Though I am suspicious of the notion that “preventative medicine will save money,” I did get a kick out of this story:

Gawande talked to one of these health consulting companies, Verisk Health, which sorts through the medical data of over 15 million employees. One of their clients includes a “big information-technology company on the East Coast” with over seven thousand folks in its insurance plan. It hoped to reduce its $40 million in health care spending by raising its employees’ insurance co-payments, hoping that would make them rethink unnecessary doctor’s visits (Sniffly nose just needs a visit to the cold aisle of the pharmacy), think twice before getting frivolous tests (I’m sure that itch is just temporary!), and not treat prescription medicine like candy (Mother doesn’t need her little helper three times a day).

Instead of falling, the company’s medical spending increased, by 10 percent yearly. When Verisk analyzed the data, they discovered that the employers’ plan had back-fired. Medical costs for the majority of employees had been capped, but there was a flair-up coming from early retirees who were the “sickest links” in the insurance plan. They cut back on their medical costs by visiting doctors less and taking their prescription medicine less frequently after the co-payment increase, due in part to their fixed incomes. That made them sicker. One retiree wound up having a heart attack that “necessitated emergency surgery and left him disabled with chronic heart failure.”

The preventative medicine thing *may* be more true when it comes to some patients (like older ones). In any event, who doesn’t love a story when a greedy corporation gets bitten in the arse (in such a direct manner) for trying to cut corners?

As Physicians’ Jobs Change, So Do Their Politics

They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states. {…}

Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors’ groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.

Even the issue of liability, while still important to the A.M.A. and many of its state affiliates, is losing some of its unifying power because malpractice insurance is generally provided when doctors join hospital staffs.

Because doctors are, apparently, completely unaware that the medmal liability insurance that their employer has to pay on their behalf comes at the expense of the value that they add (and therefore the compensation they can demand) to the overall organization. Oh, and the reimbursements they make are completely unrelated to how much of a salary that they can expect. I can buy that these things are not as much on the forefront of their minds as they previously were since they are negotiated or paid by their employer, but there’s something in the air in Maine if doctors up there no longer think medical malpractice doesn’t matter to them. Or more likely, it’s not an issue there because the issue isn’t pressing because Maine has remarkably low malpractice insurance rates despite the lack of traditional tort reform.

It also entirely contradicts my experience. Even in tort-unfriendly states, frivolous lawsuits weigh very heavily on doctors minds. It weighs on my wife’s, despite the fact that her medmal is paid for. It matters above and beyond dollars and cents. It’s partly a matter of pride, wherein a doctor doesn’t want to have to explain to a jury of 12 people who know little of medicine while the baby didn’t have a chance while John Edwards is on the other side talking to the dead baby’s spirit. Maybe this is impossibly arrogant. Maybe this is foolish. But in the years I have been surrounded by doctors - some liberal, some conservative - I have never once heard that it’s not a big deal. If anything, I think that they are too obsessive over it. But then, that’s easy for me to say because it’s not my ass - and career - on the line.

Unfortunately, this “see, they’re coming around!” tone taints my view of the rest of the article. But really, I think that there is something to the article in its totality. Particularly in family medicine, which is disproportionately populated with women and less entrepreneurial men. But I wouldn’t be surprised if it’s happening more generally. Doctors are, I think, caught between two realities. The first is that they have lived in a very Republican world. They worked hard, they were smart, they got ahead. Others that worked hard and were smart got ahead, too. It’s a very meritocratic atmosphere. Then, when they’re out of their education and residencies and/or fellowships, they are thrust into a world where they have mountains of debt but are getting taxed like they’re rich. Further, they’re taking care of people who have often broken their own bodies through ignorance or gross misjudgment and expect someone else to put them back together (almost always having worked in charity hospitals, where the expectation is that you will do so on someone else’s dime). This all lends itself to a more conservative worldview. Even the liberal docs I know have suspicious attitudes towards those below the working class.

But on the other hand, there’s this: they’re educated, high-earning individuals. This group has been trending Democratic for a while now. Regardless of the merits of conservatism and the Republican Party, the peer pressure is leaning against it. The Republican Party has become increasingly embarrassing, on a social level. The party that went from embracing George H. Bush to embracing his son to embracing Sarah Palin. Yes, yes, conservatives can argue that George W. Bush wasn’t actually conservative or was a RINO, but among the friends and colleagues of educated individuals, that is not the perception. Medicine and engineering seem to be the last two strongholds of educated, white collar (or white coat, anyway) Republicanism. So, especially when considering the demographic shifts (women into medicine, foreign imports into engineering), it’s not surprising to see the movement.

Obama, whether by benign policy or crude politics, is making the transition particularly easy for primary care physicians. Regardless of our resistence to his health care plan, there is at least the sense that Obama “has our back” in a way that previous presidents did not. By “has our back” I mean the backside of primary care docs and their families. He named a primary care doc as surgeon general. His reimbursement restructuring favors primary care over specialists. At least rhetorically, he “gets it”. He also defines “rich” as income above what most primary care physicians will make (and those who do make that much are more likely to have been doing it a while and less anxious about it). If it’s all rhetorical or political posturing, it’s really quite shrewd. Driving a wedge between primary care docs and specialists isn’t particularly hard and primary care docs are more likely to be supportive anyway, for a variety of reasons (more likely to be female, less likely to be money-driven).

I don’t know how this would translate to specialists, though, and the extent to which the Democrats may be making gains there. Obama hasn’t been as kind to them, though he might not need to be. Since they earn a lot more than their primary care counterparts, they might feel less stingy when it comes to taxes as they can pay off their student loans and such a lot faster than primary care docs can.

Or it’s possible that the NYT is drawing a trend from nothing but some weirdness in Maine.

Over in Catholic-land, there’s a news story making the rounds about a Nun excommunicated, and kicked off of a hospital’s ethics committee, for approving of an abortion.

By strict reading of Catholic doctrine, in the “no abortion, nohow, nowhere, nowhen” sense, it starts to sound plausible. Until you realize that there’s more to the story.

In sequence:
- The mother had 4 other children to take care of.
- The mother had partial heart failure, the result of pulmonary hypertension, a condition made worse by pregnancy - so worse, in fact, that she was considered too frail to be moved to an operating room, much less moved to another hospital.
- The assessed risk of her death, and the death of the 11-week fetus along with her, was “close to 100 percent.”

Eleven weeks is not considered remotely “viable” for an early birth. It’s not even halfway to the normal 24 week standard currently in place.

So the nun had to make a very difficult decision. According to the Catholic Church, again, there is a “no abortion, nohow, nowhen, nowhere” position. Except that it’s not quite the case as that seems. A “Directive 47″ exists which says the following:

Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.31

Reverting to initial conundrum: suppose you are given a choice. On the one hand, you have a pregnant woman with other kids to take care of. Her chance of living long enough to deliver the baby, even as a 24-month preemie, is around 0.1% or less. If she dies, the fetus/baby goes with her. On the other hand, if you perform an abortion, e.g. “terminate the pregnancy”, then the woman’s chances of living go up significantly, to the tune of better than 90%.

What do you do?

Britain is looking at eradicating labeling from cigarettes:

“The government accepts that packaging and tobacco displays influence young people, so there is no time to waste. It may take years to pass a new law on plain packs but the law on tobacco displays is already on the statute books and comes into force next year.”

Dr Alan Maryon-Davis, professor of public health at Kings College London, said: “It’s a very welcome statement from the health secretary and a good example of how the government can help people choose a healthier way of life by ‘nudging’ rather than nagging.”

