Why are they separate?

March 25, 2007

I am interested in a lot of things and I have many hobbies.  It’s an adverse effect of loving learning for its own sake and it leads to the familiar label: jack of all trades, master of none.  And so it is with medicine.  I do not know where I belong, and I feel torn between the worlds of medicine, law, and business.  That they often overlap should come as some conciliation, but it just muddies the issue for me.

So what is one to do?  I try to seek the advice of people I think are learned.   I am trying to decide whether or not to become an MD, MD/JD, or an MD/MBA.  I have a relative who works in the State department.  He’s as sharp as they come, and has the enviable life of traveling to a new country every three years to learn their language, represent the US, and manage the affairs of foreign relations and immigration (as I understand it).  He comes from physician stock so he is no stranger to the world I am entering.  He has an MBA and he has many smart friends with JDs.  He seemed like a logical person to ask.

But within the first few moments of speaking with him, I heard so much that betrayed that impression.  Why do people think that it is “okay” for physicians to work for less and less pay because medicine is so expensive?  How can they keep a straight face when saying, “Well it’s one of the qualities of a physician that no matter what the conditions, no matter the pay, that they are healers and will help people”?  Why do people think that because my future livelihood is invaluable means that they can strip away its monetary value?  Shouldn’t it be the opposite?

To all of those that say, “Even if you are payed less in salary, there are other benefits such as the gratitude of your patients and that is a sort of payment”, I ask you: why should they be separate?  When I pay someone to fix my car and they do a fantastic job, I am grateful AND I pay them what they are worth.  Why, in medicine, do you think it’s okay that they are separate?


The Health Care Debate

January 28, 2007

This has been an interesting week in the blogosphere. The debate over Health Care, whether it should be universal, whether it is a right, and how or why we would strive to enact it has been healthy. I’m incredibly interested in this and have been reading as much as I can. What follows is a synopsis of the debate as I have seen it. Throughout, something has not been sitting well with me, and that I finally figured it out is why I’ve brought these excerpts together. My conclusion is at the end.

Kevin M.D. posted this under the heading “Health Care is Absolutely Not a Right.” The comments that follow are fascinating, and I would encourage everyone to read through them.

This is the fundamental philosophical difference between what I (and others) believe and the stance of the single-payer supporters. Thanks GruntDoc for linking to the money quote:

As with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call “medical care” a right will merely enslave the doctors and thus destroy the quality of medical care in this country, as socialized medicine has done around the world . . .

The debate that followed in the comments circled around the EMTALA law, which mandates that any hospital must accept emergency medical cases, regardless of ability to pay. Hospitals abide by this law at considerable loss because the governement has threatened to remove funding for any hospital that does not. This would mean loss of Medicare, Medicaid, etc. One poster, Okulus, had the best comment:

In my view EMTALA is bad law. It mandates services under the threat of withdrawal of funding for unrelated services, which is extortion, particularly given that the taxpayers are providing that funding. (No different than threatening to take away a state’s allocation for highway subsidies if that state fails to comply with an unfunded mandate regarding education). Certainly I have a right to vote for candidates who want to repeal EMTALA. But even if I didn’t, that does not make EMTALA any more a good law. And it doesn’t make expropriation of services a right.

So is health insurance a right? Of course not. It is neither a de facto nor de jure right. And neither is postal service or 911 ambulance service or sewage disposal. They are services, available to the public when the public chooses to pay for them, and the converse when not. Any one of them could be here today and gone tomorrow, unlike real rights, which are far more durable.

So with the link to Graham Azon’s blog as the “single-payer supporter,” he responded with a two-parter (1)(2). These excerpts are truncated, so for his full argument you should visit his site:

Honestly, I think many people in the media use “socialized medicine” as a scare term, a blanket term for any sort of “government” health care. If that’s how you’re using it, fine, but if you’re presenting information as policy arguments, you sound a little sophomoric if you use it incorrectly. (This is like referring to the rectum as “the poop chute.”)

Socialized medicine is what the UK has.

Socialized insurance is what Canada has.

“Pay or play” is an employer-based system, where employers either have to offer coverage, or contribute to a fund to provide coverage to the uninsured.


From where I’m standing, then, if we’re going to take care of the acutely ill, we might as well keep societal costs lower by preventing people from becoming acutely ill (or from developing the consequences of chronic illness). Am I crazy? Am I missing something here? You can’t tell me that our system makes sense in this way. We will allow an uninsured diabetic to go years without any preventive care, because lack of ability to pay, but once his foot becomes necrotic and he needs an amputation, and gets an ICU stay for becoming septic–oh well, let’s definitely pay for that!?

