's going to be a shortfall of resources. Yes, we will have some ER visits missed because people will get care earlier in the course of their illness or injury, and that's all to the good; but when everyone starts getting seen regularly for their chronic issues, where are the triage decisions going to be made?

It's pretty premature to talk about withholding services when other countries manage to provide the same services for less. We should be able to provide for everyone on less than what we spend now, with money left over. Long term, measures will need to be built in to control costs, but since other countries are ahead of us on that, we could just let them solve it for us and follow their lead.

There is a lot of "defensive medicine" practiced, too, where if the patient is insured, then extra diagnostics are performed to protect the doctor in case of a rare issue...that's wasteful, but necessary given the current lawsuit-happy climate.

That was why I included legal reforms in my list of suggestions.

Again, we saw this in person when my husband developed appendicitis, and the decision was made--since he was very early in the process--to have him have some imaging done to confirm that was the case before surgery. Well, given that he had rebound tenderness, a rising fever, prior generalized abdominal discomfort changing to localized pain in the typical location, etc. I think they could either have just watched him for a few hours, or gone for the surgery. But that imaging did protect them if he had some other odd condition that presented like appendicitis, but wasn't--and if we'd sued, they were covered. Did we really need that MRI? (I'm not a doctor, but *I* told Himself it was appendicitis just from the way he was reacting...and made him see a doctor instead of driving to work.) The time for the contrast material to reach his bowel was spent watching him get sicker and sicker and sorer and sorer, by the time they did the scan they took him straight to Admissions in a wheelchair after.

But, again, how do you decide what is 'necessary'?

Diagnostic tests for suspected appendicitis tend to be directed at avoiding unnecessary surgery. What value would you place on that?

These questions are amenable to cost-benefit analysis. As mentioned previously, there are ways to draw a line in a systematic manner.

Linda

 

[jli]

I think they could either have just watched him for a few hours, or gone for the surgery.

Diagnostic tests for suspected appendicitis tend to be directed at avoiding unnecessary surgery. What value would you place on that?

In Denmark the surgeons follow the approach suggested by Miss_Kitt. As a pathologist I get to examine the removed appendices, and only very few of them are entirely normal. A small fraction only have very slight superficial inflammation, that probably wouldn´t be detectected on MRI anyway (I´m only guessing here). A cost-benefit analysis would probably (I´m guessing again) show that it is better to use the MRI-scanner capacity on something other than suspected appendicitis.

 

[mhaze]

I'm not sure whether this needs to go into this area, or Politics, so I'll start here.

In all the discussions of the muddle which is the American healthcare system, I don't hear anyone talking about the real problem. Quite simply, there are more people who would like to see nurses / see doctors / get treatment / get diagnostics, than there are resources to provide these services.

No amount of insuring, legislating, posturing or good intentions is going to fix this. Only having more doctors and nurses in the needed fields....

Thanks for your thoughts on this, Miss Kitt

Of course there is misallocation of resources viewed against an arbitrary construct of "the public good". I give one example out of thin air.

Arbitrary construct of the "public good": Increased longevity.

Logical statement from thin air:

"Money, doctors and equipment spent in plastic surgery should with rare exceptions be reallocated to primary care in rural areas and innner city areas, because this will result in increased longevity."
​

Statement is "true". Construct is "reasonable". Now, do you see the problems?