But Simon Clark, director of Forest, a lobbying group that opposes smoking bans, described the move as a “cheap publicity stunt”.

He said: “There is no evidence that plain packaging will have any influence whatsoever on smoking rates. Also, the policy is designed to discriminate against smoking and stigmatise the consumer, which is totally wrong.”

Good.is does a mock-up. Truth be told, I wouldn’t mind that one bit. In fact, I consider it far preferable to the Australian method of putting graphic imagery on packs. I’ve thought to myself if the government ever does the latter, I will probably throw out the box upon purchase and put the cigarettes in something else. That probably means that it’s effective on some level. The Good.is mockups, though, wouldn’t phase me a bit.

More effective than that (though less effective than gangrene) would be to make them less rather than more plain. I don’t want to carry around a box that’s hot orange. Of course, part of the idea is for young people and they might be more likely to respond favorably to wild coloring. Of course, the boys will probably respond positively to gangrene as well. I was vociferously anti-smoking when I was 12, but I might have fished empty boxes out of the trashcan to see how many of the disease-boxes I could collect. Boys are like that.

Does packaging lure smokers? Well, there’s two questions. The first question is whether it entices people to smoke. That I’m not sure about, though it probably does have an effect on the margins. I’m not sure it has enough of an effect to justify the time it takes to enact this law, but maybe so. The second question is whether it entices people to choose a particular brand. It does. There are a lot of brands out there and two of the main brands I smoke, Maverick and USA Gold, got my attention with their box. Mavericks had, at the time, a really sleek black and gold box that was hard to miss. USA Gold had an interesting logo. However, while the packaging got me in the door, it was the taste that kept me there. With other off-brands, I never made it through the pack.

I am sure that the tobacco companies have some research on this. I wonder what it says. Given how opposed they are to the idea, maybe I am deeply underestimating the effects of packaging to youngsters. You might think that they’d be looking at this as a way out of paying marketers money without losing marketshare to the ones paying the marketers. But they don’t, either because it is effective or because they think their marketers are better than the other guys’.

From The Independent:

There are zillions of diets and research shows that one in four of us are on one at any given time. But none of them is proven to work. Scientists at the Kissileff Laboratory for the Study of Ingestive Behaviour at the University of Liverpool found that calorie-restricted diets create powerful cravings for the very foods you are trying to avoid.

“Dieters not only have a greater preoccupation with the foods they have been forbidden, but with food more generally – with the result that they have stronger urges to eat more frequently and a greater feeling of being out of control with their eating,” says the centre’s director, Jason Halford.

The last two times I have gone back to Delosa, I let my eating habits completely fall by the wayside. So much so that, by the end of it, I barely wanted to eat at all. Yet eat I did, because it was the only opportunity to eat foods I can’t get up in Arapaho. Upon returning in November, I told myself after I returned that I was going to need to start getting back to my old ways lest I form bad habits in Arapaho. I figured that it wouldn’t be hard because gawd knows I was full. Yet, I found the adjustment quite difficult. I had assumed it was because of the metabolic whiplash of going from 3000 calories a day to 1800. This seemed to be confirmed when, after a week or so, I found myself back on my Arapahoan diet.

Something else happened during that week, making me wonder if it was about metabolic whiplash at all.

This time when I returned, I said the same thing to myself. And after a week, I could still feel myself eating more than I should. I weighed myself only to discover that I had gained weight on my return. This freaked me out. It’s one thing to gain weight in non-reproducible circumstances like a trip back home, but something else entirely when it was the environment that I was likely to stay in for the forseeable future. That day I told myself I had to get my eating under control. It was only that night when I remembered a couple of relevant factors: (1) I had been eating a lot of peanuts, which includes salt and (2) I hadn’t taken a dump in a few days. The next day, both were taken care of (I ran out of peanuts and laid down a beauty treasure of a BM). My weight dropped right back down to wear it was. Whew.

And since then, I have been eating my typical Arapahoan diet. The “something else” above was that I stopped thinking about my intake. Stopped worrying about my weight. And I think, as a result, started eating less.

This got me thinking about the above and the seemingly intractable nature of weightloss. How both of my serious weightloss accomplishments have come with relatively minimal thought about dieting or losing weight and how every overt attempt lead to misery and failure. Or at least had started out that way. And how a huge 20lb drop occurred right between my move from Cascadia to Arapaho and between arriving in Arapaho and finding a scale that my mind could use to monitor my progress and whatnot. That last part could be coincidental (the weight loss always seems to come in drops and plateaus).

Whether we call it dieting or dress it up as a “lifestyle change,” there’s no real way to consciously change your eating habits without constantly thinking about food. And it’s really hard to spend all day thinking about food without, you know, wanting some. It makes me think more and more that obesity is merely a reflection of psychology. Even the physical hunger is a product of your body taking signals from your mind. When I was preoccupied with my Delosa-weight and eating more, I wasn’t just eating more for the sake of eating more. I was hungry. My stomach was growling. I thought that my stomach was sending my head signals, but more and more I am thinking that it was merely bouncing them right back.

I hesitate to think of it this way because saying “it’s all in the mind” makes it sound easier. A lot of time and effort is spent looking at ADHD and depression from a brain-chemistry perspective, in part to sympathetically say “See! It isn’t all in the mind!” But we don’t know if the chemical reaction is merely a response to thought patterns that could be broken if we could only figure out how. The problem is, whether we’re looking at ADD, depression, or obesity, we’ve never figure out how. We tackle the first two with chemicals, which may primarily serve to short-circuit the cycle. If a pill-based cure for obesity ever comes, I wonder if it will be along those lines, changing how we eat by changing how we think (perhaps just doping us up for a couple of months until our bodies adjust) rather than changing the way our body processes food.

Pointing to this Denver Post article, Superdestroyer comments:

One point that the article hinted at but would not say is that only men and generally white men are the only ones who are going to take jobs in small towns. No woman or black who has lived in an urban setting is going to move to a small town where there is no Starbuck’s, Talbot’s, or gyms.

He may be right on the race front, but I’m not so sure about the gender one. At least, what I’ve seen suggests that he is not. Clancy came from a rural medicine residency and on top of that went to a rural medicine fellowship and women were underrepresented in neither. Yet, at least stereotypically, what Superdestroyer says makes sense. So what are some possible explanations for this:

• My observations do not reflect reality. We would need some data to support this one way or the other, and neither Supes nor I have any.
• The stereotypes of women and rural settings are wrong. Given how women tend to be overrepresented in urban areas, this does not appear to be the case. It may have to do with Talbot’s, though it could be related to career opportunities. Rural areas tend to have more of them for men and fewer of them for women. Traditionally female careers tend to be more urban-centric. So perhaps there is no lifestyle preference at all but rather economic. I don’t buy it, but it could be I suppose.
• Female doctors are atypical of their gender and male doctors tend to have more typical female wives (and more stereotypical females at that). In other words, women industrious enough to go to medical school and the like may be the type that would prefer country life to the urban grind. I don’t know why this would be the case, though. I do think doctoresses are atypical women in many respects, but I don’t see why it would manifest itself in this particular way. Doctor’s wives, on the other hand, tend to be more stereotypical. They did what mothers have been telling their daughters to do for decades. Being a doctor’s wife may be a lot less attractive if it means moving to the sticks. So the guy that thought he might practice in the sticks decides that he’ll make do in the suburbs. Notably, in the relatively short period of time I’ve been in Callie, I have already heard stories of people that come here for a job and then leave at the insistence of their unhappy wives.
• Women are overrepresented in the areas of medicine that rural places need. I think this is true. For a variety of reasons. Women may prefer the shorter residencies in family medicine. They may prefer the kind of medicine that is more focused on getting to know the patient rather than just cutting them up. Correlary: Women are more attracted to rural medicine specifically. Clancy went into rural medicine with an eye towards full-spectrum medicine because it allows her to take care of patients from the cradle to the grave. Internal medicine may not have a residency any longer than family medicine, but it may be that the latter is more attractive to women because they live up to the stereotype of forming lasting relationships (in this case, with their patients).
• Women are at the bottom of the food chain. For whatever reason, they don’t get into the good residencies and be able to compete in the mildly more competitive suburban environments. And they may find rural to be better than strictly urban (as in, undesirable clinics in the wrong part of town) for safety reasons. It’s possible, but it doesn’t seem true in my experience. Most of the women I know that went into rural medicine seem to really want to be there, rather than being cast off there.