Look, if you have a problem with the “political feasibility” of single-payer, that’s fine, we can debate that. If you’re weary of allowing a government entity to set all health care reimbursement, that’s fine, we can debate that. But to stick your thumbs in your ears and ignore that we’re already ready to pay for emergency care, because of the consequences of the alternative is just stupid, plain and simple.

So, what’s your better solution?

So from all of this, it strikes me that people are either holding steadfast to their philosophy that no resource can be mandated as a right (as that necessarily limits the rights of those providing the service), or they are holding steadfast to their pragmatism (that leaving people with their injuries because they cannot pay is not something that we are comfortable with as a society, so let’s fix that). I like Graham’s challenge though: what is the better solution?

So here’s mine.

FUND EMTALA. The Emergency Treatment and Labor Law was enacted in 1986 as a response to the act of “patient-dumping” by hospitals. In essence, the statute:

  • imposes an affirmative obligation on the part of the hospital to provide a medical screening examination to determine whether an “emergency medical condition” exists;
  • imposes restrictions on transfers of persons who exhibit an “emergency medical condition” or are in active labor, which restrictions may or may not be limited to transfers made for economic reasons;
  • imposes an affirmative duty to institute treatment if an “emergency medical condition” does exist.

That last bullet point costs money. Lots of money. Where does it come from? EMTALA is an unfunded mandate, meaning that it was decided that providing medical care was so important that it required a law to be passed to ensure it, but not important enough to be supported financially. The weight of this law rests inapprpriately on the hospital, not where it belongs on the taxpayers whose interests are represented in Congress. Why would any hospital agree to this? The guillitoine of severed Medicare payments should they not comply.

Unless you run a hospital, why should you care? Imagine a hospital that is running without making a profit. They make enough money to cover all of their expenses and meet all of their salaries. Everything is only as expensive as it needs to be and all the prices charged are fair. If this hospital had to abide by EMTALA, it will begin to lose money. It’s options at this point are to ignore EMTALA (in which case it loses money anyway as the governemnt withdraws payments for patients on Medicare), go bankrupt and close (happens way more often than you think), or make up the loss by charging paying customers more.

I give you the $10 tylenol. Now we can debate the many factors for the rising costs of health care until we’re too dead for it to matter, but the fact that a hospital that abides by EMTALA must then overcharge paying customers is inescapable. It is also unfair. If you cannot pay for your own healthcare (and receive it anyway because of this law), then you are making healthcare more expensive for those that can pay. If this doesn’t happen, then the hospital closes and you’ve not only lost that resource, but you’ve stressed the remainging hospitals that now experience increased patient loads.

I give you a downward spiral. So for anyone that will ever need hospital care, this does matter. The solution seems pretty straightforward to me, and that is to reimburse the hospitals for their costs. It makes no sense to demand that hospitals pay for your service so that it is free to you. If we are as serious about giving everyone care in an emergency regardless of insurance as we claim to be, then that requires a serious sacrifice on our parts. Our taxes are going to increase. You will have, in effect, given universal accident insurance to the nation.

The details of payment can be left to the hospitals and lawyers to discuss, but the hospital should be able to demonstrate its expenses and the US government should send a check in the mail. So that’s my first solution: fund EMTALA.

Of course, what happens next would be interesting. If hospitals were able to do this and still saw all of the current cases in the ER, they would likely welcome the non-emergency cases that they currently detest. If the governement (and by that I mean all 300 million of us) were to see the bill, there would likely be some sticker shock. “We can’t afford to fund EMTALA,” we’d realize. “We’ve got to figure out a way to keep these non-emergency cases out of the ERs,” we’d decide. And it’s because we would likely be pushed into this future that I like Graham’s second point.

To paraphrase, emergency cases cost a lot of money, and these emergencies are sometimes the result of an uncontrolled chronic condition (amputation of a diabetic’s foot) that could have been prevented at a much lower cost. So if we’re going to have a funded EMTALA with effective universal accident insurance, wouldn’t the taxpayers save even more money with universal and comprehensive medical insurance?

I stumble with his conclusion. Not every American presents to the ER, and while providing preventative care for the person that does would save tax dollars, I can’t know which person’s preventative treatment to target. In other words, universal medical insurance has perfect sensitivity but poor specificity. It seems to me that any preventative measures should be specifically targeted and if that was truly cheaper the investment would be worthwhile.

Joe Paduda at Managed Care matters has a good point and I’ll let him have the last word. He’s absolutely right that we have to define our goals and these have to be in line with our principles. So in the interest of openness, I’ll be very specific about mine:

No one can claim a right to anyone’s service. It follows, then, that health care is not a right, but a want. It also follows that the weight of any proposed solution should fall on the backs of those who benefit (the tax payers) and not on the backs of those that provide it (hospitals, physicians).

