Dr. Sam Online

If you haven’t read A Plan for Intelligent Health Care Reform Part 1 and Part 2 yet, please read them first, before proceeding with this post.

Sorry for the delay in getting this 3rd post up folks. The blame for that lays partly with a surge in activity in my off-line life concomitant with my fighting a nasty cold. (Also, I’ve recently been helping my friend get her website and blog about bargain wine reviews up and running. Go check it out if you get a minute. She’s got a pretty nice site I think.)

This stupid virus and my busy life only receive part of the blame however, as the bulk of the reason for my delay boils down to simple inertia on my part. When trying to piece together this third post in my mind, I have quite frankly been a bit overwhelmed by the complexity.

I’ve been spending a bunch of time trying to piece together all the problems I see with our current health care system, as well as their causes, and the effects of these problems, etc. When engaging in this mental exercise, it quickly becomes apparent to me what a convoluted web of entanglement our system has truly become.

I’ve been mentally caught up in that web for about a week, trying to figure out how to unravel it in a coherent fashion for the readers. While driving in to work yesterday, I had sort of a “Duh” moment and realized that I don’t need to unravel this mess for the readers. There are literally a million stories of ridiculous nonsense that people have had to deal with in regards to our health care system and I could go on for days about them, but I don’t need to. In reality, I think most people could rattle off a laundry list of dissatisfying experiences and problems. You don’t really need me to add my list to yours.

Instead it dawned on me that what I really need to do is stick to discussing the basic fundamental problem with the system that allows all these other problems to thrive. What is this fundamental problem?

Well, if you look at my letter to Dr. Susman, I mentioned that the main quality of our veterinary health care system that allows it to do such a better job in so many ways, than our human health care system, is the relative laissez-faire environment in which veterinarians practice. I also mentioned that the major problems with the veterinary system, ones which would be completely unacceptable within our human health care system, are also allowed to thrive due to this same laissez-faire environment.

Well, if we think of things in a sort of a Yin and Yang way, we can see that it is the lack of a laissez-faire environment that provides the benefit of largely preventing the problems (of veterinary medicine) from existing in our human health care system while simultaneously enjoys the blame for most of the major problems that do exist within that system.

“Okay, Dr Sam, enough with the lessons in Chinese and French philosophy. Get to the point here.”

Fair enough. In order to get to the point, we have to look at the fundamentals of the practice of medicine.

Ultimately, when all the trappings are taken away, it is about a relationship between a patient and a doctor. That is a very powerful relationship. Patients come to doctors at their most vulnerable times, bringing their questions, their concerns, their fears, and their most private and secret confessions. As a result, the doctors are in a position of great power and authority. It is a position of great trust and responsibility. This doctor-patient relationship has been the fundamental core of the practice of medicine since it’s very beginning.

It is very much like the traditional relationship that exists between a priest and parishioner or between an attorney and client. It is no coincidence that medicine, law, and divinity have classically been held as the three true learned professions.

Members of these professions are endowed by society with tremendous power and prestige and in return are held to a high standard of conduct. Unfortunately, there is nothing magical or supernatural about these members. They are human and like all humans, are prone to corruption. This phenomenon was perhaps most famously observed by Lord Acton, with his statement about how power tends to corrupt and absolute power corrupts absolutely.

There have traditionally been safeguards built into the professions to guard against corrupting influences. Traditionally, it has been a long and arduous road to enter into these professions. Traditionally, the professions have been very exclusive in that they have put prospective members through a trial by fire in the realm of education, but before even being allowed to embark on the specific professional education, they have had to prove themselves worthy, not only in academic credentials and ability but also in that nebulous subjective property, known as character.

To enter into schools in divinity, law or medicine has traditionally been more of a calling than anything else. Only people feeling this true calling would willingly subject themselves to the rigors required. Only people of true character would be able to make it through. The word profession is not an accident. Originally, member of professions had a faith and a belief which they professed! If you did not share this faith, if you did not share this belief, if you did not make it your mission to profess this faith in both word and deed, then you were not truly a professional. (Nowadays, it seems everyone calls themselves a professional. I’m curious about just what sort of calling for the betterment of mankind a professional wrestler must experience and just what it is that professional wrestlers claim to profess!)

Once becoming a full-fledged member of the profession, the professional continued to be held to a high standard of conduct by society, but even more so by his peers within the profession. To be sure, there have always been bad apples within the professions, but when found out, they have been scandalous. They have typically been individual people who went astray for personal gain. When discovered, they were typically treated with scorn and expelled from their professions. The professions themselves however did not typically allow themselves to be corrupted like this overall.

