Getting better
Bala Ambati, who is an MD, takes a sober and well reasoned look at the healthcare debate on his site, Daylight’s Mark. He breaks out who has health care coverage; why or why not; where the potential cost savings are; where the ripoffs may be located and finally lists out the measures which, in his opinion, can really make health care system better.
Now, how would I go about deciding what to cut and how to save money and “bend the future cost curve”? I would rate behaviors & services on a scale of evil (which for this discussion I define as greed:utility ratio). So things that I’d like to see happen that I think would curb costs without degrading current or future quality of care would be:
1. Significant tort reform…
2. Assigning the cost burden of unnecessary or likely futile services to patients or their families . Eliminating television and direct to consumer pharmaceutical marketing (which all started only in the late 1990s) (drug company marketing is now about $57.5 billion annually, according to a PLOS study by Gagnon & Lexchin in 2008, which nearly equals the $58.8 billion spent in R&D by the drug industry. This would help reduce costs by allowing physicians breathing room to recommend older yet equally effective medications to their patients.
3. Breaking the oligopolies of health insurance coverage present in many states & regions. … Government could do a great service by jumpstarting the infrastructure to create such a true free market but it should not take over such a market.
4. Encouraging charity care: Lawyers can treat pro bono work as a tax deduction; hospitals treat charitable services (which are often overcharged in the first place) as a tax write-off and get income tax exemption for being nonprofits. Physicians currently have no such benefit.
5. Cost Transparency: … Patients are charged wildly different amounts, and quite often indigent patients get stuck with full charges while Medicare or large insurance company patients get charged much less due to contractual arrangements. This process is just insane…
6. Encourage innovation: Increasing tax credits for R&D, establishing prizes for translating discovery for big problems, and extending patent protection for new molecular entities while limiting patent extension for me-too drugs maneuvers turning Prozac into Sarafem or Wellbutrin into Zyban, would promote advances in drug and device development and maintain America’s edge in science & technology.
Here’s his take on what is good and bad in the health care proposals.
Is the likely Democratic plan a good idea? I have to say no. Expanding Medicare & Medicaid for all (which is basically what it boils down) opens the door to government price controls, which will devolve into wait-lists, poor quality personnel, salaried staff (who by definition are incentivized to give minimum effort), increasing physician refusal to see Medicare & Medicaid patients, and underinvestment in research and facilities (see Great Britain, and Canada)….
Which of the plans bouncing around have useful ideas? I think the Daschle-Dole idea of giving tax credits to all who pay income or payroll taxes to purchase health care is a good thing – equalizing the playing field of those with employer health coverage and those without. We want health insurance to be available to all contributing or productive members of society, but we don’t want free health care as a dole to contribute to persistent unemployment.
He warns that as the population ages, it is unavoidable that society will spend more on health care.
I think Dr. Ambati’s post is a wonderful and constructive piece. Surely the present system can be improved but finding the direction of optimization in a complex system can be hard job. Dr. Ambati has taken a good, non-ideological look at the problem and has come up with definite ideas.
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and some good ones at that
This is the first health care reform plan I can endorse. Of course politically, the trial lawyers, health insurance industry, and pharmaceutical industries give much more money to politicians so this common sense plan is unlikely to be passed by the U.S. Congress and signed by the President of all the people and the great champion of good contributors.
“Costs in the last six months of year of life consume the lion’s share of health care spending; should the bill for that be covered by the hospital, the insurance pool, the taxpayer, or (in my view) the patient & family?”
The point of insurance is so that in the midst of a serious illness one doesn’t have to worry too much about the cost. This is the notion of catastrophic coverage. As a matter of reason one might rather expect that all else could be paid for and budgeted for by the patient so long as a fair market existed to set real prices.
While the young doctor makes good points the nexus is that in our society the social network of family and work is an unstable dynamic of many competing demands that an individual cannot rely on in a time of great need. I am afraid that his solution which colors his analysis paints too rosy a portrait of reality.
I do agree however that there are many things that can be worked on that can improve the health care economy. It is certainly not perfect.
Politically, the achilles heel of Obamacare is that women who form the majority of his coalition and that of dems, will be forced to wait a year for breast cancer screening and treatment, effectively killing them.
Unless they are more equal than others, a big shot like Pelosi, or Black or Hispanic.
Add to that the requirement to have a lot more (incompetent) Black doctors with affirmative action, and you have a political disaster for Obama.
He may indeed get it passed. But it threatens to break apart his coalition because it takes away health care from women and gives them higher taxes while giving them life-denying rationing and wait-lists. They and their mothers die agonizing deaths from Cancer and the like. While Black and Hispanic women are queue jumped, and doctors are mostly Black/Hispanic incompetents.
That’s too much for his coalition to take. Even women worshipping First Rockstar don’t want to die.
Supposedly Tort reform has provided very positive results in Texas. Perhaps buddy, Leo and others could speak to that. Do trial lawyers contribute to anyone’s campaign coffers?
There are much better economists out there than I. Some are expert in this field. Still, I can make some useful points that may not be obvious to all.
My basic position is the necessity of limiting all government involvement in health care to an absolute minimum, to avoid the well-known problems. Government simply cannot produce goods or services efficiently or well. I must mention Amtrak, the P.O,, Veterans’ Hospitals – there is no convincing evidence otherwise.
Dr. Ambati has a good plan.
