Michael Blim wrote a column at 3 Quarks Daily about when his doctor decided to drop him in a move to a boutique medicine practice. For those of you who don't know what that is, it is a family medicine practice where the physician has a limited number of patients who pay an annual fee in addition to whatever treatment costs they might incur for that year. The rationale from the patients point of view is that you are getting more access to your doctor. The rationale for the doctor is that you get to limit your patient load -- and the insanity that comes with an unlimited patient load -- and in most cases make substantially more money.
Blim was quite reasonably pissed that he had been abandoned by the physician. (Actually he wasn't abandoned specifically; he just couldn't afford the annual fee. The effect is the same.)
I don't disagree with his reasoning for being pissed. That sucks. What I disagree with is some of the things he said in response to that. Some of them are patently untrue; some of them just betray a misunderstanding about what makes doctors tick.
Anyway, let's get started:
First, Blim laments the difficulty in finding a new physician in the Boston area.
There must be primary care doctors who are not being overrun by patient demand, but in my quest to find a new doctor, I haven't come across any with good track records in Boston that are not.
There are a lot of reasons why my friend and I have lost our doctors. First, it would seem pretty obvious that some doctors, particularly primary care doctors, would like to make more money. The average salary for an internist in 2005, according to the US Department of Labor, was $166,000, while surgeons, for instance, made $282,000. My now former family doctor and his new partner plan to serve only 800 patients at a time. As minimum annual membership in the practice costs $3500, this means that they begin each year with $2.8 million in income from their patients that is in addition to insurance reimbursements they will receive for services rendered. Clearly, money is an important motivation.
(For the record, it should be noted that the federal government limits the number of doctors that can be trained, and the medical profession has not founded new medical faculties that could produce more doctors. As the number of doctors has actually declined 17% since 1983, according to the federal government, this would seem to be an odd set of decisions given the rising demand for medical care.) (Emphasis mine.)
He really isn't specific as to which government policy is limiting the number of doctors, but I am frankly curious about which one he is talking about it. I am not aware of any federal policies limiting the number of doctors trained.
What has reduced the number of doctors in this country over the past 20 years is not a government quota, but rather that medicine has become an unpleasant job to have. Working hours have gotten ridiculous, family lives contracted, medical school loans exorbidant, paperwork Byzantine, and malpractice premiums completely unacceptable; and you work through all of those things so that some day you may have the considerable honor of being sued by the people you were trying to help.
The government isn't why there are fewer doctors. There are fewer doctors because many people are deciding that no amount of money will make medicine worth it.
This is because our health is so valuable to us that we will seek as much care possible because we can never tell what is enough. The more opportunities that are offered, the more care we seek. As our demand for care increases, more care is offered.
Here are a few examples of how our consumption of medical care is growing. In 2004, according to the Centers for Disease Control, Americans made 1 billion doctor visits, and the rate of increases in doctor visits is running about three times the rate of our population growth. We made 35 million visits to the hospital in 2004, and the number of stays is growing by about 3% a year.
Services such as diagnostic radiology and commodities such as prescription drugs are growing much faster, both in quantity and cost. Radiology billings are increasing at the rate of 20% a year, hitting $100 billion in 2006. Americans now consume an average of 11 drug prescriptions yearly, and their costs are rising faster than the rate of inflation.
We spent $2 trillion on health care in 2005, a figure that amounts to 16% of our gross domestic product. By 2015, we will be spending $4 trillion a year, thus devoting 20% of our gross domestic product to health care.
We are definitely consuming more health care, even though we cannot determine how much health care is enough. (Emphasis mine.)
I dispute the notion that no amount of health care is ever enough.
Health care has a marginal utility like everything else. There is a point where the cost and the value received for that cost render additional health care valueless. Just from a practical point of view, could you visualize spending all day, every day in a doctor's office? No, right. Well then there is a point where you don't want anymore treatment.
I do not, however, dispute the notion that demand for health care is rising or that demand may be outstripping population growth. Blim just uses that to argue that all people want infinite health care, and that just isn't true.