Unfortunately, over the years the professions have at times allowed themselves to be corrupted. Probably the first of the three to start going down the path of corruption was the church. One does not need to study western European history long to see evidence of this.

The founding fathers recognized the importance of protecting against such corruption. This was the main reason behind their clear separation between the church and the state. I think they similarly tried to protect the realm of the legal profession (the courts) from undue corruption by making federal judges appointed rather than elected, under the theory that only people of great character would receive appointments, and since they would not have to stand for election or re-election, they would not be vulnerable to the shifting whims of the electorate. To some extent I think this has been successful, but largely the legal profession has indeed become corrupt.

Unfortunately, there was little recognition of any need to similarly protect the medical profession. Physicians by and large worked on a patient by patient basis and did not appear to have the potential to make bold societal changes of the sort that might be seen from organized religion or from the bench of the Supreme Court. So they pretty much left the medical profession to fend for itself, and for the most part, it did pretty well with this, until the last 60 years or so. ”

“What has happened during that period of time that has changed things?”

Well, basically the medical profession allowed itself to be lured into accepting outside influences. It has allowed those who are not part of the profession to play a part in shaping it, and ultimately in steering it. It has ceded power to these corrupting influences for money and/or convenience. At first, I think it was innocent enough and well meaning enough, but to be blunt, the doctors were fools who got fooled.

Prior to the second world war, the traditional doctor patient relationship largely still existed in this country. For the most part, doctors took care of patients regardless of their ability to pay and made their decisions based upon what was in the best interest of the patient. Patients trusted their doctors, and with good cause.

The doctor still needed to make a living, so he charged patients for his work. His fees were set by what the market would bear. If a patient couldn’t afford his fees, the doctor would still typically do his best for the patient and let them accrue a balance or perhaps take payment in the form of barter, such as accepting a food item or load of firewood, or if the patient was truly needy or elderly, the doctor would simply write it off as charity. To be sure doctors made a good living then, typically better than the average citizen, but they usually did not get rich. They were usually middle class to upper middle class at best.

A large part of a doctors practice in those days was the house call. The doctor was more than just a tradesman performing a service. He was like an extended member of the family. He came into your home. He brought with him kind words, gentle hands, concern, and knowledge. He delivered your children. He reassured you when you incorrectly thought you were dying and held your hand and cried when you really were. He shared your joys and your sorrows. Doctors were somewhat beloved, and deservedly so, I think.

Doctors were also human. They made mistakes. Bad outcomes occurred. Sometimes those bad outcomes were the fault of the doctor, usually they were not. Regardless of fault however, the average person would have been outraged at the mere suggestion of suing their doctor. Malpractice suits were virtually unheard of then. That was the status doctors earned and held in those days.

Both of my parents grew up in poor families in south Mississippi. My parents are getting up in years now. They can still tell you the name of their family doctors from when they were children. They still speak fondly of them, as though speaking of dearly departed relatives. I was born in the 1960s. I too can tell you the names of my parents childhood doctors, but I can tell you the names of exactly zero of my own doctors as a kid.

By and large, I think most doctors still possess the same characteristics as they did then, but the environment in which they practice has changed. They have been sold out by the leadership of their professions years ago and I literally weep as I think of all that has been lost both by my profession as well as by my society as a result.

“So again,” you ask, “what changed?”

What changed was the large scale introduction of third party payers. Prior to the second world war, most people did not have medical insurance. Most employers did not offer this as a benefit to employees. During the war, there was a tremendous shortage of labor in this country as a huge percentage of the able bodied men were off fighting. This left businesses and industries in a bit of a bind as they had to compete with one another for a dwindling supply of workers. These were the days of Rosie the Riveter. Naturally, the most common sense way to compete for workers was to increase wages. Unfortunately, this had a somewhat disrupting effect on the economy as workers had mass migrations from one workplace to another as they chased the ever increasing wages. Additionally, and perhaps even more disturbing to the economy, was the inflationary effect seen due to these wage hikes as well as to the relative shortage of goods that occurred as industrial production was forced (by law) to abandon civilian items and focus instead on military production. In an effort to stifle this effect, the Roosevelt administration enforced wage and price controls on business.

