by Bruce Douglas, MD
I’ve been practicing my health care specialty for sixty years and have enjoyed almost every minute of it. The minutes I have not enjoyed all have to do with “money.”
Financial transactions in doctors’ offices are the root of most evils in the relationship between doctor and patient. Along with that evil goes an additional detraction from good, humane health care called the fee-for-service system, which puts money between the doctor and his patient -and forces doctors to conduct their health care practices as businesses.
Health care is a “service,” provided by health care practitioners, that does not belong in the competitive, so-called free enterprise marketplace. Of course, doctors have to be paid, but the payment should not come directly from the patient. Reception areas in doctors’ offices should be places where patients register for care, provide their insurance information, fill out a history form, and wait to be seen by their doctor. Receptionists should enter the information in a computer and be fed all the information that has been stored, privately, about that patient, that the doctor needs in order to give the patient undivided, preventive-oriented attention.
Money should not be mentioned, directly or indirectly, because health care, at any level, cannot be equated in dollars and cents.
All of this is possible in a properly structured health care system. When HMO’s were first introduced, I was a staunch supporter of the new system. They were, in their purest form, designed to meet all the standards already mentioned; but it didn’t take long for the idea to be be translated into business terms and for patients to be treated inappropriately, like “customers”. Rationing raised its ugly head very early, and doctors, victimized by the system, changed quality care into quantity care.
What the USA, the last of the great nations on earth to be developing a system that makes health care available for everyone, needs is a coordinated system where doctors work together in groups, are paid salaries for the time they spend with patients, regardless of whether they are giving advice to pregnant women, shots to little children, evaluations and prescriptions to sick adults, or surgical services in the operating room. Each group decides salary levels based on experience and training and, most important, results, equated in qualitative terms.
How can this transformation take place? It must start in medical schools and in training programs, where students are trained to focus on patients, with a stronger emphasis on primary care and restrictions on the numbers of specialists produced. The financial discrepancy between primary care providers and specialists must be erased. This can be done within the ranks of professional health care organizations and health care educators, with support from government.
Yes, this system will only work well in a so-called single payer system, essentially expanding Medicare for the whole population. I don’t care if it’s called socialized medicine. All I care about is the patients who need our care. If government is the only entity that can organize such a system, so be it! That’s the way it works all over the civilized world. My wife is English, and I have experienced the English National Health Service on many occasions. It is a remarkable way of providing health care if a nation prioritizes health care as an important entity that must be funded adequately. Almost all English patients, Canadian patients, and French patients love their health care systems, and they are willing to pay the taxes necessary to keep them going. Most of the problems arise when governments squander money on less important programs and not enough is retained to make high-level health care available for everyone.
All this is not going to happen immediately, of course; but it has to start somewhere, and the wherewithal exists in the bills presently before Congress. If the Democrats rally together and pass a bill with some version of a so-called public option, America will be off and running towards a health care system that we can be proud of in the eyes of the world.
Bruce Douglas is an oral and maxillofacial surgeon.
Submit a guest post and be heard.
Related posts:
- Single payer truths, from Ontario’s Ministry of Health
- Single-payer is inevitable
- Are doctors are hurt financially by single-payer health care?
- America’s failed attempt at a single-payer system, the Indian Health Service
- Single-payer: Forcing health care down people’s throats?
- Single-payer and the Indian Health Service
- A single-payer compromise?
{ 19 comments }
As a salaried doc, working in a system that provides care at no cost to the patients, I now believe there needs to some patient participation in the payment. “Skin in the game” is the term most used these days and, from my perspective it has its uses.
Many patients intrinsically do not respect free health care. Along with this undervaluing of free care is the frequent mistreatment of staff and professionals in the system – as if they are somehow second class health care providers. You can see this in the media descriptions of VA care, Indian Health, and of course federal prison health. When care is given free, patients are under little obligation to show for appointments and not abuse ER services.
The French require patients to pay something for each visit. Even if they are reimbursed, the patients must make some payment. Although not my favorite nation, they might be on to something over there.
Healthcare Reform: The Moral Case.
Despite the considerable clout derived from the assertion of a basic human right, such contentions are nothing more than highly contestable social ambitions. In fact, alleging the “right to medical care” and protection from circumstances beyond one’s control is nonsensical, similar to this argument in Monty Python’s Life of Brian:
Stan: I want to have babies.
Reg: You want to have babies?!
Stan: It’s every man’s right to have babies if he wants them.
Reg: But you can’t have babies.
Stan: Don’t you oppress me.