No one can arbitrarily decide the worth of a service. By capping what a physician (lawyer, artist, whomever) can charge for his service, you are robbing him of his value and destroying the distinction between good and bad service by removing its incentive. It is for markets to decide what a service is worth, not governments.

I am open to (and would support) any program that successfully makes health care more accessible while not conflicting with these first principles. It remains to be seen if Single Payer is the solution to this, and I think everyone is going to be very interested with the results from the single-payer experiments in Main, Mass, Maryland, etc.

Joe Paduda’s last word at Managed Care Matters

What are we trying to accomplish with health care reform?

Lower costs today? A sustainable trend rate so care is affordable for the foreseeable future? Better outcomes, defined as healthier people and/or fewer avoidable deaths and/or higher levels of functionality? Coverage for all so no one goes without? Equitable reimbursement? Less interference in the doctor-patient relationship? Greater self-responsibility on the part of consumers? A reduced financial burden on employers, especially small ones and really big ones with lots of retirees? Ever healthier, longer-lived citizens?

All of the above?

My Health Care Education: Physician Antitrust

January 13, 2007

Over this winter break, I went to my Uncle Neurphysiologist for some advice. As you may have gleaned from this story, I’m about ready to give up on the idea of practicing medicine and to start devoting my life to changing the laws under which physicians are forced to operate. So over dinner I tell him about everything I’ve been reading about malpractice courts, medicare reimbursement, HMOs, and so on. Then he tells me something that I could hardly believe:

“You know last week a group of physicians were in an online discussion forum that was meant for something or other, and the conversation inevitably went to those issues you’ve just described. A colleague of mine said that, ‘it was ridiculous that I am paid $$ for a procedure by XX company and $ for the same procedure by company X.” We all voiced similar complaints until a lawyer that was present in the forum and representing the hospital told us that we couldn’t talk about the prices of our services.”

“Why not?”

“He said it was against the FTC’s Antitrust laws.”

“How the hell is a room full of physicians knowing what each other makes violating antitrust?”

“You’d have to ask him.”

I couldn’t really believe it, but I had to know for sure. Since then I’ve been trying to find more and today I have. Here are some excerpts:

“In the late 1970s, the Supreme Court decided the antitrust laws should apply to “professionals” such as lawyers and physicians. In 1993, lawyers at the FTC and the DOJ’s Antitrust Division made up a set of rules governing how physicians and other health care providers should run their businesses. To avoid antitrust charges, independent physicians had to organize their practices according to a government-approved economic model. Experimentation or deviation from this model would subject doctors to criminal price-fixing charges on top of potential treble-damage civil lawsuits.”

The FTC and DOJ said strict rules were necessary to “protect competition” among physicians.”

“Each of these cases presents a similar scenario: A group of independent physicians band together to deal with the administrative and regulatory burdens imposed by managed care. The group negotiates contracts with various HMOs, PPOs, and employer-based plans. The payers soon become unhappy with their contracts—they think the doctors should have agreed to lower prices—and they petition the DOJ or FTC (but mostly the latter) to intervene. The FTC opens an investigation and demands the physician group turn over thousands of pages of documents at the group’s expense. Then without further investigation, the FTC tells the group to sign a “consent order” invalidating its existing contracts and restricting the group’s future ability to represent its members (in some cases, the group is disbanded altogether.) As a matter of FTC policy, the physicians are not afforded an opportunity to tell their side of the story.”

“In the health care market envisioned by antitrust regulators, physicians should “negotiate” contracts as individuals, never in a “coercive” group. Of course, no individual physician possesses any meaningful bargaining power when dealing with an HMO that represents thousands of buyers. That’s precisely the point, however: Competition, in the government’s view, means sellers accept whatever price the buyer offers, irrespective of the sellers’ costs or economic self-interest. In antitrust parlance, the buyers have an inalienable right to the “benefits of competition”, while the sellers are presumptive price-fixers eager to subvert the government’s carefully designed market scheme.”

“Both of these models shift risk from the insurer to the physician while simultaneously distorting the price paid by the ultimate consumer. It is illegal for consumers to know the true cost of health care and for the physicians to take any action that might enable services to be produced more efficiently. “

Read the full article by SM Oliva, President of Citizens for Voluntary Trade.

My Health Care Education: MDs Need Not Apply

January 6, 2007

Via Kevin MD, I find this article by the folks over at Health Care Matters.  The post is about a job description that is filled with opportunities to shape the way that technology is used and made to be of the most use to those in health care, and being qualified for it (appearently) disqualifies you.  Read on:

When I inquired about this role with the large national firm’s recruiter retained by the healthcare system to conduct the search, I received an initial positive response on my voice mail the very next morning. Then, I found I could not contact the recruiter for several days, only getting voicemail, and the recruiter was not returning my calls.