Businessmen, being human, will always try to find a way around obstacles and things were no different in this case. Since they couldn’t offer higher wages to entice employees, they began offering non-cash benefits. Among these was employer purchased health insurance. Shortly after the war, congress confirmed that these insurance plans could be purchased with pre-tax income, and suddenly employees were left with the option of using pre-tax dollars to purchase optional extended coverage plans, that not only covered major medical problems, but could also be used to pay for all manor of minor medical issues. Soon enough, employees (and their labor unions) began demanding such extended coverage plans be offered as part of their standard benefits packages.

In spite of all their marketing B.S., insurance companies do not exist for the purpose of keeping people healthy. Insurance companies do not exist for the purpose of helping people pay for medical care. Insurance companies, like all companies, exist for one reason and one reason only. That reason is to make money. There is nothing necessarily inherently wrong with that, so long as society, governments, and representative organizations (such as the American Medical Association, labor unions, etc.) recognize these basic facts and take measures to protect themselves from undue influence and manipulation by these companies for the purpose of profit. (Unfortunately, such recognition and protection has largely not adequately occurred. The potential for such manipulation has been ignored at best, or willingly cooperated with by corrupt, paid-off, leaders at worst.)

As more and more people became insured, the insurance companies were facing a bit of a dilemma. People suddenly had effectively more money to spend on their health care, which if left unspent they never saw, so spend it they did. Doctors of course were quite pleased with this. Suddenly, they were being paid with cash rather than pies, loads of wood, or empty but thankful handshakes. People would go to the doctor, get treated, and then pay the doctor. These people would then submit a claim to their insurance company to be reimbursed. All of this was just swell for the doctors and for the patients, but it didn’t make the insurance companies happy. Again, remember, they do not exist for the purpose of making doctors or patients happy or healthy. They exist to make money, and this scenario was costing them money.

Increasingly the insurance companies began making contracts with individual doctors and hospitals to set fees for various services. They convinced the doctors and hospitals to accept the lower fees the insurance companies wanted to pay, and in exchange they agreed to require their patients go to these particular doctors and hospitals exclusively. The doctors would get less money per patient, but they wouldn’t have to compete as hard to get patients in the door. They told the doctors that they could rest easy and just focus on practicing medicine, while they (the insurance company) ensured a full waiting room and lots of business. The doctor would get less money per patient, but would never have a shortage of patients to see.

Initially, this continued to make the doctors pretty happy and also pretty wealthy. They liked this. Simultaneously, the insurance companies began lobbying and buying influence in both the government as well as within the organized medical societies such as the American Medical Association.

Before long there weren’t too many pies and not too much firewood flowing as currency into the health care industry, but there was a heck of a lot of money. Concomitant with this, medical technology was advancing at an amazing rate. All of the research and development that went into this technology was expensive. New medications, devices and procedures were becoming available, but all of it at a hefty price.

Naturally, well insured patients demanded only the best care for themselves and their relatives. “This is America dammit! We made an atomic bomb. We’re about to put a man on the moon. Why should I settle for less when it comes to my health?”

The presence of the insurance companies combined with the rising costs associated with newer technologies began to price modern health care out of reach for anyone without insurance. Simultaneously, the insurance companies, with their eyes on profits, began to charge more for coverage, and started becoming increasingly selective about who they would enroll or allow to remain enrolled in their programs. What this meant is that people who would be the most expensive from a health care standpoint, the elderly and those with serious chronic diseases, were being increasingly left out of the game. The poor and unemployed were also being left out of the game.

Simultaneously, the insurance companies, now firmly entrenched within the medical profession, a profession whose members were now largely dependent on the insurance companies for their living, began to tighten the screws on doctors. They began paying increasingly less per patient or procedure. They began dictating to doctors what medications, tests, treatments and procedures they could offer to enrolled patients. They forbid doctors from offering discounts or charging less to patients not enrolled in the insurance programs. Doctors who did not cooperate were threatened with being dropped from the insurance programs and effectively put out of business. Doctors came under increasing pressures to see more and more patients in the same amount of time. This was exacerbated by more and more patients wanting to get their money’s worth and coming to the doctor for every little ache and sniffle and demanding the latest treatments and medications.

By the 1960’s it was apparent that there was a problem. Costs were getting out of control. Quality of care was beginning to suffer as doctors could devote less time and effort per patient. Poor, chronically ill and elderly patients increasingly could not get care. The federal government decided to get involved. They were well meaning, but misguided.

