American Healthcare crisis as seen from a doctor's perspective

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Apr 21, 2004
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There have been many threads on CFC about the healthcare crisis in the US, but little in the way of any straightforward solutions. Most people posting are "civilians" and have only casual understanding of the problem. What you have all seen is just the tip of the iceberg, as far as I'm concerned, when it comes to American medical care delivery.

As a doctor, I'm in a unique position to see the inherent problems in the system, which I have been observing for some time. My opinions are not necessarily shared by all doctors, but I think I have a better perspective than most. My career has been difficult from the start. In a subculture of aristocratic legacy, I do not come from a family of doctors. I did not attend a world-class medical school or receive post-graduate training in the finest academic hospital. This has forced me to settle for lesser positions where I can observe problems. I have not had a comfortable existence in this profession so I can see how it is deficient.

Below is a summary of what I think are the salient problems.

I.

The first problem is one that everyone is most aware of -- the scarcity of medical care due to lack of adequate insurance. In the US, unlike nearly all other developed nations, medical care is not an entitlement. The exceptions include Medicare, which is available for the elderly, and Medicaid, which is available to the poor. This leaves the overwhelming majority of the population, who stand to benefit the most by preventive care, to fend for themselves. They must obtain medical care either by paying out of their pocket, or by buying private medical insurance. All of these are prohibitively expensive for a large fraction of the population. Even Medicare and Medicaid do not adequately reimburse, as those departments are not run by doctors but bureaucrats who know nothing of medicine. What tends to happen is that most people forego preventive medical care, even if they are insured, because the cost is prohibitive. This leaves them at the mercy of chronic diseases later in life, where they drain the government's treasury from Medicare. Even though the US spends the most on medical care, it has the worst morbidity and mortality statistics of all developed nations. In my opinion, the only way to solve this problem is to have universal health insurance, where all who pay taxes are entitled to it, just as it is done in most developed nations. People will no longer avoid doctor visits for preventive care because of the expense, and this will amount to reducing overall healthcare expenditure.

II.

A second and unseen problem is the tendency by the American medical establishment to allow sloppy medical care to continue without scrutiny. One often hears of malpractice lawsuits with large verdicts, but this does not appear to have had any impact, as they continue. Part of the reason for this is that there is a greater temptation by patients to sue the doctor, and gain monetary compensation, than to appeal to the State medical board for discipline. In addition, the state medical boards, like the medical establishment, have a culture of avoiding disreputing their own. Once a candidate enters medical school, it is virtually impossible to leave it, because the school will do everything in its power to make sure he finishes it. Most medical schools tend to inflate grades. This is all to foster an image of excellence. As a result, there is a large population of bad doctors circulating who continue practicing, because everyone insulates them. Time and again I see sloppy or inept physicians who go on doing more harm to patients without consequence. This will continue so long as doctors realize that there is no oversight to their actions.


III.

Third is the pervasiveness of greed and the vested interests of those who appeal to greed in American medical care, such as pharmaceutical corporations, insurance companies, and medical device manufacturers. These are the entities most responsible for delaying universal medical care in the US. As long as medical care is privatized, they can continue to charge exhorbitant fees for their products and services. They recognize that the more people are given choice to opt for a government sponsored program, the less they will have a market for their expensive goods. They go to great lengths to send lobbyists to Washington, and who try to convince the public to act against their own self-interests. They use arguments that try to scare the average person into believing that they will lose control over their medical care, as if they ever had much control to begin with.
 
Canada first started into universal health care in Saskatchewan, where the government set up an insurance program and the Federal government chipped in half the costs. Not just the local medical establishment, but the medical establishment of North America fought this pretty bitterly. They feared that it would spread, and indeed, the entire country adopted the system. It didn't spread south. How much resistance would your profession put up to something that would likely lower their pay? How much resistance would you get from those who make a fortune doing redundant jobs in insurance?
 
And if it's part of employee benefits that means the money magically appears out of thin air?
 
And if it's part of employee benefits that means the money magically appears out of thin air?
Amen to that. My every-other-week deduction from my paycheck for my family of 5 was going to DOUBLE this year (and this was their HMO plan). So, I opted for cheaper plan. And I work for an employer that is, generally speaking, considered to be treat their employees well.
 
No, but it is not the same as someone buying their own individual insurance package.

Well, it's not very different. The biggest difference is that it's not a taxable benefit, and employees get the benefit of purchasing into an insurance pool. At best, it's almost a question of semantics. At worst, it hurts employee mobility
 
Well written OP.

I think on the third point there is still always a bottom line, even if health care is fully state subsidized. I have to ask What would be the economic effect of full subsidies? Would health care technology continue to improve? Would it improve as fast?

