Dr. Val left a comment to my last post which, as I composed a response, started getting longer and longer and morphed into a post in its own right.
Just wondering what you think of the physician shortage and what that would mean for a universal coverage system?
Also - PandaBearMD had an interesting story about a patient who came to the ER for mild constipation. He believes that the primary problem with the healthcare system is human stupidity, enabled by malpractice attorneys. :)
As an intern, I once saw a recent immigrant who believed that not having a bowel movement for a day was not normal. He also was accustomed to going to the hospital for all medical care. He turned up in the ER with a chief complaint of constipation.
Yep, it's pretty frustrating. People don't behave in ways that the educated and informed consider smart. Even intelligent people without the help of a malpractice lawyer can behave in a self-destructive manner. We are in a position to help and contribute something positive in people’s lives but often find our time wasted.
It is not an efficient use of our skills and is particularly frustrating if we feel poorly remunerated.
As for the physician shortage, I’m glad you reminded me, Val. Sometimes I’m not too bright. One of the greatest impracticalities of widening coverage for the uninsured is that we don’t have enough docs to take care of all these people. This shortage is especially acute in primary care.
The remarkable shortage of primary care docs extends to certain specialties. Usual market forces of supply and demand do not apply simply in health care. More doctors create more demand. One more reason the mantra of “access, cost and quality” is absurd.
Increase access and you increase cost. There may be savings to be had in reducing inefficiencies and preventing complications, but they can never realistically cover the entire increase. Improving process quality may reduce some additional inefficiency, but health outcome quality derives from patient behavior as well and thus is much more difficult to change with health care delivery interventions.
We need more doctors, especially in primary care, used efficiently (focus on process quality), extending coverage to those in greatest need and the simple acknowledgment that it will cost a lot of money. So why is Medicare cutting physician reimbursement? Well, that's another post, isn't it?
What is the reason to spend so much money covering the unwashed, uneducated, self-destructive mass of humanity?
Because it’s the right thing to do.
10 comments:
I'm reminded of the musings of former Surgeon General Koop. We can choose unlimited access, the newest technologies, or cost control. But we can't have all three. My question is, "Who determines the optimal percentage of our GNP to spend on healthcare?"
Ms. MOM @ MOMrants.com
Right on the money... tell the kids they can have anything they want, but they can't have everything they want.
Funny how life works, huh?
The capitalist response to the GNP question is "the market." The government does it in many places, but there are advantages and disadvantages to either approach.
My question is, "Who determines the optimal percentage of our GNP to spend on healthcare?"
The answer is the free market. Most of the problems facing health care, including the PCP shortage, are the result of various groups of "experts" trying to "determine" outcomes that the market will provide if the "experts" will just get out of the way.
I think you're right, the market should be the final arbiter. The caution is that there are few examples of completely free markets that function efficiently without some degree of regulation.
Regulation is often required to MAKE a market, for example, when there are asymmetries of information which could lead to an unfair advantage.
So I wouldn't say that all regulation is bad, but that the regulations and policies that are currently in place are simply ill-advised.
Thanks for the hat tip and answering my comment, ZA. KevinMD put this post on his power 8 this week. We're a good team. :)
The solution to the physician shortage is quite clear: increase the supply. The easiest way to do that is to eliminate ALL credentialing requirements. Doctors insist upon performing profitable procedures (i.e., the 3 minute office visit) that less qualified people could do just as well.
Plus, the dirty little secret of medicine is that from a macro level it does very little good. As has been exhaustively demonstrated, increased health spending has little to no effect on macro-health indicators.
http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medicine-in-half/
Let's stop taking medicine so seriously. Let more people practice it and more people will have access. Given that medicine does so little for people, government should not be concerned about healthcare providers' credentials & qualifications.
One of the factors driving up the costs of medicine is the legal monoploy created as a consequence of teh Flexner Report in the 2nd decade of the past century. It has served us well, but the implied contract between physicians and society at large has been steadily eroded at the periphery by nuts on TV who have never seen the inside of physician's work room and the innumerable interests who would like to sell us all a bunch of snake oil in the guise of health care.
For an educated person to suggest dismantling Donabedian's first and most basic level of quality assurance is unthinkable.
But, of course, licencing requirements are a little tight. Increasing mobility and removing some restrictions on physicians may help improve competition.
"For an educated person to suggest dismantling Donabedian's first and most basic level of quality assurance is unthinkable."
Odd, Milton Friedman famously suggested that. I guess he wasn't educated; he only won the Nobel Prize.
Hey, others have had too much to drink on occasion.
The statement is out of context, so outrageous as to require a reference and preferably not from the same speech where he called the entire US health care system a bunch of communists.
Milton Friedman was a brilliant economist and also prone to making catchy statements for public consumption that are easily distorted. He was also not involved in making determinations of qulaity assurance in medicine.
Einstein was a genius, but I'm not sure he was right theologically.
Friedman's statement was not out of context. It was from a famous essay. I quote:
Milton Friedman wrote,
"I am persuaded that licensure has reduced both the quantity and quality of medical practice.... It has reduced the opportunities for people to become physicians, it has forced the public to pay more for less satisfactory service, and it has retarded technological development.... I conclude that licensure should be eliminated as a requirement for the practice of medicine."
He expressed this idea in numerous other works: Milton Friedman and Simon Kuznets, Income from Independent Professional Practice (New York: National Bureau of Economic Research, 1945); Milton Friedman and Rose Friedman, Free to Choose (New York: Harcourt, Brace, Jovanovich, 1979).
Consumers don't need boards and other professional organizations to protect them. The market can indicate quality and do a better job than credentials--and allow more people to practice, reducing costs.
Only dirty rotten guild monopolists would disagree . . . . so what does that tell you about ZA?
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