1. Tort Reform: Politically speaking, it seems impossible that the Dems would ever enact tort reform. The trial lawyers are too big a part of Dem financial support. That can be done state-by-state, however, I think Texas has enacted some tort reform laws on its own, forinstance.
2. Assigning the cost burden of unnecessary or likely futile services to patients or their families This would be desirable, but the question of who decides, and who collects the penalties, is tricky
Controlling unneeded advertising by drug companies is tricky, even though desirable in theory. Who will do it? If the drug companies police themselves, someone can always get a windfall by being the first to break ranks. Government? What do they know about the place of advertising in business. It could be done by not allowing unneeded ad costs to be deducted from corporate income, but even that bears constant scrutiny.
3. Breaking the oligopolies of health insurance coverage present in many states & regions. This is a boon to states. Their politicians use their ability to decide which insurance companies can sell insurance in their states as a major way to get campaign contributions. They are reluctant to give it up. Enough pressure should do it.
4. Encouraging charity care: This works. It is how medical charity was done prior to Ted Kennedy. Doctors should certainly get tax deductons for donating care.
5. Cost Transparency: Perhaps this could be done by combining a government watchdog agency (to provide enforcement teeth) plus the efforts of non-profit and bloggers to find and document obstruction and problems. The two together could work better than singly.
6. Encourage innovation: Giving grants through the usual grant-making organizations and applications often does not favor innovations. Offering prizes may well be a more productive approach.
(7) I think the Daschle-Dole idea of giving tax credits to all who pay income or payroll taxes to purchase health care is a good thing
When it comes to choosing Dr. Amati’s plan or almost anything produced by Congress yet, there is no question which would work best.
If we can get the government plan stopped, then the way is open for a better plan, like this one.
Dr Ambati is Exhibit A in the argument in favor of the uniqueness of the American Experiment. Comes here from India (?) at three, get an MD at 17 and now fully understands what makes this blessed thing work. Proud that my tax dollars supported his education at MCG.
The only problems with his plan is that it 1) Is based in reality, and 2) Doesnt feed a Major Constituency of the Democrat Party (Poor, Gays, Abortionists, MedMal Lawyers, etc)
I will await my second set of bypasses at age 75. If somebody says I cant have them because Im too old, well, we’ll have to talk.
I do have an issue with the family liability for aggressive treatment. That will take some argument and analysis, supported by prayer. Because we’re talking about an arbitrary end to life, or are we?
Tort reform…Better chance of hitting the powerball on five consecutive nights running! Or then again you could break the bank at every Vegas casino and then come home to find out that 0 has named you as the sole beneficiary of TARP II and III!
How about we just admit it. That the Insurance Co’s think/know they can role 0 with the Congress in their pockets. That we will get some bastard child of two siblings that drools and cannot wipe itself…
And 0 doesn’t really care about Healthcare reform. He wants to fundamentally change the structure of govt and how it works. That is why there is a office of civil rights and a office of african american health in the bill. It is all about backdoor reparations and cronyism.
My expectation is that the good Dr will soon receive a version of the Joe the Plumber treatment. Any parking tickets he owes will be dissected by Time magazine and the sad tails of the cat that got hit by his car and the girl who dumped him in High School will occupy the Great MInds who are interviewed by Charlie Rose.
joe buzz,
I’m pretty familiar with tort reform in Texas, as my dad was the founding Chairman of Texans for Lawsuit Reform. TLR started in the mid-1990s after forty years of steadily increasing tilting of the civil justice playing field in favor of plaintiffs. There were two major inflection points in this fight:
The 1995 session (with George W. Bush was Governor)
The 2003 session (with George W. Bush was Governor)
The changes to medical liability in 2003 were extraordinary, and had a very substantial impact, including:
Last year, TLR commissioned a study by The Perryman Group to figure out the impact of these reforms (the above are excerpted from that report). Here are the economic impact findings of that study:
The complete Perryman Group report is here.
As these numbers show, tort reform can have a substantial impact on economic growth and wealth creation, and a huge impact on the healthcare system in particular. Any serious national healthcare reform must include comprehensive tort reform to reduce the practice of defensive medicine and other perverse incentives.
Which is why I do not consider the current proposals from the Obama Administration to be serious (other than being seriously flawed).
Hope this helps. Cheers,
L3
One could argue with this or that point but his proposals are based on a view of the phenomenon of health care and not an initial ideological approach. Obama’s policies are ultimately based on animus (anger and hatred) and, yes, personal experience perhaps, his mother’s difficulties in getting insurance to continue her cancer treatment. But just as communism represented animus toward the czar, Obama’s health care proposals represent an animus that will be a disappointment in implementation.
Was certainly true for my Dad, hardly ill a day in his life, until his last ten days, and the cost of the (futile) care expended was certainly 95% of the health care he consumed on this Earth.
ON THE OTHER HAND 95% of that expenditure could have been prevented, if any of five or so physicians involved had acted competently to treat an 85 year old patient. Not to mention he would almost certainly have had another year or three of reasonably good health.
I am exceedingly skeptical about the *quality* of medical care that 95% of the population receives, and poor quality translates to cost, but I’ll be damned if I can find a word about this in anybody’s proposed bills.
L3′s input, as usual, has mind-boggling significance. Thanks, Leo, for once again inserting reason and common sense into an emotional subject. And Josh, is spot on. A less “protective” mode of health care – from the provider’s perspective – could very well improve geriatric health care and actually lower total costs.