An interesting story from the Boston Globe:

Geneva Fielding, a single mother since age 16, has struggled to raise her three energetic boys in the housing projects of Roxbury. Nothing has come easily, least of all money.

Even so, she resisted some years back when neighbors told her about a federal program called SSI that could pay her thousands of dollars a year. The benefit was a lot like welfare, better in many ways, but it came with a catch: To qualify, a child had to be disabled. And if the disability was mental or behavioral — something like ADHD — the child pretty much had to be taking psychotropic drugs.

Fielding never liked the sound of that. She had long believed too many children take such medications, and she avoided them, even as clinicians were putting names to her boys’ troubles: oppositional defiant disorder, depression, ADHD. But then, as bills mounted, friends nudged her about SSI: “Go try.’’

Eventually she did, putting in applications for her two older sons. Neither was on medications; both were rejected. Then last year, school officials persuaded her to let her 10-year-old try a drug for his impulsiveness. Within weeks, his SSI application was approved.

“To get the check,’’ Fielding, 34, has concluded with regret, “you’ve got to medicate the child.’’

There is nothing illegal about what Fielding did — and a lot that is perhaps understandable for a mother in her plight. But her worries and her experience capture, in one case, how this little-scrutinized $10 billion federal disability program has gone seriously astray, becoming an alternative welfare system with troubling built-in incentives that risk harm to children.

I suppose it’s only a sense of ethics that would prevent Fielding from simply throwing the drugs away (and the law from selling them). It’s an interesting dilemma. I don’t have any problem helping out parents with kids that have disabilities. My ex-sorta Delsie ended up marrying a man with a disabled (like, seriously disabled) daughter and even though she’s very positive and upbeat it sounds like a real handful. And really expensive.

Of course, when you implement these programs you always have to be on the lookout for perverse incentives. Whether Fielding is genuinely doing wrong or not is unsure. That’s part of the problem when it comes to issues like ADHD, depression, and other things. With Down Syndrome, it’s an up-or-down thing. A kid with serious autism pretty obviously has something abnormal about them. But a lot of psychological issues are difficult to nail down. There’s no good blood-test and brainscans and the like are expensive and as much a product of learning about disorder (through subjective diagnosis) than objective diagnosis. This has (unfortunately) lead some to believe that the entire disorder (ADHD in this case) is really a “disorder” or simply a product of or metaphor for our times. Or that it’s simply a matter of laziness.

Daniel Carlat is a doctor frustrated with parents coming to him for the reasons cited in the Globe article:

As a psychiatrist besieged by patients asking me to diagnose them with ADHD so that they can get a prescription for Ritalin, I both agree and disagree with Dr. Klass. Yes, there are clearly some patients at the extreme end of the severity spectrum whose brains simply won’t allow them to focus. These are the patients who end up being enrolled in all the “convincing” neurobiology studies outlined by Klass — the studies that suggest that ADHD might involve frontal lobe problems and dopamine deficiencies. But for every child or adult with obvious ADHD, I suspect there are several who have a “soft” or even, yes, a “mythical” version of the disorder.

The prototypical mythical case is the parent of an ADHD child who comes into my office saying that he or she tried their child’s Ritalin and found that suddenly they were incredibly productive at work. “I think I must have ADHD, doc.”

I then have to explain that Ritalin is a version of that old college term-paper completion engine — speed — and that studies show that just about anybody who takes an ADHD drug thinks more quickly and focuses more acutely. That doesn’t mean you have ADHD.

But what does? The inability to really answer that question is as much the problem as SSI, video games, medication nation, and a host of other things. That doesn’t, as Carlat notes, make it entirely mythical. But the ambiguity of it all is pretty problematic. It can be an attractive excuse for failure for some. If your kid having ADHD or not having ADHD is the difference between a few hundred dollars a month and better medical care, it’s not difficult for even honest and well-intentioned parent to determine that their kids probably have it. The ambiguity around diagnosis may make it hard for a psychiatrist to argue otherwise (and they can always find another psychiatrist if they do). It’s really not surprising that people would respond to these incentives. Some are dishonest, some are conflicted like Fielding, but a lot will simply believe what it is advantageous to believe.

A couple of Wall Street Journal articles of interest.

First, an article about consolidation in the health care industry:

Unlike Medicare and Medicaid, private reimbursement rates are determined by negotiations, often highly antagonistic. Insurers always attribute premium increases to the underlying cost of care, while doctors and hospitals always argue that there isn’t enough competition among health plans. Both claims are “true,” some of the time—but it depends on which side has more market power.

Insurers extract lower rates by steering patients and revenue to certain providers through their networks. Providers gain bargaining leverage when health plans can’t credibly threaten to exclude them, whether because their share of the market is too large or due to public demand for “must have” hospitals. Consolidation will increasingly feed off itself as providers and insurers vie to get the whip hand in rate negotiations.

Most neutral experts believe the balance of power has tipped toward providers over the last decade, though this isn’t always anticompetitive. Higher rates generally reflect investments in staffing, technology, specialization and sometimes consumer preferences. There is also the cost-shift to private insurance to offset Medicare’s price controls. However, most economic studies on hospital M&A over the last two decades show that consolidation increases unit prices, though there is significant disagreement over the magnitude.

If most neutral experts believe it, it’s probably true. A few factors are worth noting. If providers have increased leverage, it’s due in part because they’ve had to make sacrifices to get it. As the article copiously notes, consolidation in the health care industry is increasing. The local hospital bought up a number of the local doc practices and Clancy is an employee in the hospital. The job she interviewed in Gemini Falls was also part of a large, multi-practice group. Autonomy used to be one of the big plusses when it came to doctors but it’s no longer worth it. It’s sort of like an invading army forcing a local medieval town into the castle. Yeah, they residents have got the high ground, but only because they left where they want to be.

And I have to take this moment to point out that physician wages have, despite the leverage, been stagnant*. So where is this extra money going? I would guess it’s as the article said: infrastructure improvements. Probably increased administrative staffs, too. Clancy’s employer is building a new hospital, for instance (but they’ve also forced an essential wage-cut amongst at least some of the doctors). Another area of concern is that a lot of these infrastructure improvements can be geared towards things that will ultimately increase the costs of health care in the long run. Buying new machines that will perform expensive tests and the like**. Once you have these machines, you want to use them! So care and testing will probably become more aggressive and, hence, more expensive. There’s not much good to be said about the doctor shortage in this country, but in some ways it probably is keeping health care expenses down. You might pay doctors more than you otherwise would, but there are fewer doctors performing aggressive and ultimately unnecessary treatment***.