Thus, there is surely unmet need, even in the face of galloping demand. This anomaly dissolves once one recognizes that there are many in America who don't get enough, and many who can't get enough. For people who just can't get enough, their desire for more is transforming health care into a "quality experience," from boutique medical practices to boutique wings of hospitals.
In the past, rank and wealth surely had its privileges in towns and cities where the rich could support society doctors and special hospital accommodations. The new, more numerous class of well paid managers and professionals that has grown up since World War II has recreated American health care as a growth industry which they run and from which they profit. They have pushed the medical profession to provide care as Henry Ford pushed his workers to make Fords. Doctors, once accorded elite status by virtue of their profession, now pursue entrepreneurial projects via boutiques, incorporation and refusing insurance. Many are converting medical practice into a business model.
Even as some doctors rebel, escape, or go out their own in some out of the way place, others like the load-reducer looking for sanity for himself and better service for his patients, are becoming cogs in the wheel of large vertically integrated firms. They refer clients to a capital-intensive medical machine run by managers and doctors with profit-based business plans. Every hospital caught up in the race believes that it will soak up the growing demand by providing an ever growing supply of machines, beds, day surgeries, and importantly innovative cures for the very sick.
The assumption behind this set of statements is that the primary design of hospitals in providing "boutique" or expensive care is to make additional profit.
I got news for you. The only way that hospitals stay in business is by providing expensive care to some to pay for the care they give at a loss to others. The reason: the government doesn't reimburse what the care actually costs. The hospitals have to make that money somewhere.
Whereas Blim sees providing expensive "quality experience" -- incidentally, when did that become bad? -- as robbing other patients of care they deserve, I see it as absolutely necessary for hospital solvency. You want to fix that; get your state government to jack up Medicare reimbursement.
As the supply grows, so in turn does demand once more, fed by our unquenchable desire for more health and more well being. We return once again to the question: What is enough?
I don't know quite what to say about this pernicious brand of Keynesianism, but like what I said about marginal utility supply does not create its own demand. There is a point where no amount of supply will increase what people want or need.
And by the way, I thought he was just mad about the limited supply? Isn't it a good thing when hospitals expand to meet the demand?
Third, self-preservation being keenly desired by many does not necessarily encourage rational choices. To the question of what is enough, for many, the answer is simply the egoistic reply of what is best for them.
Our two practitioners, like us, are struggling to answer the same question in their ethically loosened and bureaucratized world. Their choices - one to ration care by making it expensive, and the other to ration care by eliminating patients - are the unfortunate products of a system incapable of rationalizing itself.
When we think of national health insurance, I believe that we think largely of satisfying the unmet demands of a near majority of Americans for quality medical care. However, we often fail to realize that any national health system will come to pass as a descendant of the one we have now, one in which the question of what is enough is answered by an anxious, insatiable demand for care in an environment of relative indifference to the needs of others. As so often happens in America, it is hard to note the suffering of others at the same time resources are expanding for the things that other individuals value.
A new national system must not only provide medical care equitably for the first time in American history, but it also must develop a collective answer to the question of what is enough. It involves answering the practical question of how much of our national income we want to devote to medical care as against other goods and services. It also involves re-setting the moral terrain through collective agreement based upon an ongoing investigation of what care is necessary for a decent life.
With respect to egotism and "what is best for them," I guess this is where Blim and I differ ethically. I do not find the physicians who choose to go into boutique medicine because they want to have a life ethically reprehensible nor do I find hospitals trying to remain solvent guilty of corporate greed. If no doctors managed to find a way to balance their professional and personal lives, we would have less doctors not more because less people would choose medicine. If no hospitals found ways to pay for pro bono medicine, we would have less equitable care not more equitable.
"What is best for them" -- both doctors and hospitals -- is not only their right to define, it is a public good that they define it and seek it.
With respect to "a collective answer to the question of what is enough," neither Blim nor I nor anyone else can decide what is enough for a particular individual. Health does not work that way.