The good doctor’s post is great. I agree with most of his ideas, though I’m curious as to how he plans on identifying the last six months of like other than with hindsight.
I only have one thing to add, a pet idea of mine that I think would benefit this nation on the issue of drug costs.
Pass a simple law: Rx companies can charge whatever price they want for their drugs, but it has to be the same for everyone – including abroad (adjusted for PPP). It’s time the Canadians, French, et. al. started paying for the American R&D they benefit so richly from. We can’t force the French to pay a particular price, but we can force the Rx companies to choose between charging a “single world price” and being frozen out of the US market. I think we have the market power to make them play ball.
My take on why the big drug companies drop so much into marketing is that they feel they have to.
I blame the FDA for this. Correct me if I misunderstand the situation, but it goes like this:
Many drugs are being developed, few of which wind up panning out. This is an expensive process. Once one does look promising, a request for approval is submitted to FDA, and right then the clock starts ticking. Working with data from trials conducted at the drug companies’ own expense approval or disapproval is given after a review process that takes years.
Then, the drug company can sell its drug to the American public. Note that the clock started ticking years before, and what this clock is ticking down is the number of years that the drug can be sold as an exclusive product before the generics arise to drive down its profitablity.
This eroded window of time in which the drug companies have to recoup their wide costs has two effects. First, the drugs are much more expensive than they would be if the window was bigger. Secondly, heavier marketing blitzes become more justified. Get the word out, boys, time’s a-wastin’!
A solution might be to lenghten the window, or at least start the clock ticking upon approval rather than submission. Also, maybe something can be done to help the original patent holder’s profitability against the generics competition, like maybe a minimal leasing fee like ones that exist in other industries (i.e, Honda, GM and Ford’s leasing of some hybrid technology from Toyota).
…an entry for the ‘distributed solutions’ file:
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L3′s data refers to what GWB as president was trying to say to the nation every time he said “I believe tort reform would be good for America”. Which was usually treated as a laff-line by our soi-disant filterpersons. (btw, L3, did you typo on that 2nd block, the 2003 when Rick Perry was da guv?)
Any solution to healthcare will need to emphasize continuous innovation. Read Andy Kessler’s “The End of Medicine” where he looked for opportunities to profit from scale and found that “doctors don’t scale,” that is, healthcare that depends on personal interventions will inevitably cost more as it gets bigger. Technology is not the end-all but it has to be used a lot more than it is (and it will be, from electronic health records management through smart diagnostics and biomarkers to pharmacogenomics and data-mining).
Which leads me to my one main beef with the good doctor’s suggested changes in healthcare: to ban or discourage “me too” drugs. Nobody sets out to build a me-too product. What happens is, everybody in pharma R&D learns about/participates in the same biological and chemical breakthroughs at the same time. Statin drugs are a great example. Lowering LDL was seen to have big positive effects, everybody raced to build a statin. They all arrived on the market at roughly the same time. So for each of the innovators it was a “pioneer” product in development; but for the market where they all showed up, it looked like a bunch of “me too” products. Except they’re not “me too.” Even tiny changes in chemical structure or formulation can have huge effects. One statin is not like another, and don’t ever let the pharmacist or doctor try to tell you otherwise. If you can get exactly the same substance cheaper (e.g. when the patent expires and the true generic arrives), go for it. But if somebody wants to switch you from say Zocor to Lipitor (or, more likely, the reverse), be careful. They are not the same stuff, anymore than a Yugo is a Dodge pickup. One last angle on “me too” is that people launch a drug for the indication about which they have the most knowledge and confidence that it will add value (safe and efficacious). As they learn more from its use in the population, they may add new indications. Sometimes these are surprisingly different and quite unexpected. Cancer meds are a case in point. And thalidomide is an example of the “Whodathunkit” effect. A drug approved for morning sickness in the 1950′s and withdrawn after it was found to cause birth defects, turns out to be a powerful anti-cancer medicine. People are now pursuing ‘me too” versions of thalidomide, in the sense that they are exploring chemical analogues with more punch and fewer side effects. That is what innovation looks like. You can’t legislate it with a rule against “me too.” If something is truly “me too,” then nobody will pay for it. It can have its fine little patent, but it will be a market dud and the patent will be irrelevant.
Sorry for the length, I am in the pharma R&D innovation business.
DEADLY DOCTORS
Dr. David Blumenthal, another key Obama adviser, agrees. He recommends slowing medical innovation to control health spending.
Blumenthal has long advocated government health-spending controls, though he concedes they’re “associated with longer waits” and “reduced availability of new and expensive treatments and devices” (New England Journal of Medicine, March 8, 2001). But he calls it “debatable” whether the timely care Americans get is worth the cost. (Ask a cancer patient, and you’ll get a different answer. Delay lowers your chances of survival.)
Obama appointed Blumenthal as national coordinator of health-information technology, a job that involves making sure doctors obey electronically deivered guidelines about what care the government deems appropriate and cost effective.
In the April 9 New England Journal of Medicine, Blumenthal predicted that many doctors would resist “embedded clinical decision support” — a euphemism for computers telling doctors what to do.
Americans need to know what the president’s health advisers have in mind for them. Emanuel (Dr. Ezekiel Emanuel, the brother of White House Chief of Staff Rahm Emanuel) sees even basic amenities as luxuries and says Americans expect too much:
“Hospital rooms in the United States offer more privacy . . . physicians’ offices are typically more conveniently located and have parking nearby and more attractive waiting rooms” (JAMA, June 18, 2008).
