The Hard Problem of Healthcare

[Ivor the Engineer]

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?

No. Please provide more irrelevant examples.

 

[mhaze]

Why is it irrelevant? Miss_Kit, and I think you also, want to control access in a fashion so as to re allocate resources according to a predetermined set of values:

Miss_Kit:
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.

 

[Ivor the Engineer]

Life must be so simple for you. Whenever you are uncertain about what the best course of action is you simply find the richest people around and ask them what to do.

 

[mhaze]

Life must be so simple for you. Whenever you are uncertain about what the best course of action is you simply find the richest people around and ask them what to do.

Really, I have no idea where you got that. I just restated the problem so as to show the relation of the conclusion to the premises used. This illustrates the importance of precisely stating what the "public good is".

But just for fun, I'll help out by inverting your statement:

Life must be so simple for you. Whenever you are uncertain about what the best course of action is you simply find politicians and have them, along with their special interests, plan what to do for you.

 

[fls]

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.

One can always find a 'better' use for an MRI-scanner. But we're not really intending to confine our use of the MRI-scanner to only the best use. Instead, we should be asking whether it is worthwhile to increase our MRI-scanner capacity.

Linda

 

[fls]

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?

I don't understand why you see that as a problem. Can you elaborate on that a bit?

ETA: A hierarchy of outcomes is often used in medical research - death, disability, disease, discomfort, dissatisfaction (if that's any help).

Linda

 

[Ivor the Engineer]

One can always find a 'better' use for an MRI-scanner. But we're not really intending to confine our use of the MRI-scanner to only the best use. Instead, we should be asking whether it is worthwhile to increase our MRI-scanner capacity.

Linda

Or maintain it. They are not cheap to run.

 

[Earthborn]

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.

They work rather well finding particular fields of high profit. Those fields may not be the fields of high need.

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.

In healthcare the consumers are patients, who most often lack the necessary knowledge to figure out whether something is necessary or whether there are alternatives available that are also viable.

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.

Which makes it a bit surprising that in countries with universal healthcare where some form of insurance picks up practically everything a doctor prescribes, there are fewer unnecessary procedures. Patients still play along with the doctors, and they should, because more often then not the doctor actually does know best.

 

[Ivor the Engineer]

<snip>

Patients still play along with the doctors, and they should, because more often then not the doctor actually does know best.

Patients play along with nurse practitioners even better.

http://www.medscape.com/viewarticle/431252

Compared with doctors, nurse practitioners had longer consultations, carried out more investigations, made more complete records, scored better on communication, and offered more advice on self-care and management. There were no differences in prescriptions, return visits, or referrals.

"Further research is needed to confirm that nurse practitioner care is safe in terms of detecting rare but important health problems," the authors write. They also recommend more studies on cost-effectiveness and training issues.

I predict increasing the numbers of nurse practitioners will be fought tooth and nail by physicians and nurse practitioners will start demanding a similar level of remuneration to that given to physicians.

ETA: As for missing rare but important health problems, I think physicians should keep quiet on the subject. Coeliac disease anyone?

 

[luchog]

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.

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.
Linda

The lack of primary care physicians (aka General Practitioners, aka Family Practitioners) is due strictly to economics. There is a huge barrier to entry in the form of medical education costs; and a huge disincentive to practicing in the field, in the form of a lower income vs. expenses ratio.

The average medical student graduates with between $75,000 and $100,000 in debt. This requires a fairly substantial income in order to have a reasonable chance of paying off the debt. On top of that, malpractice insurance costs are skyrocketing, well over $20,000 a year for the vast majority, and approaching $100,000 for many; mainly due to the litigious nature of American culture, and insurance companies attempting to recoup on bad investments.

At the same time, income has been growing at a much slower rate, or actually falling, for many practices. A large part of this is due to governmental regulations. Hospitals which accept public funding are required to accept any emergency patient, regardless of ability to pay. Furthermore, any hospital, clinic, or practitioner which accepts public funding is also required to accept Medicare benefits. Medicare has a specific schedule of what treatments are permitted, as well as a standardized payment schedule for those treatments which is well below market rates. Insurance companies also limit treatments and remuneration rates to a lesser extent.

Because of this, most new graduates are opting for more lucrative specialty practices, and forgoing general practice. The market is correcting for this situation to some degree, through nurse-practitioners who are increasingly taking over the role of a GP physician; but this is of limited utility, and not a viable long-term strategy. Some medical programs have offered scholarships which reduce the cost of medical education, with the requirement that student server a term as a GP in an economically disadvantaged region after aquiring his certification; but these are also a very limited solution, and very likely underutilized.

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.

This is complete crap. A worthless conspiracy theory that completely ignores the actual economics of the medical field. The AMA does create some comparitively minor barriers to entry based on proficiency and conduct; but these are perfectly reasonable to ensure a functioning and reliable medical industry. Even then, there are many who believe these restrictions to be too lax, and the number of bad doctors allowed to enter and continue to practice to be too high.