And I can absolutely guarantee that if we as a society decide to instruct people as to what is enough it will not result in a freer, healthier society with no boutique medical practices. It will result in a society where his physician can tell him that he can't have that particular treatment because a two-bit bureaucrat decided he didn't need it. A society where no doctor can choose to have a boutique practice is also a society in horrible danger of having no doctors whatsoever.
Collective answers always result in the tyranny of the majority.
I understand Blim's frustraction with medicine. Medicine as a system is broken. However, I will always reject people who say "there aught to be a law!" or "people should just be better to one another...we should make them better!" when they encounter something they find reprehensible.
There is no reason to expect a collective answer to the problem of health will be any more effective than the collective answer to the problem of wealth, and we have the last century of history to show that the problem of wealth did not respond well to collectivist answers.
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I tend to agree with your skeptical attitude about the limits of what you call "collectivist answers," but still think that in order to provide universal access to needed healthcare, some degree of "collectivism" is necessary. And if this is accepted, then there must be some limits imposed on what range of healthcare "services" are to be universally available. Health sevices research has established, quite convincingly I think, that people's appetite for healthcare doesn't conform to familiar "laws" about supply and demand. Health seems to hold a different place in the scheme of human valuation than most commodities, and most people seem never to reach a point where they have enough health, let alone a surplus.
I dispute that, but I also don't know nearly enough about the subject, so I would be interested in hearing what research specifically you are referring to.
My instinct on economics matters -- having studied the history of economics much more than its first principles -- is that every time some one says "that commodity just doesn't behave like the others," someone comes along later and proves that it does.
It happened to Henry George when he argued that land was special -- it wasn't. It happened when the monetarists showed that money obeys the same laws as any other commodity.
Health care is not a special commodity. Don't believe me? Look at food. Food is absolutely essential to human life. In this way, it would be easy to argue that like health care it should follow special rules. It doesn't. It is a commodity like everything else.
Not knowing the research, I am sure that counter-arguments can be made -- very reasonable ones at that. But my knowledge of economic history leads me to believe that everything is a commodity the conforms economic laws. Health care is no different.
The only way to improve health care is to ration it somehow. No one wants to admit that dirty secret. You can do this by limiting patients, increasing costs or doing something like Canada does an put many treatments on a waiting list and outright rationing them on a more egalitarian playing field.
But the doctors are really left out in all this. They are overworked and that leads to correspondingly worse health care.
Jake -
It's been years since I actually studied the economics of healthcare, and my memory is too gappy to permit confident reference to specific books and articles. But you might start with early assessments of the British NHS -- planners seriously underestimated the level of usage because they didn't foresee how expanding supplies would stimulate expanding demands. They haven't yet found a point where consumers are "satiated."
You might also consider how the marketing departments of pharmaceutical and medical device manufacturers have exploited the malleability of "health seeking behavior," (i.e., demand for healthcare services) even persuading the public (not to mention many healthcare providers) of the existence of hitherto unknown medical maladies when they had ready to hand "therapeutic" agents/devices. If somebody offers a "cure," people will convince themselves that they are suffering from the "disease."
My experience is that doctors themselves are creating more demand for medical services of all kinds, and especially referrals to medical specialists.
Why should one borderline PSA level reading result in immediate referral to a urologist? Shouldn't the primary physician know that the urologist will do nothing further until 2 or 3 abnormal levels are found after several months?
Why should the ER suturing of a lacerated finger result in immediate referral to a plastic surgeon specializing in hand injuries, when the primary physician is perfectly capable of evaluating the progress of healing, which is all the specialist did?
Is it really necessary to send every asymptomatic person who turns 65 for evaluations of peripheral circulation and ultrasound checks for aneurysms?
Most members of the general public get the services that are recommended by their primary physician. They tend to trust his/her judgment and don't have the background information to tell whether the service is actually needed or not.
I just wanted to take a minute to respond to a few of the discussion points.