Reg: I’m not oppressing you, Stan – you haven’t got a womb. Where’s the fetus going to gestate? You going to keep it in a box?
Judith: Here! I’ve got an idea. Suppose you agree that he can’t actually have babies, not having a womb, which is nobody’s fault, not even the Romans’, but that he can have the right to have babies.
Francis: Good idea, Judith. We shall fight the oppressors for your right to have babies, brother.
Reg: What’s the point?
Francis: What?
Reg: What’s the point of fighting for his right to have babies, when he can’t have babies?
Francis: It is symbolic of our struggle against oppression.
Reg: It’s symbolic of his struggle against reality.
The health care debate has become exactly this: a symbol of our struggle against reality. Heath care is presented by advocates as a technological panacea, a supernatural wonder that ends suffering and delivers us from death. As Max Frisch wrote, “Technology is a way of organizing the universe so that man doesn’t have to experience it.” It is mere fantasy to assert a fundamental human right to avoid reality, and without a rational basis to assert an entitlement to health care, there is no corresponding government duty.
Even if one firmly believes in the existence of an individual’s right to health care, such a right neither implies nor justifies a requirement that other citizens supply it, only that we do not stand in the way of that pursuit. It would seem that if the right existed, the corresponding government duty mandated by our society’s moral code is to secure the right to access by eliminating restrictive interference, not to provide a system of regulation dependent upon taxation, rationing, and other limitations of personal liberty.
Read the whole thing …
“Money should not be mentioned, directly or indirectly, because health care, at any level, cannot be equated in dollars and cents.”
Totally disagree here. If costs of health care should not be considered why not spend millions on new MRI scanners and Da Vinci robots? Cost control is very important. Unless patients realize the costs of the procedures that doctors order on them, patients will never appreciate the costs of healthcare. If the public doesn’t realize what’s causing a rise in health care costs people will cry out against rationing health care.
“Rationing raised its ugly head very early, and doctors, victimized by the system, changed quality care into quantity care.”
Currently we have rationing through health insurance accessibility and cost. Would your rather exchange that for rationing through government bureaucracy? With single payer, rationing is inevitable. Also, a single payer health care would be just as unsustainable as Medicare. Medicare will go insolvent in a few years. Is that the kind of future we want?
Rationing is exactly what takes place in those countries that you described. Here there is rationing for people who cannot afford it, there, there is rationing for everybody.
Health care is a service- for sale, it is NOT a right.
Dr. Peikoff of the Ayn Rand Institute writes:
“The only hope — for the doctors, for their patients, for all of us — is for the doctors to assert a moral principle. I mean: to assert their own personal individual rights — their real rights in this issue — their right to their lives, their liberty, their property, their pursuit of happiness. The Declaration of Independence applies to the medical profession too. We must reject the idea that doctors are slaves destined to serve others at the behest of the state.”
I agree with Dr. Peikoff!
I think that, as a nation, we have the responsibility to provide affordable healthcare for everyone in our nation. “Affordable” being the key word. That does not mean “free” healthcare. I sense a feeling of resentment by healthcare providers against healthcare reform for several reasons: a) they feel that their services are being devalued by use of the term “entitlement,” and b) there is fear that healthcare providers will not be paid well and their lifestyles will thus be threatened, and c) nothing is certain yet regarding which changes will be made and healthcare providers are therefore uncertain of their own future — we’re always more secure with the devil we know than the devil that is unknown.
I think that a copay should be required of all patients, in the ER or in their PCP’s office. That will make it clear that the service is of value and may reduce the number of nuisance appointments. It would also make sense that doctors be open about costs of equipment (I have no idea how much an MRI or centrifuge costs and I’ll bet a lot of healthcare providers don’t know either) and procedures… I do like it that my doctor is open about discussing costs of care with me since my husband and I are on fixed incomes — no, not Medicare or Medicaide, but a fixed income nonetheless. Those of us campaigning for a private option are not blaming doctors for the high cost of our care. We blame the insurance companies, the pharmaceutical companies, the blatant waste we see when we visit or are admitted to hospitals.
Bruce,
I think you have to look at the whole picture, and not just how you wish things were. It is clear that you do not want to have to deal with the financial side of patient payment in your specific practice. Its not for you, you don’t like to focus on it, its uncomfortable to bring it up. I agree that it is uncomfortable and I often wish that I didn’t have to deal with it so directly – I wish that my staff or others could handle these things without me, frankly, having to be involved.