 

[luchog]

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 bad side to the Canadian system, and one which my own family has experienced, is that doctors there are more likely to declare even minor intervention futile, in order to contain costs and free up resources; particularly when the patient is of advanced age.

 

[luchog]

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

Indeed.

AAMOF, I also have personal experience of this. I was in the hospital for appendicitis a few years back. The doctors at first didn't think that it was appendicitis, but rather a more minor gastrointestinal problem, due to the fact that my appendix was somewhat outside the typical location, and my symptoms were somewhat atypical as well. Normally, they would have simply proscribed a wide-spectrum antibiotic and waited for the symptoms to subside somewhat before sending me home. To be safe, they did a CAT scan, and determined that yes, I did in fact have acute appendicitis, and immediate surgery was strong warranted. My surgeon informed me afterwards that I was very acute, and that the appendix would almost definitely have ruptured within less than 24 hours; and had I waited much longer to come in, or had they not done the CAT scan, I could easily have died from peritonitis.

 

[blutoski]

The bad side to the Canadian system, and one which my own family has experienced, is that doctors there are more likely to declare even minor intervention futile, in order to contain costs and free up resources; particularly when the patient is of advanced age.

I'm sorry to hear about that.

I'd be interested, though, to see if the difference is real, and if so: is it a consequence of resource allocation or is it formed from our culture and values? The US population has more adherence to religious views on life preservation.

 

[Miss_Kitt]

No, I didn't say that!!

Why is it irrelevant? Miss_Kit, and I think you also, want to control access in a fashion so as to re allocate resources according to a predetermined set of values:

Miss_Kit:
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.

I need to clarify my wording instantly, if it is subject to this misunderstanding. I do NOT want to control access: I am arguing that, since there is more demand for 'healthcare' than supply, some form of access control / rationing / shortfall of care will occur. That's what I think is being missed in the discussions of medicine / healthcare reform / medicalization of conditions that previously were untreated.

If, as seems to be the dominant preference of US pundits, a government-controlled insurance or health provision system is put in place, that's not going to make the issue go away. I think that people often don't understand that real scarcity exists, and will get worse just due to demographics. The Boomers are getting older, and older people are in general less healthy. They need more care; they have more chronic conditions; they are more easily injured, and their recovery time takes longer, than for younger people.

More and more medical conditions are now treatable, or at least, are being treated, than before. Just to pick three, blood pressure medication, anti-depressants, and fertility interventions are now fairly common, where 30 years ago they were nearly non-existant. Cancers that used to be undetectable or untreatable are now producing larger 5-year-survival rates, and some even larger 20-year-disease-free rates. The list goes on, but the bottom line is that the "wasteful" medical system has produced some amazing advances, along with the gigantic overuse of resources typical of having the people using the services not paying the bills (as most insurance works).

I am, if anything, against having a single payer or single provider exactly because it would "control access" against some pre-determined set of values. I'd like to find answers that let individuals (or groups of individuals) decide where they want to draw the lines, not some agency or entity decide for everyone.

Apologies in advance if later in the thread someone already recognized my intent, Miss Kitt

 

[Miss_Kitt]

Indeed.

AAMOF, I also have personal experience of this. I was in the hospital for appendicitis a few years back. The doctors at first didn't think that it was appendicitis, but rather a more minor gastrointestinal problem, due to the fact that my appendix was somewhat outside the typical location, and my symptoms were somewhat atypical as well. Normally, they would have simply proscribed a wide-spectrum antibiotic and waited for the symptoms to subside somewhat before sending me home. To be safe, they did a CAT scan, and determined that yes, I did in fact have acute appendicitis, and immediate surgery was strong warranted. My surgeon informed me afterwards that I was very acute, and that the appendix would almost definitely have ruptured within less than 24 hours; and had I waited much longer to come in, or had they not done the CAT scan, I could easily have died from peritonitis.

Luchog, good catch by your doctors. What was odd in my husband's case is that they said, "You most likely have appendicitis, you're just early on" but then did the MRI anyway. Given that he didn't have any really scary symptoms yet, and we were a block from the hospital, would it have more sense to 'keep an eye' on him by checking his vites hourly and having him contact the staff if he suddenly felt more ill, rather than spend that time sitting in the radiology waiting room with contrast medium percolating through him and then spending thousands of dollars worth of device, technician, and radiologist time? I don't know, but I truly wonder.

Linda raised the question, what price do you put on avoiding unnecessary surgery, and it's a good one. But are an MRI and immediate surgery the only options? That's the kind of question I lack the medical background to answer, but I can as an educated layman raise them.

Thanks again for your input, MK

(BTW, in Seattle we have a regular flow of Canadian patients coming down to get their MRI or CT work done here. Apparently, there are more devices and radiologists in the Greater Seattle area than there are in the entirety of British Columbia, so it's faster to schedule a trip down here than to wait for access to a device in BC.)

 

[Ivor the Engineer]

<snip>

I am, if anything, against having a single payer or single provider exactly because it would "control access" against some pre-determined set of values. I'd like to find answers that let individuals (or groups of individuals) decide where they want to draw the lines, not some agency or entity decide for everyone.

