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.

The Problem of Modern Healthcare, pt. 2: Who Pays is Moot

From the New Yorker Article mentioned in part 1 of this series, the most crucial three paragraphs:

As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care.

Emphasis mine. Not that the single-payer/insurance debate isn't a valid one. But it's not a valid one when it comes to absolute cost. That will come from changing the autonomy of doctors, which I discuss in part 3 of this series.

The Problem of Modern Healthcare, pt. 1

The New Yorker recently had an article examining how healthcare in the US goes wrong. The article is a great read, in-depth and devoid of the classic free-market/single-payer argument that pervades the discussion of healthcare reform in the US today. Notably, the article focused on two separate methods of healthcare practice in the US. Healthcare in McAllen (in Hidalgo County), where average medicaid costs are $15,000/person, and the practices of the Mayo Clinic, which costs medicaid an average of $6,688 per person. McAllen also has some of the poorest health of anywhere in the nation, while the Mayo clinic is a national leader in quality. The fascinating part of the article is that these differences happen within the current free(ish) market for healthcare in the US, and they go against standard logic that more $ = better. Here's my breakdown of the salient points in the article:

The McAllen Model:

• high doctor autonomy
• doctors paid per service rendered, not salaried
• extra tests/medicines incentivized
• do the expensive thing by default
  
• reliance upon patients with medicare = almost unlimited pool of money available to patients
• patients always choose more services, assuming more = better
• the culture of the doctors is very much medicine ==> wealth
• as a corollary, doctors make millions and are the major landowners in the county
  
• this is rather justified by the high initial costs of getting into and practising medicine
• the other justification for such wealth accumulation, fear of/protection from malpractice lawsuits, isn't really a threat in Texas, where McAllen is located

The Mayo Model

• doctors salaried, at a decent pay level
• doctors paid in 6 figures
  
• doctors work in concert as medical team, rather than as individuals
• preventative medicine is offered more consistently, as doctors have no reason to want to do more expensive things later
• wait to see if low-cost methods work before recomending expensive methods
• patient-first healthcare considerations are emphasized

While this may seem obvious (profit-incentive for doctors doesn't equal good care for patients), it's a point that renders almost moot the debate over single-payer healthcare. (See part 2 of this post for a full excerpt explaining why).

It does, however, is present a strong case for doctors being civil servants (or quasi-civil servants, which I'll get into in part 3 of this post.

George Will: Wrong on Language

George Will, it seems, is taken to inaccurate hyperbole about personal pronoun usage by our sitting President. This is really no surprise, since he has frequently overstated cases against our president before, but it is nice that a linguist complaint now joins those raised earlier. The best line?

Now, maybe there's some selection of Obama's interactions where his use of the first person singular pronoun is higher than expected for someone in his circumstances. Alternatively, maybe George F. Will is a bullshitter, who doesn't bother even to ask one of his interns to check whether the alleged "facts" in his columns are true or false. We report, you decide.

Men and Their Wars

A cousin of mine, when asked what kind of museum she wanted to go to, said "Not one about men and their wars". We're in DC right now - museums are what one does, and so this was rather nontrivial. I am, as you may have guessed, rather interested in War. That said, it's perfectly reasonable to defer to something we all like, like the Natural History Museum, for our DC time. That can be done if one dislikes war, is upset by it, is made uncomfortable or angered or has a hostile reaction. Valid reasons all for not going to a war museum. They are not, in my mind, reasons to skip a history museum. This wasn't about not liking history; this was about 1) treating the whole of history as a series of wars, and 2) treating war as an exclusively male phenomenon.

1. The vast majority of history is the developments, changes, and evolutions in human society, as well as interactions between separate human societies, during peace time. Or times of relative stability - in ages of small-scale and irregular war, it is challenging to classify everything as peace; neighborhoods post-Katrina New Orleans, for example, could be labeled war zones, but that doesn't remove the story of New Orleans from the complicated period of domestic US policy we classify not as an actual war but as the War on Drugs. In order to address the social problems/challenges of such a city, we can't write the violent nature of it's present state off as a discontinuity from the whole prior history of the city; yes, Katrina is a delineating point, but one chaotic force of natural violence isn't the be-all end-all of violence in the area. It is far, far more complicated then that. We don't write the history of New Orleans as a series of unfortunate events beyond human control with no interlude - we write it as catastrophe-survival-adaptation-relaxation-catastrophe. Hurricanes, plagues, and, yes, wars, all serve to mark and identify the end-periods of eras, but the history isn't "this crisis made all this happen". It is "this historic tension, altered by this violence, led to this future, thanks to the actions of these folk". Writing it as a series of crises cheapens the history of the crises and of the city. More than that, though, it is inaccurate - they are both parts of the coherent whole of human experience. To treat history as nothing but war would be to do chemistry with exactly one element - not just dull and useless, but rather impossible. Treating history as a full range of experiences means that yes, it gets more challenging and complicated, but it also means that you are actually treating the subject as though it has worth.