The feds could have taken steps to roll things back to the way they were prior to the second world war, back when health care decisions were made by doctors and patients, both of whom were firmly vested in those decisions, rather than being made by some bureaucrat in a distant city, whose only motive was profit. Instead however, the feds decided that what was really needed was more bureaucracy and more interference with, and destruction of, the centuries old doctor-patient relationship.

So, they created the Medicare and Medicaid systems. Rather than recognizing that the root of the problems with the modern health care system was the presence of third party payers, the feds decided to make themselves into a really huge and draconian additional third party payer.

For those who had become disenfranchised by the system (the poor, the chronically ill, the elderly), this was a good thing. It did provide them with access to health care. As far as addressing the fundamental problem facing the health care system however, it has only made things much much worse.

Our nation’s health care costs have continued to skyrocket out of control. Now, rather than simply having for profit corporations who are at least somewhat accountable to the folks paying their fees interfering with the doctor-patient relationship, we have bloated inefficient government bureaucracies, who have absolutely no accountability enforcing increasingly stupid and wasteful rules upon doctors and patients. These government entities are just as good (if not better) as any corporation at dictating to doctors which patients they will see, which treatments, tests, procedures, etc they may offer. They are also just as good at forbidding doctors from offering discounts to people not enrolled in their programs.

Unlike the private corporations who might threaten to drop a non-cooperating doctor from their program however, the government entities have the power and the willingness to prosecute and jail non-cooperating doctors.

Yes you heard that correctly by the way. It is a violation of federal law for any doctor to charge Medicare more for any particular procedure than he charges anyone else. So, if you are a hard working stiff under the age of 65 and make too much to qualify for Medicaid, but not enough to afford ridiculously expensive health insurance, you’re screwed. If your doctor accepts Medicare patients, he is required by law to charge you at least the same rates Medicare pays (regardless of the fact that as a cash-paying patient you do not bring with you the mountain of bureaucratic expense Medicare brings to the table). No matter how much you need care and no matter how strapped for cash you might be, your doctor cannot cut you a break or he could go to jail. No more pies or charity folks. Uncle Sam has outlawed Dr. Sam from accepting such payments.

At this point, it is worth mentioning two 800 pound gorillas that are in the room.

The first of these 800 pound gorillas is the plethora of peripheral industries that have blossomed within this environment. These include manufacturers and suppliers of durable medical equipment, hospital corporations, electronic medical records vendors, compliance companies that help doctors and hospitals stay in compliance with the 130,000 plus pages of Medicare regulations, plus all the regulations from OSHA, JCAHO, etc, medical billing companies, accrediting organizations, etc., and last but not least the pharmaceutical industry. All of these entities, and more since this is just a small list that immediately comes to my mind, have a strong vested interest in keeping things on their present course. Third party payers, particularly government third party payers, have created an absolute cash cow for these companies. These companies heavily lobby our political leaders and heavily contribute to their elections campaigns.

The other 800 pound gorilla in the room that nobody wishes to talk about is that the destruction of the traditional doctor patient relationship has resulted in the destruction of the bond of trust and devotion that doctors and patients held for one another. This has been fostered by and profited upon by the other massively corrupted profession in our society, the legal profession. They will cite all sorts of skewed statistics and studies to try and convince folks otherwise, but make no mistake about it. Our current civil liability system has an absolute and massively negative effect on the quality of medical care in this country and has an absolute and massively contributory effect on the skyrocketing cost of that care. Until we, as a society, can effectively put this gorilla back in his cage, not only health care, but pretty much every other aspect of our society is doomed. This gorilla is rich and well connected and not afraid to spend lots of money to get the right corrupt folks into positions of political power and influence. Ultimately however, they can do nothing without our cooperation. Members of our society really need to recognize that and quit being so damn greedy and myopic.

So, as a society, we approach rapidly the edge of a great precipice.

Our health care costs are ridiculously high, and only getting higher.

Our patient satisfaction is at an all time low. Satisfaction amongst doctors and others in the health care industry is at an all time low. Applications to medical school are dropping. The best and the brightest are increasingly attracted into other fields.

There are shortages of doctors in nearly all parts of the country, and the third party entities are currently trying to sell the public on the idea that physician extenders (which should more accurately be called physician diluters), such as nurse practitioners and physician assistants, are just as good as physicians, and cost less. This is evident in the increasing use of the term “provider” which is an all encompassing term that lumps together doctors, nurse practitioners, physician assistants, etc.

