Monday, June 22, 2009


Some orphan issues in the health care debate:

1. Expertise. Ask any number of established physicians if they order more or fewer tests now than they did right after residency. Nearly all will answer "fewer." Ask the same regarding specialist consultations, and referrals to the emergency department and you likely will get the same answer. The underlying principle is that expertise is essential to cost-effective medicine, and cannot be replaced by giving glorified cook books to mid-level practitioners, imposing practice guidelines, or trying to shoehorn an experienced physician's decision-making into some mold fashioned by remote academics.

2. Providing more money for physicians to be primary care providers is not the same as paying them to take care of primary care problems. Just improving reimbursement for office visits and level of service provides no incentive to keep the primary care provider from referring the management of a COPD patient to a pulmonologist, fob off adjusting a heartfailure patient's diuretics on a cardiologist, or sending a diabetic with proteinuria off to the nephrologist.

3. "You will get to choose your doctor" masks a simple truth in the setting of universal care. You will only be able to choose those doctors that are willing to have you. Physicians, like any rational participant in an economic environment will do whatever is allowable to maximize their income as a function of effort. Some patients frankly are a pain in the neck and consume resources out of proportion to the acuity of their medical complaints. These patients will be competing for the physician's schedule with patients who have problems that are relatively straightforward, can be addressed in a limited amount of time, and provide satisfactory reimbursement. Expect your doctor to keep his schedule open for the dog bite or uncomplicated cellulitis, in preference to the person trying to make the eighth or ninth appointment for back pain in which "nothing works," or the fibromyalgia patient who is intolerant of all prescribed therapies.

4. The claim that health care consumes 17% of gross domestic product is a glaringly one-sided assertion. It only makes sense if you view the economy as something of a gigantic Easter-egg hunt, with a pre-determined GDP distributed around the yard, harvested by the people and then spent on items reflecting varying degrees of necessity and discretion. What percentage of GDP does manufacturing or legal services "consume?" An equally valid formulation would be that health care produces 17% of GDP. So then we have to ask, how much is too much? If less is spent on health care, will something else produce a compensatory amount of wealth? True, health care expenditures go up, but the expenditures go somewhere. How much will we spend on education, or transportation infrastructure or scientific research before we start complaining that it "consumes" too much of our economy?

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