2. War is not an exclusively male phenomenon. It is a predominately male phenomenon, but exceptions at all levels abound: espionage at all times in history, at the command of warring nations in the form of Hatshepsut, Zenobia and Boudica in antiquity, as well as Indira Ghandi, Golda Meir, and Margret Thatcher in the past century, as well as countless others throughout history. On the field of battle itself, women fought in defense of Madrid during the Spanish Civil War, and in many specific instances wonderfully compiled here. History is not devoid of women in military roles. What is interesting, then, is how exceptional all these cases are - war is an incredibly gendered phenomenon. Perpetrating and fighting in war has for so long been an overwhelmingly male phenomenon (and, as corollary, women have been especially victimized by war). But that shouldn't make war an irrelevant area of concern for feminists - the gendered nature of conflict should be especially interesting for that reason, not less so.

My point is this: if one objects to studying history because war is unpleasant and history means covering wars, then one should say so. But don't object to the study of history because war is a gendered phenomenon, because that is exactly why it is relevant to gender studies. And more broadly why it is relevant to people as a collective whole.

I really dislike George Will

In my own field, George Will gets the very concept of State Capitalism wrong to hate on Obama.

In the field of climate change, George Will gets the very facts wrong, claiming a past global cooling consensus from a paper whose very point is that there was never a global cooling consensus.

And just today, George Will is upset over the very idea of changing transportation within this country, singling out my birth city of Portland, Oregon as this dreaded, unattainable dystopia where people bike to work. Most notably, he hyperbolizes that we will never reach a point where 0.01% of Americans bike to work. However, 0.4% already do, a number "forty times larger than a percentage that Will deems unrealistically utopian." (Edit: wonkette has a nice angry take on the transportation issue as well)

So, dear readers: can you find another example of George Will deliberately getting facts wrong in a field that isn't Keynesian economic policy, global warming, or transportation? Comment with any and every example you can find, hopefully in a "new field, new error" format. It'd be nice to have a comprehensive list of this online.

George Will: Wrong Again

Editor's Note: This was originally sent in to the Albuquerque Journal as a letter to the editor. They didn't print it, and it is still almost-timely, so I'm posting it here. Relevant links: George Will's article ad-gated at the Journal or free-membership-gated at the Washington Post or in its entirety and with handy visual aids online here . Ian Bremmer's article in Foreign Affairs is paid-subscription-gated, but you can listen to the whole of it as a podcast.

Edit #2: Thanks to commentor ThingsBreak, here's a .pdf of Bremmer's piece. It is really, really good.

On Monday, the Journal published an article by George Will entitled "Too Many 'Free Markets' Belong to the State - Really". Will spends his time misinterpreting Ian Bremmer's article "State Capitalism Comes of Age." Substituting bias for an understanding of the material, Will disputes Bremmer's premise that "the state must eventually retreat" from long-term state control of capital. Will says, instead, that Bremmer is "probably wrong, because he underestimates the pleasure politicians derive from using their nation's wealth as a slush fund for purchasing political advantage." Nowhere in Bremmer's article does Bremmer exhibit an underestimation of political greed - instead, he refers often to the close ties between economic and political leadership in both Russia and China. Will also implies that the new states that have taken ownership of their free markets (Brazil, India, Turkey, and Mexico) have done so out of greed; Bremmer instead explains that they did so because these countries had "a much weaker rule of law than was the case in established free-market democracies".

The country that Bremmer does not feel is at risk for permanent state control is the one that Will writes the most about - the United States. Nowhere in Bremmer's article is there a basis for government in the US becoming "the only agent and the sole arbiter" of American happiness. Instead, Bremmer states correctly that "in the United States and in Europe, the power of the invisible hand remains an article of faith. Governments on both sides of the Atlantic know that to maintain popular support, they must keep their promises to return the banking sector and large enterprises to private hands once they have been restored to health." This is a far cry from the authoritarian USA Will reads into Bremmer's article. Once again, Will cherry-picks the his quotes, and misses the truth.