Also, did Medicare kill the family doctor?

Eventually, that disconnect (and subsequent program expansions) resulted in significant strain on the federal budget. In 1966, the House Ways and Means Committee estimated that by 1990 the Medicare budget would quadruple to $12 billion from $3 billion. In fact, by 1990 it was $107 billion.

To fix the cost problem, Medicare in 1992 began using the “resource based relative value system” (RBRVS), a way of evaluating doctors based on factors such as education, effort and specialized training. But the system didn’t consider factors such as outcomes, quality of service, severity or demand.

Today most insurance companies use the Medicare RBRVS because it is perceived as objective. As a result of RBRVS, specialists—especially those who perform a lot of procedures—do extremely well. Primary-care doctors do not.

The primary-care doctor has become a piece-rate worker focused on the volume of patients seen every day. As Medicare and insurers focused on trimming the costs of the most common procedures, the income and job satisfaction of primary-care doctors eroded.

If you wonder why it’s so hard to get much of a doctor’s time, this accounts for a lot of it. As mentioned before, doctorly pay has been stagnant. This is due to the fact that doctors have made up for what would be substantial losses by seeing patients in much more rapid succession. Due to the general nature of their work, there can simultaneously be a shortage in primary care (both in absolute terms and relative to specialists) and primary care physicians can be seen as “a dime a dozen” when it comes to negotiation. The result is fewer and fewer doctors going into primary care and more and more specialists which end up limiting what primary care physicians can do (for instance, Clancy can only perform cesarean sections because there are no obstetricians in town to object) which ends up making it so that primary care physicians get to do less of the things that might provide job satisfaction and pay boosts.

Specialization doesn’t have to be a bad thing, but at the very least you need a more complete “front line” to screen patients and refer them to specialists. This is an area where having mid-level providers may be more of a help. Or importing more doctors. I am skeptical of the notion that having more primary care docs (or docs in general) will lower health care costs without other substantive change, but it could help the front line problem. The only alternative to the supply-side is the demand-side, and it’s difficult to ask patience to triage themselves, determine that they don’t need care after all, or to seek the cheapest available option when their copay is the same no matter what they do.

One idea I have been toying around with is shifting more of the primary care to the government or insurance companies and let them worry about containing costs. I am not sure how much I trust the government to contain costs and I’m not sure how much I trust insurance companies to give patients a fair shake.

* - This isn’t a complaint. Doctors are still very well paid.

** - I don’t have any information on whether any of this is going on at Clancy’s hospital. But it’s an industry-wide issue.

*** - Some of this may be in the form of doctorly profiteering, but that’s not even what I am referring to here. Tests can be unnecessary but still be beneficial. Think of it like taking medicine to get over a cold two days earlier than you otherwise would have. It’s not necessary, but it’s nice. It’s nice, but it ultimately costs the system money. One of the peculiarities of the health care industry is that the two primary decision-makers, doctors and patients, often have little incentive to consider costs of treatment. Those whose job it is to consider costs, insurance companies and the government, face really bad publicity by stepping in and stopping payment on what a doctor thinks would be beneficial and a patient wants on the grounds that the substantial cost outweigh the smaller but potentially very real benefits.

Transplanted Lawyer has a well-rounded post on the subject of paying for emergency services:

So what is looking like the Outrage Of The Week in development is a Tennessee emergency situation. A homeowner in a rural area did not pay the annual subscription fee to the emergency services district and therefore opted out. Saved himself $75 a year and hey, times are tough, so you skimp on things. Sure enough, his home caught fire. And the firefighters drove out — not in response to his calls for help but rather those of his rate-paying neighbor, who feared that the fire would spread and harm his insured house — and watched the house burn down, ignoring the homeowner’s offer to pay the entire cost of saving his. So now the homeowner has learned a terrible, expensive, and deeply painful lesson about what insurers call “moral risk.”

Now, this looks awful for the libertarian purist. The guy said he offered to pay the firefighters their full expense for saving the property; they were already there and ready to go in case the fire spread out to the insured neighbor’s home. So why not go ahead and take his money? While there are a bunch of reasons one might suggest, bear in mind for all of them that the homeowner probably didn’t really have the money. After all, this is a guy who chose to not spend $75 or $100 or whatever it was on subscribing to the service in the first place. Desperate people will say pretty much anything to escape the pressure of their desperate circumstances and while I’m not passing moral judgment on that, I do think it’s reasonable to not place a lot of trust in a promise made by a person whose house is literally burning down in front of his eyes.

Saving the home would have to have been done as an act of charity by the fire department. One is never obliged to give to charity; that is the definition of “charity,” after all. An insurer is not obligated, and in fact would be foolish and doing a disservice to its regular policyholders, to take a premium on a policy at the very time that a loss was occurring.

There is the point that before voluntary subscriptions were available, the fire department simply didn’t service this area. A worthwhile point, but none of these economic arguments sweetens the taste of firefighters watching a house burn down.

The whole post is worth reading. The rest of this post is about the introductory ambulance part of the post rather than the fire part of the post.

The only thing I take issue on (and he may be completely right and I completely wrong) is that I think a lot of people abuse ambulances and emergency rooms and the like for lack of having a keen sense of the severity of the problem and the severity of the bill. My ex-roommate Dennis called for an ambulance for a problem that was, while urgent, nothing so serious that he couldn’t have had me take him to the emergency room. I don’t think he ever expected to get out of paying the bill. Likewise, I remember a case when Evangeline went to the emergency room for something that struck me as pretty non-urgent. She apparently hadn’t given much thought about what to do if she had a problem and her regular doctor couldn’t see her for a while. She didn’t exactly pay the bill on that, but it wasn’t a case where she knew it would get written off. She did have no idea how much that bill would be, though.

Prior to getting married to a doctor, having a regular doctor was something of an alien concept to me (except for eyes and teeth). We had a clinic that (for me, anyway) went on a first-come, first-serve basis. So you could always get in the next day. Even when I got pneumonia, I never visited the ER. But I was raised in a particular way with particular expectations. If the blood isn’t ongoing or you don’t have a limb flailing about, you don’t go to the emergency room. If you can avoid taking an ambulance, you do so. One of the jolting experiences upon leaving home and seeing the wider world is how different this was than the way that a lot of people approach things. If you’ve got a problem and that problem seems like it might be serious, you go to the doctor right away and the ambulance is what they associate with going to the doctor.

The only experience that I have personally had with ambulances was when my car caught on fire driving down the Interstate. Someone else called the ambulance. They didn’t need to take my anywhere, but they did tend to me and make sure that I was lucid and breathing right and other things that warranted a $500 bill (that insurance didn’t cover because there was nothing wrong with me).

The Well has an interesting piece by a doctor regarding the difference in managing health care for people versus those of our pets:

My own patients have a far harder struggle in every respect. My foray into the insurance world as a patient exhausted me and pointed out everything that was wrong with our health care system. How is that the simplest routine medical matters have been made so complicated by our insurance companies? Why does every encounter require a veritable girding up for battle? And how many patients do not get the care they need simply because they are defeated by the bureaucracy?