1. If anyone is responsible for limiting the availablility of medical practitoners, it appears to be the AMA. Here are a few links to articles (new and old) discussing concerted AMA efforts to depress the number of medical doctors trained in the US. This appears to be a self-interested move to preserve the very high wages of medical professionals.
http://www.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm
http://query.nytimes.com/gst/fullpage.html?sec=health&res=9A0DE4DE123BF…
http://en.wikipedia.org/wiki/American_Medical_Association#Criticisms
2. Jake, I agree with your assertion that there is nothing inherently unethical about boutique doctors or hospitals. However, I think your dismissal of a collective solution to an obviously fatally broken medical system is shortsighted. In fact, I think we, the people paying the salaries of all involved, should think carefully and come up with a collective (politically implemented) solution to restrain costs and improve efficiency. This would include some changes you allude to such as improving Medicare to cover real costs and promote preventitive over interventional care. I also think it will have to include some collective governance/rationing of available resources. Unless you are fabulously rich, two bit bureaucrats at insurance companies already decide what procedures are available to you assuming you are fortunate enough to even have insurance. However, their interest is in their companies bottom line, not in promoting good outcomes for patients (or doctors). I do agree that doctors should always be free to charge more for boutique/extra services, assuming that people are willing to pay out of pocket for these extra (i.e. non-necessary) items.
3. You are correct that demand for healthcare services is saturable at some theoretical point, but the original post contained a slightly different (and very important) point. Blum states "we will seek as much care possible because we can never tell what is enough." In other words, medical professionals are in possession of priviledged information relative to patients. The situation is much the same with your car mechanic (assuming you are not knowledgeable about cars). If your car is not working and are told that you need a new alternator/brakes/etc you are likely to simply believe the mechanic, having few viable alternatives. Similarly if your doctor tells you to see a specialist or undergo a questionably useful procedure you are not likely to decline. This is especially true since you have relatively little financial interest in what happens - you pay your insurance bill either way.
Interesting discussion...and all have valid points. I can state unequivocably, after practice medicine for 30 years, that we utilize far too much "medical care" in America. The experiments in socialized, universal care run by the government in Canada and the UK reveal the problems with such a system, since money restrictions drive the medical engine, resulting in rationing by delay and denial. On the other hand, the relative unfettered system in America produces an alarming increase in costs as all parties (patients and medical providers) attempt to maximize access to care and utilization of resources in an ever increasing and expanding consumption of "care".
And in the US, we don't want to follow good, common sense matters of diet and living. We don't want to diminish our fat intake, we want a pill to block its absorption. We don't want to stop smoking, we want annual chest Xrays to catch our cancer at the early stages. We don't want to exercise, we want to watch TV and then get liposuction.
The main problem from my standpoint is:(1)a complete lack of scientific examination of cost/benefit analyses of our procedures, medications, and therapies; and (2) society's soul searching attemt to answer the incredibly difficult issue of the value to society of any one person's life. Can we afford any and every new treatment if the cost to improve or even save one life is $500,000 or $1 Million or whatever. My life may be invaluable to me but from a societal standpoint, there is a limit on its value........no matter how difficult it may be to arrive a such decision.
We have two and in my mind only two choices: we can intelligently adjust/limit/ration our medical therapies with a careful attention to the cost/benefit to society; or we can do what Canada et al do and adjust/limit/ration by virtue of beauratic decree and political whimsy. America cannot afford to continue with the voracious appetite we seem to have developed for all things "health care" related.
Things that are necessary for human life behave just like other commodities - until there isn't enough of them. Then we treat them differently.
It doesn't matter how scarce Ming vases become, people aren't going to riot in the streets and murder their neighbors to get them. Cut off the food supply to a major city and watch what happens.
"The government isn't why there are fewer doctors. There are fewer doctors because many people are deciding that no amount of money will make medicine worth it."
Which is exactly why I left medicine. I could have a six figure income or I could have my soul and my family. I think I made the right choice.
As far as health care rationing, I've always said it should be left up to the doctors. It's called triage--the ones who can be helped are given priority and the ones who can't we let go. Instead, the ones who are going to die anyway are given a painful, lonely, $250k ICU death and the ones who can be helped are left without medical care until they get to where they're going to die anyway (then they get the ICU bed too).