You probably could simply work for Kaiser, work for a hospital, or some other large entity that will handle all the icky money details and allow you to practice ‘pure’ medicine, unencumbered by other concerns.
But to jump from your discomfort regarding getting money from your customers to socialized medicine is quite a leap! You make a very bland assertion, to wit “Health care is a “service,” provided by health care practitioners, that does not belong in the competitive, so-called free enterprise marketplace.” But you do nothing to support this position. Indeed, it is hardly tenable. The only reason any other countries’ health care system is as good as it is (and I’m not saying they are good) is because of the many inventions and products developed in the United States (Germany and France contribute too, of course; but the companies in many cases intend to make their money in the United States). Much of the current technology that makes you the doctor you are, is due to the free market system that you would destroy. Take an inventory of the tools in the operating room that you use on a daily basis, and ask yourself who made them and why. You will realize, I hope, that the free-market has greatly contributed to your own efficacy as a physician. The future of medicine (meaning progress in medicine) lies with the free-market. Kill it completely, and you will find yourself, not standing still, but probably moving backwards.
And don’t be fooled by WHO reports regarding health care in this nation. (http://online.wsj.com/article/SB125608054324397621.html). If you eliminate shootings and automobile accidents, the United States has among the ‘best’ health care, even though that is hard to measure. It is difficult to control for factors such as obesity, diabetes, genetics. Another balanced article regarding these issues is here: http://tpmcafe.talkingpointsmemo.com/talk/blogs/khin/2009/10/does-the-us-have-the-worlds-be.php
I couldn’t disagree with Douglas more. I have worked as a salaried public doctor and at the other extreme as a solo fee for service doctor who often took the payment personally directly from the patient. I found the latter far far superior in cultivating the most therapeutic doctor patient relationship than the former–and superior to the more common system of having the insurance company in the middle as well. In that real fee-for-service system, the patient is not a supplicant hoping the doctor will stay on task and give him his attention. He, by handing over the fee, is the customer, the owner, the boss, who expects and demands full value. Only then does he become the patient. (I collected the fee before the visit). At the time he enters the exam room, I was fully cognizant that in addition to seeing a suffering human being who trusted me to help, I was seeing the person who put the bread on my table by their willingness to trade several hours of their labor for a much smaller part of mine. It really focuses the attention.
It also is a highly efficient system (in contrast to the dominant pre-paid third party system misnamed “insurance”) which instead of encouraging overutilization puts the payor in the room demanding value and accountability for expenditures.
It is both and humbling and empowering position to be in, and one that in my practice yielded the most consistent results.
When people are not paying for their care, there is a trend towards either being a supplicant begging of favors ( a position that some doctors like–but not the most helpful healing relationship) or an ingrate devaluing what they have not paid for. The first position cultivates passivity and the second non-compliance. Both foster poor communication.
In America both patients and doctors have a lot of freedom in choosing which they prefer. Freedom means responsibility for the consequence of the choice and that is what many in this nation, in a state of childishness, want to avoid.
The European systems are neither so uniformly different nor so uniformly beloved as he would suggest. British hospitals, in the most socialist of European systems, have been described as the dirtiest in Europe. Other European countries for the most part have higher out of pocket costs to patients than Americans pay on average. A great many Brit are so disenchanted with their system that, having paid taxes to fund it, spend from their remaining funds for private care supporting a growing and thriving private medical sector. Likewise with Canadians who fortunately nearly all live close enough to the US to seek care here when they chose.
I have also worked in the “group” system that he describes–a salary model mutlispecialty group running it’s own HMO. It too introduces distortions and distractions from optimal care. The perpetual quibbling over salary setting is itself a major distraction.
Sounds like Dr. Douglas (I note he is a surgeon) came around at about the right time to enjoy his career, and will be leaving before it really goes to Hades for the rest of us.
Of course, some of us who drank the “public service” Koolaid have been in Hades for a long while.
It amazes me how many otherwise very smart people think that (1) taking fiscal accountability and responsibility for the patient out of the equation, and (2) handing the system over to the government to run, has a snowballs-chance-in-Hades of working.
Dr Douglas is an example of an individual who may be extremely knowledgeable in one field and very ignorant in another. The health care “debate” boils down to how to allocate a scarce resource. Regardless what the good Dr may wish or proclaim, we cannot, neither individually nor as a society, have all the healthcare we want. It is time for society to grow up.
I have some sympathy both with Dr. Douglas and with Dr. Stone. If HC is free at the point of service, it will be overused and under-appreciated, or under-provided. If it costs too much, well, we see what’s going on now in this country. Doc 99 hits the nail on the head with an excellent post. There will always be trade-offs and there will never be perfection.