There’s a lot we can learn from animals in many facets of life — Lord knows, a nice massage behind the ears could do a lot of us some good — but I am consistently impressed by how much smoother veterinary medicine runs. Of course it’s too simplistic to make a direct comparison, but I hope that in this ongoing health care reform we consider ways to make things easier for patients.

As Dr. Ofri points out, insurance companies don’t exactly have incentives to make collections easy. I agree with her that it’s not an accident that they make it as complicated as they do. I don’t think it’s a huge conspiracy, but they have no incentive to make it simple and the specificity that comes with making it difficult benefits them even apart from discouraging people from making claims.

Conservatives will be quick to point out that one of the chief differences between animal health care and human health care is that the former is purely market-driven while the latter is a combination of public, private, and private but driven by public policy (namely health care tax exemptions for employers). This is quite true. Veterinarians have every incentive to make pricing as transparent as possible and without the intrusion of insurance companies they don’t have to negotiate different rates with different entities that leads not only to opacity, but disparate pricing.

This is one of my main frustrations with our health care system, though it could be addressed either with a market system or a purely socialized system. Namely, when I go visit the doctor I have no idea how much I am going to pay. I don’t know what the insurance company is going to quickly agree to and what they’re not. And then, if they don’t agree, then suddenly I am on the hook for more than I would have paid if I’d simply paid up-front. There’s no way of knowing, up front, what the cheapest method of paying is. Since I am healthy I saved money when I was on catastrophic health insurance, but what I remember most fondly about it was the fact that since I knew I was paying for all non-catastrophic care out-of-pocket, I didn’t have to worry about any of this stuff. Even under the current system, when you tell them that you’re paying up-front, the pricing becomes a lot more transparent and you can even save money in the process as they will often charge you less than the listed price in return for not having to submit claims to insurance companies.

However, there is another significant difference between human and animal care, which is that we as a society are willing to let animals die for non-payment and we’re simply not willing to let humans do so. This changes a lot and makes a purely free-market health care system very problematic. Since we force emergency rooms to treat anybody and everybody that comes in, people that are uninsured can simply go there if they’re worried about it, racking up substantial bills that they will never be able to pay but who cares because they need the help now. This ratchets up the price on those that can pay who have to pick up the tabs for the former. (Yes, I am aware that illegal immigrants play a role in all of this, but if they all disappeared tomorrow we would still have a problem in this general area. And this is not a post about immigration.) And apart from emergency rooms, when you force insurance companies to pick up the tab on people with pre-existing conditions and people know that they can get insurance at any point and coverage will be assured, they can wait until they get sick before they get coverage. We are simply far more reluctant to deny care to people than animals and this has wide-ranging repercussions.

Anyhow, back to the health insurance companies. It’s easy to attribute the Charlie Belcher Theory of Economics to the insurance companies that they are only denying care and making payments difficult because they want more money. Insurance companies are an easy target and I dislike them myself as a matter of course. On the other hand, I have been covered by for-profit and non-profit insurance companies and I can’t say that I ever really noticed a difference in terms of paperwork and thriftiness. They all have incentives to hold down costs and even the for-profits tend to have small profit margins (which they make up for in volume). The only really good insurance company I’ve ever felt really comfortable with is our current one. It could be related to the fact that they’re not-for-profit, but I also wonder if they treat us differently because they know my wife is a doctor or she works at a hospital.

The biggest problem with insurance, as I see it, is not so much the profit motive as it is the incentives. They have no incentive to make it easy on us because we’re not the ones that chose them. In some ways, our current system is the worst of both worlds where we have profit-seeking by many of the players but not the consumer choice that guides these institutions to serve the consumer’s needs. Not just on price, but on simplicity and transparency. They have to be cheap in order for our employers to sign with them, and if they don’t cover anything the employers won’t sign with them, either, but they can thread the needle by being opaque enough and, from their perspective, it’s easy to justify the opacity as caused by the cloud of the inherently complicated nature of health care generally.

Per the New York Times, smoking does not actually relieve stress. Or, rather, it creates more stress than it relieves:

A year later, 41 percent had managed to stay abstinent. After controlling for several factors, the scientists found that the abstainers had “a significantly larger decrease in perceived stress,” roughly a 20 percent drop, compared with the continuing smokers, who showed little change.

The scientists’ hypothesis was that the continuing smokers were dealing with uncomfortable cravings between cigarettes multiple times a day, while the abstainers, after facing some initial withdrawal, had greater freedom from nicotine cravings and thus had eliminated a frequent and significant source of stress.

Meh. I don’t think that’s why. Or that’s not the whole reason why. Rather, I think it’s more like recent studies that have demonstrated that caffeine consumers are generally more tired than those that don’t consume caffeine. With caffeine, you’re in a sense shortcircuiting your body telling you that you need rest and sleep. So you respond by consuming more caffeine. That pushes you along until it wears off and you consume some more and so on. Oh, and you don’t sleep as well when you are resting. It provides short-term relief at long-term cost.

And so it is with cigarettes and stress. Yes, I think that the stress caused by wanting a cigarette and not being able to have one plays a role. However, it’s also the case that an over-reliance on cigarettes short-circuits your coping mechanisms when it comes to stress. I know that during periods of abstinence when I am feeling stressed, I have no choice but to decompress while doing something else. I have to deal with whatever is stressing me. I have to develop coping mechanisms. Once I get over the hump, the worst cravings come not from stress at all but rather from other precursors (stomach irritation, for example) or cues (doing something that I am used to smoking while I am doing, such as drinking). Eventually I get over the stomach irritation reflex as well. The cues are a bit harder because they come one at a time. I can conquer one cue and then three months later be confronted with another.

In response to a post by Megan McArdle on frustrations in the search for a cancer cure, someone replied right on cue:

Why should we expect a cure for cancer? It would hurt the profits of the drug companies. What would happen to the drug companies after the cure was found?

This is a stance that I have never found very credible (my stance has actually hardened since writing that). Fortunately, there was a swath of comments in response shooting the theory down before I could even comment myself. Even so, I couldn’t resist piling on, so I wrote:

Absolutely. It’s like vaccines. No drug company would ever come up with a vaccine because imagine how much more money they could make treating smallpox or rubella or whatever. They could charge desperate parents with sick kids thousands upon thousands of dollars for treatments. A vaccine would just cut into profits. That’s why drug companies don’t make vaccines.

Speaking of vaccines, there’s another article about whooping cough breakouts:

California is in the midst of its worst outbreak of whooping cough in a half-century. More than 2,700 cases have been reported so far this year — eight times last year’s number at this point. Seven of the victims, all infants, have died.

And here’s what really worries pediatricians like USC’s Harvey Karp: Doctors thought they wiped out whooping cough when they developed vaccines decades ago.

The disease hits young children hardest, especially ones who are not vaccinated or who have not yet built up full immunity. The prescribed vaccination regimen begins with a shot at two months and continues until children are 5 years old. For many children, it can take that long for complete immunity to develop — and until then, they’re vulnerable.

The California epidemic has raised plenty of questions about the role of vaccination and the increasing numbers of parents who decide not to vaccinate their children. California’s Department of Public Health cites three schools in the state where 80 percent of parents have signed a “personal belief exemption” to keep their children from being vaccinated.

I bolded the part about infants because it belies the notion that vaccination is a “personal choice” and that those who would condemn parents that don’t vaccinate are being judgmental when it’s none of their business. These parents are not just putting their own children at risk, but also infants that are too young to have the vaccine themselves. Infants that don’t already have fully developed immune systems. I am on the border as to a parent’s moral right to put their young child at such risk (always a complicated topic and usually dependent on the level of risk), but I have far less patience for those that use others’ children at risk.