No one has leveled with the public about these dangerous views.
Nor have most people heard about the arm-twisting, Chicago-style tactics being used to force support. In a Nov. 16, 2008, Health Care Watch column, Emanuel explained how business should be done:
“Every favor to a constituency should be linked to support for the health-care reform agenda.
If the automakers want a bailout, then they and their suppliers have to agree to support and lobby for the administration’s health-reform effort.”
Do we want a “reform” that empowers people like this to decide for us?
Kill ‘em Off, Who Needs Those Old and Decrepit People Anyway?
Make Everything In Life A Horror! Then people will quit wanting to live so dang much!
The perfect solution –free choice to check the heck out ASAP you escape the abortion brigade and work for da Man a couple decades!
better hurry and get that Soma out into the people’s happy clinics.
A Soma Holiday keeps the Doctor away.
When Iran ‘tests’ their nuke in New York, it will move the health care issue to where it belongs, the back pages.
So far I have yet to see anyone come up with a list of what’s wrong with American health care.
My guess is you will never see the real reason published; Insurabce Companies want more money. They want the government to force people to buy medical insurance, just like they force people to buy car insurance. Forced car insurance = Billions, forced health insurance = Trillions.
With free will, folks already have the option to check out whenever they wish, unless they are in a hospital. Who needs Soma? Or pharma for that matter.
A lot of folks think that a kind of catastrophic care is what health insurance is all about. It isn’t unless it is (the quirky duck quack kind). So who has the money to pay for regular expected care out of pocket?
i just hope they didn’t let the swine flu loose to pass healthcare, like they did the financial panic to take over a third of the economy and pass TARP and Stim (of course no can do manufactured crisis with capped trade, have to just ‘blame the weather’ –and send Fat Albert to phart and phume).
like these good-hearted souls really care about your health care –the same people gaily keep entire swaths of the population poor and ignorant, just for the power/money.
hard to add anything to L3′s excellent post, but I have a few anecdotal bits to contribute from another Houstonian’s perspective:
1) a lawyer friend of mine, who typically defended insurance cos., etc.. against the plaintiff bar, said that their work is way down since the enactment of tort reforms here in TX. i’m in favor of most things that reduce the burden on our legal system
2) it is amazing how many California license plates i have seen in Houston over the past several months. and i doubt that they are here to vacation. it used to be very unusual to see one here, as most Californians seem to look down on TX. but if businesses (or people) vote with their feet and relocate, the argument of passing tort reform state by state could get a real boost.
particularly if independents comprehend that better state economic/legal climate = more and better jobs. during the past economic boom, this wasn’t an issue as the economy was generally strong across the country, so this may not have impacted the average voter as much as it does now.
It seems that Ted Kennedy would be a good case study to demonstrate the societal benefits of ObamaCare, and how it would work out in practice.
Old guy, terminal condition, options are (a) cheap palliative care, or (b) very expensive but futile care.
You’d think all the Dems would be pushing for option (a). I forget whether its blue or red pill in ObamaCare jargon.
You left out option (c), Old Guy, faster and cheaper yet:
The trunk of an Oldsmobile, sunk.
TOG/27; see
IOWAHAWK: You Stay Here While I Swim and Get Us Some Universal Health Care.
Posted at 9:17 pm by Glenn Reynolds
***
Steeple/26; that’s gotta be hurting California –it’s not the tax eaters that are hauling ass to Houston –it’s the generators. Brain Drain. Oh well, both states deliberately set those conditions, so, hooray for Texas!
Wow this was a great list- and it seems so obvious that tort reform would improve our health care system… What does it take for our government to do something so obviously beneficial? How will our government return to of the people, by the people and for the people rather than just for the lawyers?
Tort reform has got to be the single biggest thing you could do to make healthcare costs more reasonable. California SO needs this!!! (Though they won’t get it, because the inmates are running the asylum.) But I always thought, too, that one of the driving factors in the ridiculous rate of growth of healthcare spending is the transfer of responsibility for incurred costs. If someone else pays for every single aspirin tablet, then nobody has any incentive to limit the healthcare they get. I think health insurance needs to have a sizeable deductible, say $500 or $1000 a year, and that healthcare should effectiely be insurance against catastrophic illness. $10 copays don’t do anything to control costs – they might as well be $0 copays. And HMOs are already Government-controlled healthcare. They’ll kill you because their incentive is to discourage treatment – they only lose money if they have to treat you. Get rid of ‘em.
MTL/30; –by you converting a lefty, MTL. Then another. Then another. And so on. Own the long hard road. Take heart from the process –and pray the result will come.
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willdo/31; –exactly. imagine we consumed food the way we consume healthcare. Everyone would go to the store just whenever, and fill up their carts with just whatever, and just throw out whatever they couldn’t eat.
Unfortunately, I have a problem with tort reform.
After my Dad’s passing, I’m certain we could have sued the doctors involved for negligence and had a certain win for whatever numbers the system would assign. However, that number might not be so high for an 85 year old man, and winning a suit would not bring him back. And it wouldn’t change the system, and it was 90% “the system” that was at fault.
But the friggin doctors, joint and severally, should have been sued, horsewhipped, and at least one of them de-licensed. And this is WITH the current tort laws. And these were all, afaik, considered good doctors. The mind boggles.
buddy @17
Arrggghh! Yes, in 2003 Rick Perry was Governor, not GWB.