I prefer basic care for all, with a co-pay, plus the option of paying for insurance for fancier care. And yes, there are pros and cons to this approach.
It’s no wonder your healthcare is in such a mess when you turn on one of your own like this. The last poster has it right – ‘I prefer basic care for all, with a co-pay, plus the option of paying for insurance for fancier care.’
The sooner you all wake up to the reality that healthcare security is a vital factor in social and economic functioning the sooner you can accept it as a rightful public utility that needs proper planning.
Though I believe it to be Utopian to indicate that patients and doctors should never discuss money, reducing the importance of money in health care interactions by an order of magnitude would improve the delivery of health care and save money in of itself.
Given that many of the doctors who provide us health care are often running a form of small business, they end up dividing their attention between payment collection and practicing their skills. Reducing the overhead in tracking every billable service provided and dealing with different insurers would allow them more time to provide patient care with less effort and thus less cost.
It is in neither the patient’s interest nor the doctor’s to be trying to argue with a health insurer to obtain permission from the insurer to pay for a procedure or medication. This interaction takes time that comes out of the pocket of the doctor and ultimately the patient while at the expense of the patient’s health. These delays in patient treatment can lead to further health problems that result in greater health care expenses for the patient later on.
That said, cost containment must definitely be in the equation as it is the one real weakness in the Canadian and British systems. These systems provide excellent care, but because even those who don’t take an active interest in their own health are treated equally , costs are constantly a problem. However, this is better than a system where people who are otherwise looking after themselves can be rendered bankrupt through factors they cannot control.
You get what you pay for. Why can’t doctors understand that basic principle?
As long as medical care has a cost that is more than trivial, money does come into the equation.
Suppose a patient has a condition for which there are two treatments, one of which costs $N and has an 80% chance of success, while the other costs $10N and has an 81% chance of success.
Do you think that the patient and doctor will make the same choice between treatments if the patient were self-paying, versus if the patient’s care were fully paid by a third party in the immediate case (even if the patient eventually pays indirectly through insurance premiums or taxes or pay foregone due to having insurance premiums paid by his/her employer)? In the third party payment case, do you think that the third party might have some interest in how the money is spent (especially if the third party is the government, funded by everyone who pays taxes)?
“You get what you pay for. Why can’t doctors understand that basic principle?”
Skepticus, shouldn’t you direct this comment to the american people who balk over a $20.00 copay? As stated above by some posters, there is a complete disconnect between what that patient acutally pays (directly) and what things actually cost. Hence, the patient wants everything (he doesn’t directly pay for it), there is no incentive for the doctor NOT to order everything (in fact given the medical-legal climate there is incentive to order everything) and thereafter insurance costs continue skyrocket. The situation doesn’t take an economist to figure out, the issue to the solution.
When are we going to realize that a service has a cost whether it is paid for by the consumer or through taxing citizens? One way or another you are going to have to discuss payments for your services. It would be much easier to collect an upfront fee than to spend millions lobbying your favorite corrupt political party for a measly fee increase.
Patients will always be customers, no matter how you look at it. And what is wrong with that?
It is apparent that doctors are not a monolithic group and I’m sure there are many who share Douglas’ ideology. But, why is it you feel your ideology should trump others’ and that your version is the best version of how medicine should be practiced and everyone else should aspire to it?
There’s plenty of room for a wide variety of healthcare delivery systems some of which have not come to fruition because healthcare is not allowed to operate as a free market. If it were, Dr. Douglas could innovate a practice that aligns with his personal philosophy and meets the needs of patients. Have you sought opportunities that might fulfill your desire to operate as a public servant? You know you can work for the US government in underserved areas, make about $120,000 AND have your malpractice insurance covered by the government? Or, you can volunteer for Smile Train where your services would change the lives of many around the world. Better yet, you could start your own foundation, raising funds from philanthropic organizations, setting your salary and providing services to the uninsured and underinsured. America is the most generous nation on earth after all.
There was a time when medicine provided charity care but that was before medicine became so litigious. Dr. Douglas, your vision for healthcare is just that–yours –so go out and fulfill it but, don’t expect others to fall in line behind you.
If patients don’t pay for their care themselves, some unknown third party will ration it from the shadows.
Give us health care savings accounts, all of us, so we can pay for our care ourselves, and decide for ourselves what is worth the money and what isn’t
Comments on this entry are closed.