Whether we should legally allow parents to take a pass on shots is a somewhat complicated topic. I do believe in religious freedom enough that I am disinclined not to have an exemption process of some sort. But 80%? That’s simply horrifying. And whether what these parents are doing should be legal or not, they are quite deserving of judgment and I have no fear of being considered judgmental on this topic. It’s not a personal health decision so much as a social health one and I am a member in the society in which these people live.

According to a top doc in Britain, smoking in the car with children is child abuse. Well, that’s what the article’s title says but the article doesn’t quote him as saying that. I am actually not entirely unsympathetic to this argument as such. It seems to me that smoking in a car with young children does present a health hazard and while in the absence of laws banning smoking in restaurants (for instance) that adults can avoid, the children are captives. Cars are pretty small and can get really smokey really quickly if the windows aren’t more than just cracked open. When I was a kid, Mom would open the windows unless it was raining outside in which case the car would just get really, really smokey.

The doc goes a bit further, though, in arguing the same is true for parents that smoke at home in front of their children. This has got me thinking about some of Sheila’s recent post about the CPS and pot and makes me wonder when we will approach the day when smoking inside the home or in front of the children will be considered some sort of abuse. I think we’re a long ways off from that, but as smoking becomes more and more something that poor and dysfunctional people do, I could genuinely see it happening. Even if the smoking itself isn’t considered so terrible (for the kids), it could be one of those things that gets the CPS’s attention. And it seems that as I learn more about the process, the best way to deal with the CPS is to avoid their attention in the first place.

But I found this comment to be bizarre:

“Evidence from the US indicates that more young children are killed by parental smoking than by all other unintentional injuries combined.”

Errr… by what measure, exactly? Smoking isn’t one of those things that kills you on the spot. Generally speaking. Second-hand smoke even less so. So how is it killing young children? How is it doing so more than all other injuries combined? The only way I can think of this being remotely true is if you count deaths that occur later by conditions incurred when they are young children. Or maybe smoking when the child is in the womb making the infant’s life a very short one. Even so… all others combined?! In the first case, how do you control for other variables such as the fact that children of smokers are more likely to become smokers themselves (due not only to parental example, but genetics)? All others combined?! I have to think that swimming pools, sports injuries, and (these days) extreme food allergies would be larger threats.

Maybe I’m missing something, but without elaboration it strikes me as a number of other “health facts” that I heard growing up that were and are transparently false. I remember being told in the 5th grade that second-hand smoke was actually more dangerous than first-hand. That could only be true if you’re looking at second-hand smoke affecting more people, but that did not seem to be what they meant. Besides which, I am willing to bet in a household of four where one party smoked and the other three did not that the first is more likely to die from tobacco-related illness than the other three combined despite the 3-to-1 ratio. There is a world of difference between breathing something in the air and sucking it straight into your lungs. It, like the doc’s quote, strikes me as one of those things you say to reinforce the point that smoking is not a strictly private behavior. But it does not have the benefit of being credible. At least not without a thorough explanation of how you’re assessing comparative danger.

Oddly, it seems like the next 15 pounds is more noticeable than the first 35.

My weight loss has now exceeded 50lbs. Or, at least, it was prior to my trip to Delosa. I’m still a bit at a loss as to how I succeeded this time where I’ve failed so many times when I’ve tried so much harder. I attribute a fair amount of it to the cereal (perhaps I should hire an agent and try to be their Jared), but I can’t even lend any more credit to the company cafeteria at Mindstorm and I’m still drinking 3-5 soft drinks a day and that’s just wrong.

We never found and unpacked the scale from our move. I’d noticed that my pants seem to be fitting a bit looser and I was defaulting to the next belt notch over. I also discovered that another round of old shirts that didn’t fit have begun fitting again. The general sense of things was confirmed when I went to the doctor and they weighed me in. Hospital scales have a history of being particularly unkind, but that day it was my bestest buddy in the whole wide world.

It’s not just that my weight dropped another seven pounds since my last weigh-in, or that my total over the past two years has topped that arbitrarily important number “50″. Rather, the big deal is that I crossed a more significant barrier: 225. That was the the wall I kept running into. No matter how much I exercised (or tried to) or how much I tried to hold back on how much I ate (or tried to), I couldn’t get below that number. Ever. About seven years ago I dropped 30 pounds… to 225. About four years ago I dropped 15 pounds… to 225. Then, in both cases, it slowly started to come back.

I celebrated by purchasing my first size-down pants in about a decade. None of my jeans fit anymore, which isn’t a huge problem because that’s what belts are for. But I’d been holding off buying a new size until I determined what size I would want them to be. My cargo pants are a more dire situation. I’m about to have to abandon the pairs I own.

The most gratifying thing, though, has been my return trip home. Oddly, the next 15 pounds have been far more noticeable than the first 35. Only a couple people noticed enough to say that I had lost anything the last time I was in town. This time around it got a lot more attention. Some of that can be attributed to a Facebook status noting the 50lb barrier that may have prompted some folks to notice, but even people that are not on my Facebook list noticed. A couple said that the combination of my weight-loss. shaved face, and haircut make me look ten years younger or like I’m back in high school.

When I went down from size 40 to size 38 (I always had a big waist - even when bone-thin, I wore a 34), I took all my size 40 pants and stored them at my folks house in Colosse. I use them as backup pants when I am hanging around. Trying to wear those things (which I don’t even try to do without a belt) was another source of satisfaction. It’s a bit mixed, though, since baggy clothes make you look bigger. What really got me was when I was at the security line for my flight home. I hadn’t thought it through and was wearing some of my outsized (still 38, but a bigger 38 than my jeans) cargo pants. I barely kept my pants from falling down around my ankles. Getting new pants (I recently bought a pair of 36’s that seem to fit about perfect) has become more of a priority.

None of this is to say that I don’t still have work to do. First off, as I have mentioned ad infinitum, I have eaten a lot while travelling and so I’m going to have to be careful to make sure that it doesn’t become a habit. That didn’t prove a huge problem over Christmas, though, where I put weight on and it came off as soon as I re-entered my old routine. I don’t know if this portends better or worse things, but I feel a hell of a lot worse after this trip than previous ones. Could be worse if it means I really ate that much more, could be better if it means that my body is more prepared to reject my new (temporary) heftier intake. In any event, my last day in Delosa I ate a sensible breakfast and lunch and then nothing else all day. Not that I didn’t want to eat more - there were a number of Delosian (and later Estocadian) establishments on my must-eat-at list that I missed - but my body just couldn’t take it anymore.

But beyond this temporary hurdle, I would still like to lose at least another 10-15 pounds. I am about 30lbs from my all-time low, but that’s a place I truly don’t want to go to back to. I looked gaunt and unhealthy. From there I think the objective will be converting some of my fat to muscle mass.

Or maybe none of this will happen. While I still can’t isolate what I’ve done this time around that has made it different, the fact that this was an unintentional diet as were my two previous most successful diets, suggests to me that I shouldn’t push it. At 20 pounds, 35 pounds, and 50 pounds I have felt that if I don’t lose any more weight I will be comfortable with that. That seems to be a key component to my success. That and the magical cereal.