Sometimes not even the cool 8-minute editing function here at the BC can make up for mental fatigue:
Cheers,
L3
L3, did you know that Cervantes fought at Lepanto? A sailor on one of the Catholic League galleons that sank the Turk and saved Europe from Jihad. That was before he wrote DQ.
(taking advantage of that wonderful editing feature here)
The 1972 play about Don Quixote, Man of La Mancha featured the song “The Impossible Dream”, the lyrics of which are:
To dream the impossible dream
To fight the unbeatable foe
To bear with unbearable sorrow
To run where the brave dare not go
To right the unrightable wrong
To love pure and chaste from afar
To try when your arms are too weary
To reach the unreachable star
This is my quest
To follow that star
No matter how hopeless
No matter how far
To fight for the right
Without question or pause
To be willing to march into Hell
For a heavenly cause
And I know if I’ll only be true
To this glorious quest
That my heart will lie peaceful and calm
When I’m laid to my rest
And the world will be better for this
That one man, scorned and covered with scars
Still strove with his last ounce of courage
To reach the unreachable star
maybe producing more medical doctors, and less phd’s would help the situation. also creating atiered system so that someone who is less than a full doctor but more than a nurse, could handle the 95% of cases that aren’t serious. eventually technology will drive down health care costs to very manageable levels.
in a movie from 1966 a character complains that surgenons want “$500 to fix a bum knee”; fast forward 30 years and the price is now close to $20k. even allowing for inflation, that is a huge increase in cost. i suspect illegal immigration has been driving up costs for everyone else for some time now.
Josh,
Sorry to hear about what happened with your dad. We had a very similar experience with my grandfather.
But here’s the thing: in retrospect, there are always things that could have been done differently that would have changed the outcome in a given situation. So, when someone dies, almost by definition someone made a mistake, in that they took (or failed to take) some action that would have prevented the death.
Now, if you have a system in which there is some third party who has an enormous financial incentive to punish those mistakes, it is easy for the entire system to be corrupted. In Texas, we used to have no caps on punitive damages on medical professionals. This meant that plaintiff’s lawyers had a chance to get a multi-million dollar fee on every mistake, so every mistake was a chance for a massive transfer of wealth from physicians to lawyers. In such a situation, you get the following consequences:
1. Physicians practice very defensive medicine, ordering large numbers of diagnostic tests just to make sure there is not something they’ve missed. This drives up cost without much benefit. If there is a 1% chance that patient A has condition X, and there is a test for condition X, the doc orders the test. This leads to a lot of waste and patient discomfort.
2. More attorneys are incentivized to enter medical malpractice law. This increases the number of suits.
3. Fewer people want to enter medicine. If you can work for 10 years to get a medical license, incurring big debts along the way, but just when you are starting to make a good living you could lose it all because of one mistake, fewer people will tend to sign up for the profession.
4. Most crucially, feedback loops are cut. Medicine is a trial-and-error enterprise. The human body is extraordinarily complex, and we only learn from trying things and seeing what happens. Bad outcomes are actually full of important lessons, and ways to improve medical practice, but because any bad outcome risks a costly lawsuit, lessons are not shared. It used to be that hospitals had regular committees that reviewed deaths, and changed their protocols based upon any lessons learned from those cases. Most hospitals have shut down those committees, with the result that mistakes are repeated because there is no feedback loop. In BC terms, the OODA loop goes away; the link between A and O is severed.
5. The system is prone to corruption. The the 1980s and 1990s, plaintiff’s lawyers had made enormous sums of money, and they were pouring those dollars into the political system to further stack the deck in favor of plaintiffs. This can happen because judges in Texas are elected. We were dangerously close to reaching the point where the system would be irredeemably corrupt.
Another point worth considering: as we grow older, our bodies become less resilient, less able to repair themselves. Again, in BC-talk, our design margin decreases. Some of this is because our store of stem cells – which are the feedstock of our body’s regeneration process – decrease as we age. Wounds heal more slowly, it takes us longer to recover from things like colds and flus, etc.
As design margin decreases, the margin of error decreases with it. This means we are increasing the likelihood of any problem escalating into a mortal threat. If we set up a system to punish any mistake, we create a strong incentive for physicians to refuse to treat anyone with a small design margin – typically the very young, the very old, and the very sick.
This is why we saw a flight in Texas from specialities like OB and oncology. But these are precisely the people who need physicians most.
In the final analysis, the point of tort reform is not to skew the system toward defendants or plaintiffs. It is to create a balanced system that optimizes the social benefits when participants act in their own, individual self-interests. This is a very complicated problem, and sometimes the system gets out of whack. It clearly was in the 1980s and 1990s in Texas. It is then that citizens have to get involved to help rebalance the system.
Anyway, sorry for the long response. But I hope this helps clarify some of the issues involved, and why tort reform is a good thing, at least in my opinion.
Cheers,
L3
LL #37 ” So, when someone dies, almost by definition someone made a mistake, in that they took (or failed to take) some action that would have prevented the death.”
This is what is at the root of all of our troubles.
Leo, my brother, EVERYBODY DIES. The mortality rate of Medicare beneficiaries is 1.0. Occasionally, mistakes are made, of course – but virtually every Medicare death is made a Federal case, and yet, in the aggregate, nothing is more certain.