Our health care system is broken.
"The experiments in socialized, universal care run by the government in Canada and the UK reveal the problems with such a system, since money restrictions drive the medical engine, resulting in rationing by delay and denial." So says
kelvin contreary MD.
Delay and denial? not in my experience in Canada. Though one has to admit that there are occasions when the health systems fails, of which there are examples in every country on the planet and which suggest a cause other than "money restrictions".
What I find most disturbing about the entire exercise - and this is part and parcel of who you are - is that the U.S.A. will forever be a country of "ME", and not of "US".
The idea behind health care that is universal is "US" as a society, as members of something larger than an assortment of individuals. Whereas the driving force in American everything appears to be "ME first and foremost". Which certainly precludes even a rational discussion of the possibility of a universal system.
Have you people never thought about the ethical lapse that condones medicine first and foremost for profit? That accepts that insurance companies weed out those most in need of coverage precisely because they will eat into that profit?
I too just lost my doctor to boutique-ism. And I am sorry, but the reason they go boutique is greed. My doctor is going to get $900K/year without doing any work. I already had conceded to using a physician's assistant most of the time rather than the doctor himself (I think I have seen him 3 times in 5 years), but now this? The reason that there aren't more family doctors is due to the fact:
that there are the same number of medical schools now as there were 20 years ago, but an aging population;
that people want to go into specialties rather than general medicine because there is more money;
that a lot of doctors these days feel that they are entitled to BMWs, Mercedes et al rather than just making a good living and doing some good in the world (while I agree that if you put that much work into studying that you should make more money, but the average salary in the country is about $50K/year, why should they need to earn 4, 5, and sometimes more than 10 times that in a year, if it is medical school bills, let's get subsidies for those willing to work in areas that need doctors, but you don't see teachers even getting paid $50K/year in a lot of places and they have more education than average as well;
that there needs to be more control on whethere someone can file a malpractice suit while still making sure patients get quality care;
Go ahead, limit the number of patients you see, I can respect that, but to go boutique so you can do that while earning hundreds of thousands of dollars while some of your patients go untreated? That is callous and supposedly not what the profession of medicine is supposed to be about. If doctors want the respect of yore, then they should be charging equivalently and not be all about the money, don't comply with pushing unnecessary drugs and tests that up medical costs, help get others through medical school. Basically we are going to need to go to universal health care with medical education subsidized by the government where we pay for someone to go to medical school and then, like the military, they have to work it off.
Meg your ignorance concerning the economic sacrifice needed to become a physician is blatantly apparent in your naive comments. You sound like a socialist if not a communist.
How dare you dictate to physicians what they may earn? Aside from the poor business decision to become a doctor do you have any understanding of the additional risks we take upon ourselves and our families. We are exposed to virulence of all kinds(any words you are not familiar with you can look up yourself, I am not going to give you any free medical schooling), we are exposed to greedy attorneys and patients as yourself who feel entitled to our hard earned knowledge and skill. Do you think free or cheap health-care is your right? Show me the in our Constitution where it says you are entitled to free health-care or even cheap health-care. Our constitution is not the Marx Manifesto. It is a capitalist Document for a capitalist society. After dealing with entitled whining patients as yourself I have come to the conclusion that health-care should be strictly treated as a commodity just like you treat the plumbing industry. We want to get paid like the plumber, that is now. Also we would love to make as much as the plumber. Get my point? I doubt it. Why don't you got to college for four years pass lots of extremely difficult tests with GPAs 3.8 to 4.0. Take the MCAT, get into med school for four more years of earning nothing. Go to residency for four to six years earning under minimum wage for he time you put in and then come out and open a practice with large overhead, employee health plans, malpractice insurance and so on. Then I would love to hear your tune. I know by the sound of your whining you will not take up my challenge because you are not smart enough or because you just don't have the guts and fortitude it takes to become a physician. Better yet go to Cuba and be a doctor there, you will love it!