I have been plagued with a cough for what seems like a week but has only actually been a few days. It started Friday and then got progressively worse really quickly. I am not generally big on medications, but I have taken everything my wife has thrown at me. At first it was just a throat discomfort. There were kind of rotating symptoms. I wasn’t hungry and then I couldn’t talk (but could eat) and then was coughing up a lung (wanting to eat and talk but being scared to). The coughing outlasted the rest and it’s been a persistent problem then.

There have been mild improvements. It’s extremely frustrating because I will be perfectly fine for hours and then suddenly I just can’t stop coughing. I’m not getting enough sleep because I start coughing most when I lay down and when my coughing muscles are too exhausted and I fall asleep I wake up after four hours coughing my brains out. Insult to injury, I can’t even yawn because it stretches my throat forcing me to, you guessed it, cough.

Question: Are doctors in the United States overpaid?

Answer: If we judge by how well compensated doctors in foreign countries are paid, the answer is an affirmative. There are a couple of caveats to this, however. For one thing, being a doctor in the United States is often a more expensive proposition than abroad. In many countries, doctors do not have to spend a full eight years in school (and incur the costs thereof) and higher education has greater subsidization by the state. By the time a doctor finished a three-year residency at 29 years of age or older (excluding prodigies), they have made maybe $150k in salary as a resident and may be in debt anywhere from $150k-500k. Had the same student chosen a business, engineering, or technical field, they could easily have earned in excess of $300k and will owe only what they paid for their undergraduate education.

All of that being said, even if you factor these things in, our physicians are still very well paid and from a financial standpoint will be better off for having chosen to be a doctor. I mention the caveats because they will come up later.

Q: Is this because of an artificial shortage of physicians created by the medical establishment?

A: The evidence for this is pretty weak. Back in the early 1980’s and 90’s there were fears within the medical community of an excess of doctors. They severely reined in the number of slots at medical schools and the creation of more medical schools. Thus, the physician shortage was either born or at least exacerbated. The result? Physician compensation since the early 90’s has been stagnant. Between 1995 and 2003, it actually fell 7%. A good portion of that fall can be ascribed to the average number of weekly hours a doctor works falling from the mid 50’s to the low 50’s, though even if you factor that in you still have stagnation.

Further, if shortages drew up compensation, you would see differences in how much specialties have changed over time. Primary care physicians are in particularly short supply, but it has not resulted in an increase in compensation. If anything, their wages have been the most constant and consistently below specialties where the shortages are not occurring or at least not occurring as loudly.

Q: What about supply and demand?

A: They don’t seem to apply as much to physicians as you might think. There are a lot of reasons for this, which will be explored below. The long and short of it is that physicians don’t work in a traditional market economy. Their ability to fully take advantage of their scarcity is limited by the fact that they have to negotiate with insurance companies and the government who contain a large amount of bargaining power. Rural hospitals, for example, have a really difficult time recruiting. Doctors often don’t want to live in the sticks and the ability of a hospital to bribe them to do so is limited by a relatively inflexible payment structure.

That’s not to say that the industry is immune from market forces. If we’d been adding thousands upon thousands of doctors since the 90’s, it’s possible that pay would have gone down more than it did because it would have given insurance companies and the government additional negotiating leverage. However, as I will explain below, that would not necessarily lower the collective costs of health care. Even if they didn’t, more doctors would increase access to care, though, and that is a worthwhile goal in its own right. Nothing I write here should be construed as a desire for the perpetuation of the physician shortage.

Q: So are physician salaries responsible for the skyrocketing costs of health care in this country?

A: Not in the direct way that a lot of people imagine. As explained above, the increased money flowing into the system has not been making its way into the hands of physicians. As I will explain below, without other changes you’re not going to see significant savings when the bill comes due.

Q: Still, though, we could reduce costs if we paid physicians less. Right?

A: Right, though not as much as you might think. According to health care economist Uwe Reinhardt, Physician take-home pay is about 10% of total health care expenditures. If you cut that in half, you have saved 5% of health care expenditures. That’s an aggressive estimate. Some people cite a the McKinsey Global Institute figure of $64 billion that we spend on higher earnings for physicians. Two noteworthy things about the MGI numbers. First, they cite “physician compensation” as being rougly 8.7% of health care expenditures instead of 10%. Second, while $64b is a large number, eliminating it would only represent a savings of 3% of total health care spending.

However, in order to make those cuts we would probably need to do one of three things: We would either need to reduce the costs of becoming a doctor, we would need to resign ourselves importing our doctors, or we would have to accept medicine as a less desirable profession that the best and brightest are not going to be interested in..

In the case of reducing the costs to become a doctor, there are ways we could do that which wouldn’t be expensive. For instance, we could scratch the requirement that doctors get an undergraduate degree. That way they could go straight into medical school and get out in fewer than 8 or 9 years. Other solutions, though, would involve subsidizing their education and that would cost money. Right now it’s not unfair to expect doctors to incur all manner of debt to become doctors because after they do they will be compensated enough to pay them back. Take away the compensation and you take away the willingness of the best and brightest top become doctors. If you’re thinking that we can count on them doing it for the job satisfaction, think again.

We could still import foreign doctors. Keep in mind, though, that the foreign doctors we would be importing would not be be coming from Europe and England. Since we wouldn’t be pay much more over here than they do over there, they would have no reason to come here. Instead, we would be getting doctors from India, Latin America, underdeveloped East Asia, and Africa. To be fair, I can’t remember the last time I saw an eye doctor without a thick accent and I have been very satisfied with the service that I have gotten from them, so it’s not something I am personally deeply afraid of. But it’s just something to keep in mind. A lot of people feel differently.

Q: Still, though, we could reduce costs if we paid physicians less. Right?

A: Yes, if we are willing to cut physician wages, if we still let them fend for themselves when it comes to getting their medical education, if accept that an undetermined number of those among the best and the brightest that become doctors now would instead do something else, if we are willing to see an increasing number of doctors from the third world, and if we are willing to risk losing American-educated doctors to Canada, we could save 3-6% of our health care costs.

Oh, and if we’re able to figure out a way to reduce physician pay. Reducing reimbursements and fees alone is not only unlikely to accomplish this, but could backfire and cost us more money. A lot of it. I mention above that health care costs are skyrocketing while physician pay has been stagnant. Arguably, these two are related. As costs have gone up and reimbursements have not, many doctors have chosen to get… creative. Entrepreneurial, even.

Let’s consider a fictitious doctor named Dr. Arthur Pineur. Dr. Pineur gets $70 every time he runs Test X, which costs him $50 to run and he does twice a week costing insurers and the government $140 and netting him $40. If you cut his reimbursement to $60, he can either accept the slashed pay or he can make up for it somehow. If Pineur is not a particularly ethical man, he can just target random patients and run the test twice as much. He used to run it twice a week, now he runs it four. He is making the same $40 he was making before, however the system is now paying $240.

A year or so passes and expenses have gone up but reimbursements have not. How can he avoid taking an income hit? Well, he can order Machine Y so that he can run Test Y. That way, he can profit every time Test Y is run. So he puts down $10,000 and buys Machine Y. Okay, well now he has to justify that investment and pay back the loan he took out to buy it. So now he’s running Test X and Test Y as often as he can. The more he is squeezed, the more ways he finds to supplement his income.

Now, Dr. Pineur has an ethical shortcoming. But there are a lot of gray areas that he is exploiting, so he’s not committing out-and-out fraud. In fact, maybe he can even convince himself that he is doing the right thing because he’s just giving his patients the most care that he can. The more docs do this, the more he can justify it to himself. Before long, you have a medical culture built around it. You have McAllen, Texas.