Leo Linbeck III,
Dan Quayle touched the third rail of tort reform and became a test case for “the politics of personal destruction.” The techniques used to demonize him and falsely convince most Americans that he was an idiot were a refinement on the methods used to destroy Robert Bork’s nomination to the SCOTUS. THe trial lawyers are the true soul of the Democratic Party. The campaign against Quayle could be seen as a precursor of the campaign against Sarah Palin. The lady should know who her enemies are.
gokart-mozart,
lambkins, we will live
- Pistol, Henry V
gokart-mozart,
Leo, my brother, EVERYBODY DIES. The mortality rate of Medicare beneficiaries is 1.0. Occasionally, mistakes are made, of course – but virtually every Medicare death is made a Federal case, and yet, in the aggregate, nothing is more certain.
Exacta-mundo. This is why the notion of punishing physicians for ordinary mistakes (easily framed in the courtroom as negligence) is so wrong-headed.
Mixing post-modern hedonistic materialism, a self-corrupting legal-political complex, and rent-seeking, bombastic, sanctimonious bullies creates a toxic brew.
Boil, boil, toil and trouble…
Cheers,
L3
GM/38; death, from The Tempest, by the Bard:
We are such stuff
As dreams are made on; and our little life
Is rounded with a sleep.
I’m a doc in Texas and greatly appreciate the medmal reforms here. California has medical liability limitations, their law is called MICRA and it is a model fir the rest of the nation. Indiana actually has the best medmal protection, not only is it onerous to file but a three-doctor panel has to certify the suit as valid to proceed.
There are some interesting issues to medmal reform. By capping noneconomic damages, it is reputedly difficult to find malpractice attorneys to take the case of children or retired people. They have no economic damages to go after, about all the attorneys can hope for is medical care reimbursement and maxing out the noneconomic cap at $250K for physician and hospital. While I agree with the tort reform wholeheartedly, there are always unintended effects. The 18-64 age group is now the big malpractice concern.
The FDA can regulate drug advertising just fine, and pushing the newest cholesterol drug at $5 a pill may not help as many people when they could get simvastatin for $4 a month at Wal-Mart and actually, you know, take the meds they need. Pretty much every drug I administer except contrast is generic, so maybe I’m not the best one to judge the issue, but the me-too introduction of similar drugs to get some of the blockbuster cash involved in a Viagra or Mevacor does kind of grate on me.
Determining the “last six months” will indeed be hard, we’ve had people walk out of the hospital that I would have sworn were goners. If the idea is to back-bill the family for the last six months of care, it might get rid of some of the “Do everything for my Momma/Daddy/Brother/etc.” that we run into so often. Someone comes in with a couple of chronic diseases and an organ or three shut down, they end up intubated with a feeding tube and a dialysis catheter and the meter runs at $15K a day or
more while family emotional pathologies are assuaged with the Green Poultice of Medicare, or just foist on the hospital.
Texas does have a rarely-used Futile Care Act that allows a hospital to withdraw care after consultation with multiple physicians. The patient can be transferred, but if no accepting institution is found the tubes come out and the care stops, often with expected results.
Oh, and “making more doctors” isn’t as easy as it sounds. The staff to train physicians doesn’t grow on trees, there is an infrastructure problem that you can’t just throw money at. Guessing at future physican needs has a horrible track record, a fellow resident once spoke up at an AAMC meeting to raise the fact that over their career female medical graduates (now 50%+ of most graduating classes) were the equivalent of 0.85 FTE compared to male grads. This being politically incorrect, nobody wanted to discuss it.
Mid-level practitioners have their place, but who’s to determine what the “easily-curable 95%” is? Many things have benign early symptoms, and who’s going to be cool about a missed meningitis treated as an “ear infection”? “Whoops” does not cover it.
LLIII, I agree that some tort reform is needed, but my first-hand and second-hand experiences with the medical system are so uniformly filled with idiotic mistakes, that frankly I consider the entire system something of a horrible joke.
That medicine is a practice and everyone dies, are very convenient excuses for sloppy, sloppy, sloppy standards and practices.
I know my own field of software development, and I can see who gets it right and who doesn’t, and a lot don’t, but our mistakes are generally correctable. If anything, I believe the average medical practioner is sloppier than the average software developer, even though the costs are much higher and the pain and suffering from errors immensely higher.
Which is why I hesitate to put more taxpayer money into the system as it stands, or as anybody has proposed. I see increased horrors, not to mention waste, overwhelming some degree of increased benefits from increased accessibility, or however we should talk about it.
OTOH it should be clear that I see a tremendous need for change – of some kind.
He forgot to mention state-level insurance regulation (specifically, what and who must be covered) as a big factor in insurance costs. If you live in Maine or NY, you’re screwed.
Josh @ 44
Josh, are you suggesting that the human body, including the brain, is no more complex a system than computers and their software? I suggest that a closer parallel to the complexity of the human system is the weather system, and with how much accuracy are we able to predict the weather a few days or weeks ahead–and sue the weather man if an error is made?
How many software developers live with a constant awareness that any keystroke may be irretrievable, may cause the death of a company, or may erase all that they have earned, maybe even before paying off the debts of 7 to 12 (or more) years of education after college?
Speaking as a physician, I think you have little concept of the thought that goes into making medical decisions and the soul searching that follows when treatment fails, either through error or just limitation of knowledge. Patients may not like this truth, but there is far more unknown than known in medicine. Also what is known is so vast that no physician can know it all. In fact, it is not even possible for any physician to know what he or she does not know–what other physicians might know that he or she does not know. But when things go wrong, most physicians, in their own mind, think “I should have known that”. This may be one reason that the incidence of depression and suicide is so high among physicians. Are physicians likely to admit publicly that “I should have known”? No, that is what the trial lawyer will drum into the jury.