I think the theory on the free market is that innovation proceeds faster in a free market than in a socialist system. An as innovation proceeds, some technologies become cheaper and more affordable to mass produce on a scale that the average citizen gets some. I lean towards this point.

I think I can agree with the third point if one is talking about lobbying via campaign contributions, as political corruption helps no one but the corrupt.

#2 sounds like a symptom of too few doctors, too many patients. I suspect if the government made it easier to pursue the training (training subsidies, possibly through internships through mllitary hospitals without service obligation), so the population of trained professional was larger, then it'd be more affordable to cull the bad apples.

I think #1 is mitigatable through simply decentralizing the training when it comes to preventive care level of medicine. If more professionals can be made at that level of training, then it'd free MD's from that role (so they can stick to the more specialized treatments). This is kind of the trend with Physician Assistants.
 
Well written OP.

I think on the third point there is still always a bottom line, even if health care is fully state subsidized. I have to ask What would be the economic effect of full subsidies? Would health care technology continue to improve? Would it improve as fast?

I think the theory on the free market is that innovation proceeds faster in a free market than in a socialist system. An as innovation proceeds, some technologies become cheaper and more affordable to mass produce on a scale that the average citizen gets some. I lean towards this point.

While many advances in medicine come from private sources, many also come from government and foreign sources. So there is a good chance that advances would slow, but not stop.

But the effect on public health would be offset because of the generally improved level of health in the nation.

I think I can agree with the third point if one is talking about lobbying via campaign contributions, as political corruption helps no one but the corrupt.

#2 sounds like a symptom of too few doctors, too many patients. I suspect if the government made it easier to pursue the training (training subsidies, possibly through internships through mllitary hospitals without service obligation), so the population of trained professional was larger, then it'd be more affordable to cull the bad apples.

The health care industry itself is responsible for any shortages of professionals. It has long been a priority of the AMA.

As for the other point, the AMA, state boards, doctors themselves, and the insurance industry have long been colluding in protecting doctors from the consequences of their actions. This practice worked well for decades. And is only breaking down in recent years because of the large cash awards some juries are handing out. This is the impetus behind tort reform and malpractice reform; they want to go back to the comfortable little niche where doctors are not responsible for their screwups.


I think #1 is mitigatable through simply decentralizing the training when it comes to preventive care level of medicine. If more professionals can be made at that level of training, then it'd free MD's from that role (so they can stick to the more specialized treatments). This is kind of the trend with Physician Assistants.

We need far less costly medical schools or subsidies for medical students to increase the numbers and improve the level of training. If medical school was a more viable option for more students, there would be more docs.
 
Third is the pervasiveness of greed and the vested interests of those who appeal to greed in American medical care, such as pharmaceutical corporations, insurance companies, and medical device manufacturers. These are the entities most responsible for delaying universal medical care in the US. As long as medical care is privatized, they can continue to charge exhorbitant fees for their products and services. They recognize that the more people are given choice to opt for a government sponsored program, the less they will have a market for their expensive goods. They go to great lengths to send lobbyists to Washington, and who try to convince the public to act against their own self-interests. They use arguments that try to scare the average person into believing that they will lose control over their medical care, as if they ever had much control to begin with.
Isn't it the profit motive that invents all of your drugs????

The first problem is one that everyone is most aware of -- the scarcity of medical care due to lack of adequate insurance. In the US, unlike nearly all other developed nations, medical care is not an entitlement. The exceptions include Medicare, which is available for the elderly, and Medicaid, which is available to the poor. This leaves the overwhelming majority of the population, who stand to benefit the most by preventive care, to fend for themselves. They must obtain medical care either by paying out of their pocket, or by buying private medical insurance. All of these are prohibitively expensive for a large fraction of the population. Even Medicare and Medicaid do not adequately reimburse, as those departments are not run by doctors but bureaucrats who know nothing of medicine. What tends to happen is that most people forego preventive medical care, even if they are insured, because the cost is prohibitive. This leaves them at the mercy of chronic diseases later in life, where they drain the government's treasury from Medicare. Even though the US spends the most on medical care, it has the worst morbidity and mortality statistics of all developed nations. In my opinion, the only way to solve this problem is to have universal health insurance, where all who pay taxes are entitled to it, just as it is done in most developed nations. People will no longer avoid doctor visits for preventive care because of the expense, and this will amount to reducing overall healthcare expenditure.

I don't know. Paying higher taxes>=medical insuarnce. And preventive care is the reason we have 4 hour waiting times in Canada. I have a question. How long are waiting times in the States? Can I get hip surgery within 6 months? thank you.