Now, McAllen is an extreme example, but at the end of the day at present it is not the job of doctors to control costs. Throw in litigation concerns, doctors earnestly wanting to try to treat and screen for everything just in case, and incentives to inflate costs and they can (sometimes intentionally, sometimes unintentionally) generate a whole lot of costs even while ultimately taking home comparatively little of it. Racking up a quarter’s worth of cost for a nickel’s profit.

If you’re looking at doctor pay and the high cost of health care in this country, you’d do a lot better looking at the “how” rather than the “how much” doctors are paid. Of course, that’s easier said that done. Most available options involve some list of things undesirable to many or most Americans. The potential savings from that, however, are much more significant.

-{Disclaimer: Do I really need to even say so? Well, I will for new readers. My wife is a doctor. She is a doctor in one of the least profitable sectors of medicine (because she chose to be, not because she didn’t have options). She is a salaried employee, so my Dr. Pineur example should not be considered commentary on how she practices medicine. She did not contribute to the writing of this post.}-

Trumwill: Formatting and restoring is like going to the dentist. It’s something you should probably do every six months or so, but it’s really inconvenient and not very fun, so most people - myself included - put it off until the last possible moment.

TrumDad: Speaking of dentists…

Trumwill: I knew I shouldn’t have used that metaphor!

TrumDad: How long have you had that cavity?

Trumwill: Six months, possibly a year.

TrumMom: And when do you plan on doing something about it?

Trumwill: Well, the way I see it I don’t know when Arapaho licensure is going to go through and when her insurance is going to kick in, so that could be a problem.

TrumDad: How?

Trumwill: Well, let’s say that I visit a dentist who determines that I have a cavity. Then, by the time it’s time to get that cavity filled, I’m on her insurance. But they don’t have a record of the first visit. Or it becomes a pre-existing condition.

TrumDad: Or I have a better idea. Why don’t you call tomorrow morning, explain the situation, and make two appointments. Find out if any of the dentists in Callie can do that.

TrumMom: I like your father’s idea.

Trumwill: Yeah… but… you see… that’s… uhm…. how many extra calls? Or I can wait for a couple months and visit then.

TrumParents: {Forcefully failing to buy it}

Trumwill: Dad’s pressuring me to go to the dentist.

Clancy: Didn’t you say you had a cavity?

Trumwill: Well, let’s say that I visit a dentist who determines that I have a cavity. Then, by the time it’s time to get that cavity filled, I’m on her insurance. But they don’t have a record of the first visit. Or it becomes a pre-existing condition.

Clancy: I’m sure if you explained it to a dentist they would see what they can do to get the two appointments before the insurance change. Why not at least call and find out?

Trumwill: That’s exactly what Dad said!

Clancy: … and?

Trumwill: And y’all are throwing monkey-wrenches into my logic here.

Clancy: I’m looking around and I’m not seeing any logic here.

Trumwill: Stop that! You’re ruining my plan!

Clancy: I’m looking around and I’m not seeing any plan - any real plan here.

Trumwill: It’s hiding. My plan is a shy one.

There are three main health care-related insurance types out there that I am familiar with (excluding disability or life insurance, which are health-related but not health care-related): Health, dental, and vision.

The benefits of health insurance are pretty straightforward. People never know when or if they’re going to get hit with some massive health problem that is going to cost more money than they have. So you join a risk pool to mitigate the consequences of whatever occurs. Even if you stay healthy, you at least theoretically have the comfort of knowing that you will be taken care of if you have a heart attack. And if you don’t stay healthy, you don’t have to worry as much about paying for everything out of pocket. Of course, modern health insurance goes above and beyond that, but whether these changes have been good or not, the basic concept is still there.

Dental insurance is similar, although the stakes and premiums are smaller. You’re not generally going to get hit with anything enormously expensive, but there are some things that it’s difficult to account for and getting hit with a multi-thousand dollar bill at the wrong time can be pretty dreadful. I am inclined to think that dental insurance is not a particularly good idea if you have the kind of savings that you can pay for root canals and the like out of pocket, but a lot of people can’t. And even when my wife and I get to the point where we can we can pay out of pocket for anything that comes up I will still want the insurance because it encourages me to go to the dentist more often.

But vision insurance is a real puzzler. People either need vision care or they do not. Then, once they need it, the expenses are pretty regular. Vision check once every year or so. One new pair of glasses every few years. Contacts every six months. The thing is, though, that all of these expenses are relatively minor and they’re scalable to whatever the family needs. Nobody needs an emergency prescription update. If you can’t afford contacts, you can just get glasses. You can get glasses easily for under a couple hundred bucks or you can spend more if you have more money. Unlike health insurance or dental insurance, you’re not going to be hit with bills in the thousands of dollars.

In the event that something bad with your eyes does happen and it’s the sort of thing that is expensive, it’s typically handled by health insurance. My suspected glaucoma was a health insurance matter as was all of the testing as to whether or not I had it. As far as I know, that’s how it generally works.

I genuinely do not understand why vision insurance exists.

I mean, I know why each of the actors play the part that they do. For employers, it’s one more thing they can put on their list of benefits. For employees, it’s something that they get without paying full freight for. For eye-doctors, it encourages people to go to the eye-doctor. For the insurance companies themselves, well it supplies their jobs.

But it’s a whole lot of money changing hands for little or no ultimate purpose. The vision insurance companies may have deals with the eye-docs for reduced rates and all that, but economically that’s not any more logical than AARP and military discounts and the like. It’s a shoddy reason for an industry to exist. The amount in overhead and billing statements and the like far outstrips the benefit that they provide. Hospitals and health care workers have to lean on insurance companies because often insurance is the only way that they’re going to get paid because a lot of what they do can get really expensive. Patient-paid eye care centers, on the other hand, are often quite profitable.

I personally never get vision insurance even if my employer is picking up part of the cost. Simply put, I don’t want the hassles involves. It seems that every bill I get from any regular health care provider ends up being a ping pong match between the clinics and the insurance companies over who must pay what and it seems rare that I actually end up paying what I was told up-front that I should have to pay. The same is true of my dental insurance. It’s all rather incomprehensible. Why should I invite that complex mess into my life for eyeglasses when I can just go up to Walmart and get a prescription written and filled for a stated price that will not be altered because some conversation between two other agents that I am not privy to did not break in my favor?

Is there something I’m missing here? Some real service or benefit they provide that I’m not seeing here?

There’s an interesting bit over at Medscape: most of the expiration dates on medication are pure horse manure.

As it turns out, medications in the US generally are stamped with a really, really conservative “expiration” date. Some foodstuffs that don’t actually expire have expiration dates stamped on them as well. The legal points for meds are that FDA regulations (which I’m sure the pharma industry didn’t fight too hard against) require the medicine manufacturers to stamp their products with a date to which they “guarantee the full effectiveness” of the medicine. For marketing reasons, they generally stamp them at the 2-3 year mark, not because the medicines lose effectiveness that quickly, but because they sell more meds if people don’t realize the things are good (with proper storage) up to 10 years.

On the one hand, if the manufacturer is required to “warranty” the efficacy of their product, it’s probably best for them to limit their liability by not guaranteeing it for too long. On the other hand, by mislabeling that date as an “expiration” date, they’re tricking unwary consumers. Maybe we need some truth-in-advertising laws to come into play here.

Since this post discusses anatomy and bodily functions that some people are uncomfortable discussing, I’m going to put it below the fold. (more…)