Jim
Jim,
I understand what you are saying. Any single cell of the human body, is 1000x more complex than any computer system. But on the other hand, the body tends to take care of itself pretty well, doesn’t it? I’m afraid you put your finger on the sore point, when you say, “what is known is so vast that no physician can know it all.” But again, it’s soooo easy to use that as an excuse for shoddy work.
Something I did learn, watching my Dad’s last days, is the difficulty of being a physician in that environment, where you *will* lose a lot of patients no matter how hard you try.
But without going into the details, trust me, my Dad’s primary care physician was clearly negligent, repeatedly, and every other doctor in the chain knew it. My information is that the treatment recommended was inappropriate, we did not get even competent textbook decisions, even after I gently questioned it. And because of the weekend day and afternoon hour he went in, the proper tests and interpretations were done just a few hours too late.
The admitting ER doctor seemed sharp, and the critical care nurses seemed excellent, but the system, and priorities, and responsiveness, of the system certainly abused and lost a patient who should have had a much better outcome.
Not to mention, it would have saved the taxpayer probably six figures.
Josh,
my Dad’s primary care physician was clearly negligent, repeatedly, and every other doctor in the chain knew it
This is interesting from a couple of standpoints.
First, the failure in your Dad’s case was with the primary care provider (PCP). One of the major flaws in both the managed care model and in the concepts embedded in the Obama Administration’s healthcare reform is to increase the importance of the role of the PCP. The idea is that the PCP can act as a gatekeeper (and cost controller) for the specialist system. They do this by effectively blocking access to specialists unless they are referred by a PCP.
This has the effect of limiting access to the specialist docs, and bottlenecking the system. The response for PCPs is then to turn care into an assembly-line, in an attempt to “process” patients as “efficiently” as possible. Less time per patient, both to visit and think. In my general experience, limiting the amount of brainpower applied to a problem is a bad strategy, and in medicine time and experience with patients are the two biggest drivers of brainpower.
What we should do is let specialists decide who they want to see, and let patients decide who they want to see. Some patients will prefer to see PCPs, so that they can establish a long-term care relationship that spans all of the health issues they may encounter during their lifetime. Others will want to “roll their own.” They should be allowed to do so, so long as they can find a doc, and are willing to pay for it. You know, a market of “buyers” and “sellers.”
Instead, we put a huge and unnecessary burden on the PCP, limit the customer pool for the specialists, and take the responsibility for the most important decision – who will treat me – from the patients.
The other interesting thing is how the other docs knew by whom the screw-up was made. This is not surprising; they’re the ones with the most data with which to do pattern matching. There is an argument to be made that the momentum for lawsuit abuse was created by the systematic refusal of physicians to “police their own” in an effective manner. This left people with no other choice than to go to court.
If you ask people why they sue for malpractice, the vast majority do so because they want to get an incompetent doctor out of the system. They know that winning will not bring their loved one back, but they feel a responsibility to get rid of a bad apple who might hurt others. And they have come to believe that docs simply won’t pursue one of their own. If docs really went after the “bad guys” in the system, a lot of malpractice would end, and a lot of the incentive to sue would go away.
At least for the victims and their families. The plaintiff lawyers, of course, are another matter…
Cheers,
L3
L3,
FWIW, the PCP was an excellent doctor, once upon a time, I believe suffering a little late-career burnout and simplifying his practice but still excellent, until his group was bought up by another group. I believe that is when his policies changed. But under ANYONE’s policies, it’s clear that he was grossly negligent in this case.
But, was his negligence any worse than the average care of the average physician, under the same guidelines? I have to wonder.
Josh and Leo,
The problem of inept physicians is a real and difficult problem, for at least three reasons:
1–About 40 years ago a study was published in the American Sociological Review entitled ‘The Protection of the Inept’. It discussed the wide-spread phenomenon, across all societies and groups within societies, in which the inept members of a group are protected by the group, even when it would seem to the group’s disadvantage. For example, it was observed that members of professional sports teams would try to hide from the coaches the mistakes that the more inept team members made. It is only when there is a wide gap between the most inept and the next member of a group that the group is likely to withdraw this protection. The hypothesis is that members of a group fear a domino effect: if the most inept is removed, then who is next and when will it end up being me?
2–Physicians on professional standards committees in hospitals, chosen because their knowledge is respected, accept that role from a sense of responsibility to patients and to their profession (not a paid position) but they also fear it. The process of removing a physician from a hospital staff is likely to result in a ruinous lawsuit against the physician on the professional standards committee by the inept physician.
3–It turns out that there is little or no correlation between the competence of a physician and the likelihood of being sued. Often the best physicians are referred the most difficult cases–cases with the greatest chances for mistakes and bad outcomes. And so when physicians see other physicians make mistakes, there is a knowledge often of ‘there but for the grace of God go I’.
I am not arguing against the importance of monitoring and enforcing the quality of medical care. It is just not easy.
Best wishes,
Jim
JN, you think that’s difficult, did you know that almost 50% of physicians are below average in skills? No known fix for that, either, unless Obama’s unicorn has given him one.