I finally reached the recruiter yesterday, and the the response I received was unexpected and disappointing: “the organization was looking for a nurse and they would not even talk to a physician.”


My Health Care Education: Links 01

January 5, 2007

Thank you, Google Reader, for all of these presents.

To begin my education in the Health Care of these United States, I’ve traveled around trying to find the blogs that are already writing about these topics.  Here are a few:

Kevin MD covers the daily news of malpractice, health care reform, etc.  He doesn’t offer much commentary, but he makes up for it with access (there is little that he misses).  He’s like medicine’s Matt Drudge.

Joe Paduda over at Managed Care Matters is a regular read these days.  His writing is great.  This article about Senator Wyden’s proposal to fix health care caught my attention.  I’m also paying close attention to his “Essential Blog Reads” in the right-hand column.

The Health Care Blog: Everything You Wanted to Know About Health Care but Were Afraid to Ask.  I liked this recent synopsis on how to fix the problem of the uninsured.

Consumerism Commentary just started a series of posts about getting his MBA online with the University of Pheonix.  While I’m thinking about an MBA, I have to wonder whether I’ll go brick and mortar or straight to the series of tubes.

A Stitch in Haste has this whirlwind post covering many of the topics that concern opponents of Universal Health Care (and should concern the supporters).  Not a lot of pro/con balanced argument, but a quick survey of the topics nonetheless.

Things to Come

December 27, 2006

A few things are going to start popping up here. First, I’m going to begin studying for the USMLE come Jan 4th and I plan on keeping everyone who cares up to date on how I select review books, choose a plan of attack, and generally fare over the next two months with a “How to I Prepared for the USMLE” series.

Second, the medico-economics of health care continues to fascinate/infuriate me. I’m a Pessimistic Kantian, so if I’m going to walk around wishing that someone had already written a personal guide to explain this to me then my ethic dictates that I have to make one myself (since I wish some future-self had saved me the trouble). I’ll be gathering what I can online and bringing it here for your easy consumption as “My Health Care Education.”

Third (and a sensitive topic for those in the Caribbean), I am applying for transfer to a US medical school in March with the possibility of interviewing in June/July of 2007. This will be interesting for me because 1) I have no idea how to go about it as information for prospective transfers isn’t exactly advertised or accessible at SGU, 2) I may end up producing a helpful guide while publicly failing myself, and 3) I’ll get to address some of the reasons why I think transferring is an important step for me and whether that contradicts what I’ve written (a guide about how great SGU is) and said (with MedScape) previously. “Transferring from a Caribbean Medical School” should be interesting.

But that all starts in a week. In the meantime, I’d like to draw your attention to the updated “SGU Guides.” Whereas before it was simply a link to the Welcome to Grenada site, it now has a menu of things I’ve written that don’t fit easily into the longer version but still deserve a home. I hope it helps.

Cheers for now, topher.

My Problems with the Business of Medicine

December 26, 2006

My family reads what I write here and I struggle sometimes with that knowledge. Exactly how free am I to write stupid things and reveal embarrassing secrets? I handle this in the style of our times: denial. Sometimes, though, I am reminded that they are out there in Al Gore’s internet when they send me their opinions about my writing. After receiving the following email, I realized that instead of writing about a small thought that belongs in a larger argument, I should have just written the whole thing.

Where did you get the idea that Universal Health Care meant that the Doctor was not compensated for his services? My understanding is that you (the Doctor) would be compensated for your services, at a possibly reduced rate the same as Medicare and Medicaid compensate the Doctors. While I know this is not the full amount, you are under no obligation to accept the patient in the first place. There are Doctors all over this country that do not accept Medicare patients for this exact reason. However, if you hope to have Hospital privileges, the Hospital’s policy will trump yours.

Just curious. Mom.
For some background, she is responding to my post No Right to Health Care. I wrote it because the more I read about Medicare, Medicaid, and the “funding” of physician services (hat tips to KevinMD) the more frustrated I get. It’s been happening a lot lately. It’s the frustration of having to enter a system that (in my mind) shouldn’t be allowed to function the way that it does. Supply and Demand curveI’m a strong believer in markets. I believe in the meeting of supply, demand, and value complete with a fulminate crush on Dagny Taggart. These days, I’m frustrated over that fact that the value of the service that a physician provides is not strongly coupled to what he can charge, and instead his recourse is to make his salary through volume. I started writing this during exams, so in that spirit I offer you a medico-economic vignette. Read the rest of this entry »