These blog posts started months ago, with me questioning why exactly Universal Health Care was innately bad on Facebook and proceeding with me reading various analyses and articles on the issue. So the following blog posts are a summarization of my understanding of the issues at stake and an overview of the solutions that have made the most sense to me in my readings. I’m writing this for my benefit as well as anyone who would like a bigger picture view of the system and it’s flaws. I am organizing the posts so that I explore all the flaws first, and then some potential solutions that make sense to me, and I am trying to keep the posts to bite-sized chunks. I am of course, always open to discussion.
The Problems with Doctors
There have been a lot of words thrown around about the “fee for service” structure that we have in place – where a doctor’s income is based not on a salary but on each specific service they provide. A patient may be diagnosable with reasonable confidence based on one test, and multiple tests may not increase the confidence of the diagnosis at all, but the system is set up so that the doctor gets paid more for ordering more tests, the patient sees no extra cost (because insurance covers it all), and furthermore the doctor is seen as going above and beyond due diligence which protects him from malpractice lawsuits. A great number of analysts point out these three reasons as the main drivers behind the unneeded medical services provided each year (the 30% figure previously mentioned).
Fee-for-service is the immediate incentive that lawmakers hope to address. Doctors swear, of course, to only do what is best for the patient, and no doubt most intend to do only that. But the system has a built-in incentive to provide more services – which also has the side-effects of giving a doctor incentives to see more patients and spend less time with each to maximize the “effectiveness” of their time (and their income).
Patients have no problem with more taking more tests – from a non-medical point of view, more information can only be a good thing. And the cost of the tests is never known due to the insurance blinder, so it’s a win-win in that your doctor is better able to diagnose your problems while you don’t have to pay anything else. Except that tests – like MRI’s or CAT Scans – can cost thousands of dollars, and the more people who get them the more insurance premiums go up. Consumers aren’t able to link the two – the system does not provide any connectivity between more tests and higher premiums.
This is even worse in markets that are heavily saturated with healthcare providers. Certain analysts have surmised that in over-saturated markets there is a built-in market incentive for excess; because if one doctor won’t order the extra tests, surely another will. So a doctor is compelled to go above and beyond to keep his patients and thus is able to make a living in an otherwise very competitive market. It has been estimated that this can double overall medical costs for markets with this problem.
The hardest aspect of this issue to rectify is that more information does not increase a doctor’s ability to diagnose you – the extra information can many times be unnecessary to a diagnosis. But consumers don’t know this, and because they also see no connection between extra tests and rising premiums, they do not understand that excess is a bad thing. In reality, we want excess because it gives us peace of mind, assures us that doctors are solving all possible issues with our health.
This is where malpractice comes in – the issue of tort reform is another one thrown around in the political debates. America is a very litigious society and medical malpractice lawsuits abound – they are so troublesome that for healthcare providers often the biggest operating cost for providers is malpractice insurance. In these suits it must be shown that due diligence has been performed by a doctor, and if it has not been performed then settlements in the millions of dollars are not out of the ordinary. But what is due diligence? It’s a very nebulous idea, specifically in the realm of a specialized field like medicine. If a doctor does what he knows will give him the best diagnosis and reaches a confidence of 99% that someone does not have cancer but it turns out he was wrong, has he performed due diligence? To a trained medical person, the answer may be yes, but to a lay person this answer is often no – whatever could have been done should have been done, no matter the cost or unlikelihood of helping. And there is no real incentive to the doctor to not order the extra tests and do the extra procedures – he makes more money that way.
Once again, the system incentivizes excess: the doctor cannot do what would be necessary to reach a confident diagnosis, instead he must do every possible thing he can to ensure that there is no doubt left in his mind. We expect perfection from doctors, and if they fall short we sue them.