Friday, June 12, 2009

The Problem of Modern Healthcare, pt 3: Doctors as For-Profit

As outlined in post 1 of this series, McAllen (in Hidalgo County) manages to have the highest healthcare costs in the country at the same time that it has among the worst care provided. This is in stark contrast with places like the Mayo Clinic, where low cost and high quality healthcare combine. The most obvious and glaring difference between the two systems is the goals of the doctors. In McAllen, they are for-profit and paid for procedure, and they let this focus determine the kind of care they provide. At the Mayo Clinic, doctors are salaried, and so while they are well off, they have no need to order procedures for procedures sake. Instead, Mayo Clinic doctors put the emphasis on effective care, rather than expensive care. And it works.

If this sounds a little socialist, it's because it is, in a way. It is very much a not-for-profit ethos, and it knows that the profit motive here doesn't lead to best care. The US already has a class of people engaged in nonprofit work, as government employees, with 6 figure salaries, who could stand to make a lot more in the private sector but instead function as civil servants. The federal court system is a great example of this - it combines job security, meaningful work, a generous pension, and a 6-figure income to take brilliant and qualified people and employ them appropriately.

The example isn't perfect; the fact that the private practice of law generates millions for the kind of people sought out as public servants limits the candidate pool. And in medicine, it makes the Mayo Clinic model riskier, as doctors are drawn towards the greater wealth accumulation (and accompanying security) of for-profit medicine. But that doesn't' mean a civil-service model for healthcare doesn't exist.

In part 2, I mentioned that the single-payer debate is mostly meaningless as far as the pricing of medicine is concerned. Government can, however, be much more involved in price structuring of medicine, and as the payers of doctors under a single-payer program, they can change medicine from the source of wealth it is to McAllen doctors into a stable, well-paying civil service job. As a corollary, government can also offset the high costs of medical school with loans and debt forgiveness, a power almost unique to government and one that would make the profit-seeking of doctors less vital. This, more than anything else, is the promise I see inherent in any talks of universal healthcare reform. But it doesn't actually require a single payer model to come into being.

The Mayo model came about in a very profit-centric world. It thrived and expanded. Government doesn't need to be in control to allow that kind of success to continue. They just need to stop disincentivizing against it. Providing debt forgiveness for doctors who work in Mayo-model or similar clinics, changing away from a pay-for-procedure model, and providing additional benefits to salaried doctors are all within reach of government legislation.

It just takes effort, observation, and political will.

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