A second and unseen problem is the tendency by the American medical establishment to allow sloppy medical care to continue without scrutiny. One often hears of malpractice lawsuits with large verdicts, but this does not appear to have had any impact, as they continue. Part of the reason for this is that there is a greater temptation by patients to sue the doctor, and gain monetary compensation, than to appeal to the State medical board for discipline. In addition, the state medical boards, like the medical establishment, have a culture of avoiding disreputing their own. Once a candidate enters medical school, it is virtually impossible to leave it, because the school will do everything in its power to make sure he finishes it. Most medical schools tend to inflate grades. This is all to foster an image of excellence. As a result, there is a large population of bad doctors circulating who continue practicing, because everyone insulates them. Time and again I see sloppy or inept physicians who go on doing more harm to patients without consequence. This will continue so long as doctors realize that there is no oversight to their actions.

If the government runs it this will get worse.

The health care industry itself is responsible for any shortages of professionals. It has long been a priority of the AMA.

Not to root for China but just want to point out that in China despite less medical professionals per capita the speed at which you get care is much faster. Of course, some people can't afford medical care.... It seems to me this is largely an issue of doctors 'working times. The ones who work more benefit more under private system.
But i think
 
As for the other point, the AMA, state boards, doctors themselves, and the insurance industry have long been colluding in protecting doctors from the consequences of their actions. This practice worked well for decades. And is only breaking down in recent years because of the large cash awards some juries are handing out. This is the impetus behind tort reform and malpractice reform; they want to go back to the comfortable little niche where doctors are not responsible for their screwups.

However, what if the doctor was NOT responsible for the screw up and was sued anyways?
 
Why would a Universal Health Insurance lead to a reduction in innovation? Especially if the hospitals still competed against each other; they'd be buying equipment in order to attract customers.

It's like saying that Saskatchewan's single-payer vehicle insurance has reduced innovation amongst mechanics and repair shops. I don't think it has.
 
Isn't it the profit motive that invents all of your drugs????

Not on earth, no. Many, yes, but there is a huge amount of public money in the pot.

I don't know. Paying higher taxes>=medical insuarnce. And preventive care is the reason we have 4 hour waiting times in Canada. I have a question. How long are waiting times in the States? Can I get hip surgery within 6 months? thank you.
Can you wait 9 hours in an emergency room to be told you have a minor infection in Canada despite having very good insurance? That happened to my sis a few months ago in the US.



If the government runs it this will get worse.

US health care is already worse than the health care of more than 20 nations with government controlled health care. And it's deteriorating rapidly.
 
The US healthcare system is known far and wide by how terribly it sucks.
As for the solution, there is no need to invent bicycle.

Indeed, I believe the solution was mentioned within 12 minutes.
 
just want to point out that in China despite less medical professionals per capita the speed at which you get care is much faster.

Yup. You'll be sure to receive treatment before things get out of hand.:yup:

Spoiler :
 
Well, it's not very different. The biggest difference is that it's not a taxable benefit, and employees get the benefit of purchasing into an insurance pool. At best, it's almost a question of semantics. At worst, it hurts employee mobility

No, it's an important distinction, because the bargaining power of a company with a million employees is much greater than the bargaining power of one of those employees.
 
Teeninvestor said:
Not to root for China but just want to point out that in China despite less medical professionals per capita the speed at which you get care is much faster. Of course, some people can't afford medical care.... It seems to me this is largely an issue of doctors 'working times. The ones who work more benefit more under private system.
What the hell doe the cost of medical care have anything to do with working times?

Gogf said:
No, it's an important distinction, because the bargaining power of a company with a million employees is much greater than the bargaining power of one of those employees.
You bargain with insurance companies?
 
So, insurance costs are really crazy in the US even though 60% of the population is getting such a huge bargaining advantage?
 
However, what if the doctor was NOT responsible for the screw up and was sued anyways?


How do you separate it? There are several things that can happen. Incompetence, accident, pure dumb luck. You have automobile insurance to cover you even if you were at the wheel but the accident something that you could not have avoided, like a kid running out from between cars that you couldn't possibly have seen in time to take action. Sometimes there is simply nothing a doctor could have done. But how do you prove that? So... insurance.







Why would a Universal Health Insurance lead to a reduction in innovation? Especially if the hospitals still competed against each other; they'd be buying equipment in order to attract customers.

It's like saying that Saskatchewan's single-payer vehicle insurance has reduced innovation amongst mechanics and repair shops. I don't think it has.


Yes, because one of the things that universal health care would bring is cost controls. And one of the ironies of the current system is that pharmaceutical companies and medical equipment companies have a lot of cash to play with.
 
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