<snip>

Then you don't want a healthcare system, you want what you have already (i.e. a complete shambles), just "nicer" in some vague, forever to be unspecified way. I'm sure Obama will be able to give a great speech about it and how great America is. Oh, and something about god thrown in for good measure.

There is a huge amount of objective information available to allow efficient organisation of healthcare resources, but you would prefer to ignore all this and distribute them according to what the market demands in the short term.

In case recent events have passed you by, even when they are not doomed to failure from the outset, markets are not rational.

 

[a_unique_person]

The bad side to the Canadian system, and one which my own family has experienced, is that doctors there are more likely to declare even minor intervention futile, in order to contain costs and free up resources; particularly when the patient is of advanced age.

My grandmother became seriously ill when she was in her late '70s, I think. She had private health cover, was in hospital and had a fortune spent on her. She checked herself out, went home, died not long after where and how she wanted to. The vast majority of health care is spent on prolonging the life of those whe are going to die soon anyway.

 

[fls]

I need to clarify my wording instantly, if it is subject to this misunderstanding. I do NOT want to control access: I am arguing that, since there is more demand for 'healthcare' than supply, some form of access control / rationing / shortfall of care will occur. That's what I think is being missed in the discussions of medicine / healthcare reform / medicalization of conditions that previously were untreated.

As you point out, though, access is already controlled. Your access depends upon what you can afford to pay. The question is, do you wish to contintue to control access in this manner, or some other manner. Single-payer systems control access to expensive services by need, so that your access depends upon the extent to which you can afford to wait. This limits the drive toward excess capacity, since need is fairly inelastic.

If, as seems to be the dominant preference of US pundits, a government-controlled insurance or health provision system is put in place, that's not going to make the issue go away. I think that people often don't understand that real scarcity exists, and will get worse just due to demographics.

Right now the US has an excess supply of expensive services. It's not that these services are scarce, it's that too many people can afford them. And since need tends to be inversely proportional to ability to pay, these services are being used in situations where there is little return. Your husband's MRI is a good example.

The Boomers are getting older, and older people are in general less healthy. They need more care; they have more chronic conditions; they are more easily injured, and their recovery time takes longer, than for younger people.

More and more medical conditions are now treatable, or at least, are being treated, than before. Just to pick three, blood pressure medication, anti-depressants, and fertility interventions are now fairly common, where 30 years ago they were nearly non-existant. Cancers that used to be undetectable or untreatable are now producing larger 5-year-survival rates, and some even larger 20-year-disease-free rates. The list goes on, but the bottom line is that the "wasteful" medical system has produced some amazing advances, along with the gigantic overuse of resources typical of having the people using the services not paying the bills (as most insurance works).

I am, if anything, against having a single payer or single provider exactly because it would "control access" against some pre-determined set of values. I'd like to find answers that let individuals (or groups of individuals) decide where they want to draw the lines, not some agency or entity decide for everyone.

You have that now.

The pre-determined set of values used in single-payer systems is fairness, equality and sustainability. I can see why you'd want to avoid that.

Linda

 

[fls]

Luchog, good catch by your doctors. What was odd in my husband's case is that they said, "You most likely have appendicitis, you're just early on" but then did the MRI anyway. Given that he didn't have any really scary symptoms yet, and we were a block from the hospital, would it have more sense to 'keep an eye' on him by checking his vites hourly and having him contact the staff if he suddenly felt more ill, rather than spend that time sitting in the radiology waiting room with contrast medium percolating through him and then spending thousands of dollars worth of device, technician, and radiologist time? I don't know, but I truly wonder.

Doesn't Luchog's story answer your question?

Linda raised the question, what price do you put on avoiding unnecessary surgery, and it's a good one. But are an MRI and immediate surgery the only options? That's the kind of question I lack the medical background to answer, but I can as an educated layman raise them.

And these are the kinds of questions we use medical research to answer. What are the costs and outcomes of various strategies, and how can we maximize the trade-off between costs and benefits? And the answers help guide individual and group practice, hospital policy, reimbursement schemes, etc. But when you have excess capacity to begin with, the cost in any individual case becomes irrelevant once you are granted access (i.e. you can afford anything). There was no particular disincentive when it came to which particular course of action your physicians recommended, so they picked what may be the most accurate course, even though accuracy had very little additional value in this case. If some attention is paid to cost-benefit, then the bulk of that accuracy can be obtained for a much lower cost (wait and watch as an outpatient, ultrasound).

(BTW, in Seattle we have a regular flow of Canadian patients coming down to get their MRI or CT work done here. Apparently, there are more devices and radiologists in the Greater Seattle area than there are in the entirety of British Columbia, so it's faster to schedule a trip down here than to wait for access to a device in BC.)

Exactly. Your capacity is excessive - scarcity is not the issue.

Linda

 

[mhaze]

....Your capacity is excessive - scarcity is not the issue.

Linda

Why should anyone care if many radiology groups invest in MRI facility and it does not do well as a business venture?