/
Too bad we’re not back in the 1950s, or 1850s, when there was virtually no real medicine to know, so almost any doctor (or barber) was “qualified”. But, what about 2050? This is where the problem is (sort of) similar to the case of software developers. The public – and management – tends to have faith in “the technology” or “the science” and doesn’t believe the virtue of the individuals involved is nearly as important. And in this they are very wrong.
Obama seems to be case in point, believes all he has to do is ask for a solution, and voila, it will appear. He said this almost exactly as part of his campaign rhetoric. Seems to believe that’s all it would take to get the bill written and passed, too.
Science is difficult, is what I’m trying to say. The idea of calling medicine “practice” I find a horrible anachronism and a large part of the problem. I suppose computers will improve things over the next ten, twenty, fifty years. Yes, I know the debate about that, from back in the AI expert system days. The AI mostly sucked, and who has faith in cold Bayesian statistics? And yet, the computer can know all that is known, or apparently a lot more than your average practitioner.
So, I actually support a lot of what Obama is suggesting, but I wonder if it doesn’t leave out some critical items. That is, I’m certain it does.
all I know is when this Obama care came about our dependents disability insurance was abruptly cancelled after almost twenty years.
leaves disabled folks with just medicare which while paying 80% it still either will not cover or ya cannot find a doc accepting new “medicare” patients.
The FUBAR of medicare’s 80% with Insurance paying 20% after deductable of $500.00 paid by the patient means the 20% will not get paid by the insurance who do drag their feet about making payments and it all ends up being paid by the patient.
Recent medicare that will pay 100% on a procedure (cataracts surgery) still only pays 80% if ya got insurance, which means instead of 100% payment to docs still leaves the patient paying that 20% that was covered by insurance which insurance will not pay on 100% SSI covered surgery and add to it the $500.00 deductable and the patient will end up paying basically for what is a free procedure. $500.00 deductable + 20% = $2100.00 paid by patient, without insurance procedure is paid 100% by SSI (example)
Sound complicated? Fokkin’ “A” right it’s a FUBAR.
One of the most helpful insights I have found is from Taleb’s “The Black Swan”, namely the fact that what you know is not as important as what you don’t know. This is kind of shock for people with a lot of education (like physicians) but it is nonetheless true.
If a patient comes in with lower abdominal pain, the differential diagnosis is huge. Appednicitis, diverticulitis, kidney stone, genitourinary infection, musculoskeletal injury or strain, an undiagnosed malignancy, neurologic disorder such as shingles, or a ruptured aortic aneuryusm are just some of the things to consider. It’s possible to rule out a bunch of those, if you have the time. If it happens to be a rupturing AAA, then you most likely don’t have the time to work the process out and the patient is likely to die. Even at the beginning, the unknowns include how much time you have to get to the right answer.
Therefore “not being able to know it all” is a given, and not only that but a lot of what we know is probably wrong, too. The thinking when I was in medical school was that estrogen replacement for postmenopausal women was pretty much all good. It was supposed to be good for the heart and bones, and may help stave off dementia. In the last 10 years, all of that has been proven wrong. It’s worse for the heart, the phosphonates are better drugs for the bones with fewer side effects, there is no effect on dementia and it probably worsens breast cancer risk in some patients. Anyone who says “the science is settled” is overgeneralizing or wrong, particularly in medicine. The example of peptic ulcer disease being primarily caused by bacteria is yet another world-shaking discovery that proved nearly everything wrong that other authoritative people built their careers around.
If this weren’t bad enough, there is a couple of trainloads worth of new data coming toward medicine in the form of genomics. It will probably end up being a two to three-year fellowship after a full three-year internal medicine residency. We’re learning so much more everyday that keeping up is getting to be not just difficult but impossible.
Most docs don’t feel the need to protect the incompetent though what happens most often is that they are shunned. Nobody wants to get involved in their cases because they don’t want to end up named in a suit. It becomes difficult for them to practice, and so they leave some location and head elsewhere. Often the proximate cause of their departure is threatening of their hospital privileges, and since that is a reportable event to the National Practitioner Data Bank (and often to state medical boards) most docs in that situation would rather resign than have the black mark against them, and most hospitals would rather they leave instead of pursuing something likely to land them in court. I get worried when a physician has a career comprised of 2-3 year stints in multiple states.
We are told by medical malpractice insurers that bad outcomes don’t generate suits, angry people do. Particularly if a physician doesn’t communicate well, or angers patients or their families. The hole in the whole bad doctor problem is that if a physician is personable and incompetent, it can be very difficult for accusations of their incompetence to be seen by the public as anything other than professional jealousy. Their patients love them, they talk to their patients, they listen to their patients, and the patients will raise a stink, particularly in small towns. A physician who demonstrates that they care in a convincing fashion and yet lacks clinical skills commensurate with their perceived competence is very hard to dislodge.
“If anything, I believe the average medical practioner is sloppier than the average software developer,”
You lost me right there. I’ve been a software developer for nearly 2 decades, and I’ve spent more than the average time in a doctor’s office. My own experience with doctors is of course anecdotal, but I’ve worked in maybe a dozen different software shops, large and small, so I know that end pretty well. It’s a very, very large thing to say that doctors are broadly sloppier than software developers. When I joined my current shop, there was no versioning, no source control, and no system of any kind for backing things up. Each system that went out the door had its own code base. There were no standards of any kind in place for coding, design, or pretty much anything else. There was cursory unit testing and no system testing before code hit the customer.
Much of this has been rectified in the intervening 3 years, but this shop, in my experience, was just a tad below average when I got here in the realm of sloppiness.