Yes, we are approaching the edge of that great precipice at ever increasing speed. We as a society must act. In my opinion we should slow down and reverse course.

Sadly, it appears to me that the population as a whole has been lied to much too convincingly. The population has been sold a bad bill of goods and has become convinced that the answer to our problems lies in doing more of the same of what has already been done. When things started getting bad in the 1960’s, we massively increased government involvement in health care. We have incrementally increased that involvement ever since. Things have not gotten better. They have gotten worse. So naturally, the answer we all seem so eager to embrace is further government involvement. There is a massive cry for universal single payer government controlled health care in this country.

I fear this.

Although it is clear to me that this will be a massive massive mistake, I think it is inevitable.

Clearly the current situation cannot be sustained. Change is mandatory. Unfortunately, the change I hear prescribed will only make things much worse.

In an ideal world, I think the government should get completely out of the health care business. In an ideal world, their involvement should be strictly limited to enforcement of laws to ensure that people are treated fairly by doctors, hospitals and insurance companies.

In an ideal world, people would recognize the ridiculousness of having medical insurance for anything other than catastrophic major medical coverage. They would recognize that just as they don’t use their car insurance to get the oil changed, medical insurance should not be used for routine minor medical care.

In an ideal world, they would be able to imagine how expensive an oil change would become if uncle sam was paying for it and the oil change guy did not have to worry that individual customers would simply take their business elsewhere if he set his prices too high.

In an ideal world, they would also be able to reason that doctors and hospitals are likely no different.

In an ideal world, they would recognize that if they did use their car insurance for routine car care such as oil changes and tire rotations, then the cost of car insurance would soon become prohibitively high.

In an ideal world, they would be able to imagine how often folks would take their car in to the shop for stupid little things like a dirty windshield or new tires, if the bill was always going to be paid by some third party entity like the federal government. (As a real non-ideal world example of this, I cannot begin to tell you the number of times I’ve seen people show up in the ER with nothing wrong other than a mild headache, simply because it was cheaper to let Medicaid pay hundreds of dollars for the ER visit and then let Medicaid pay to fill a prescription for Tylenol, than for them to just go buy the Tylenol themselves for a couple of bucks out of pocket. And no, this isn’t just speculation on my part. These people have typically explained all this to me at the time, without the faintest hint of shame.)

In an ideal world, just as people pay out of pocket for routine automobile maintenance and repair, and carry auto insurance only for major expenses, they would similarly see the wisdom of paying out of pocket for routine medical care and carry only higher deductible but much less expensive major medical insurance.

If everyone did these things, in my ideal world, there would be a re-introduction of true market forces into the health care system. Prices would come down to earth and quality of care would go up in response to the forces of competition.

(Of course, for all of this to happen, that previously mentioned 800 pound gorilla - the trial lawyers - would have to go back into it’s cage, in my ideal world.)

All of this brings us back to Dr. Susman’s editorial and my email response to it, in which we contrast and compare our health care system with the veterinary health care system.

In all but a few key small ways, my crazy ideal world currently exists for our animal friends.

Dr. Susman’s beagle, Lucy, is a patient in that ideal world.

Lucy’s doctor is not called a veterinary provider.

Dr. Susman’s veterinarian is in a profession (holy cow there’s that word again) whose members are routinely ranked amongst the highest in career satisfaction.

Dr. Susman is amongst a population that routinely ranks their satisfaction with veterinary medical care amongst the highest of all service industries.

Although I note (with some alarm) the disappointing beginnings of a change in this, for the overwhelming part, third party payers and malpractice suits are virtually non-existent in veterinary medicine.

It is getting rather late, and I have been writing quite a bit on this post, so I’m about to end it and go to bed.

I know some are sitting in front of their computers, both here and abroad, with Zen-like patience, wondering when Dr. Sam will quit monkeying around with all the foreplay and get to the actual plan he has in mind.

Hopefully, that will start to fall together within the next post or two.

So far, all of this has been pretty much laying out the ground-work.

In my next post, which hopefully will be a much briefer one, I will attempt to point out what I perceive to be the previously alluded to problems with veterinary medicine.

As I mentioned before, there are indeed some problems in this system, which Dr. Susman’s editorial sort of missed.

These are problems that must be addressed however as they are serious indeed, and while tolerable within the realm of veterinary medicine, they would be intolerable in human medicine (They are in fact in existence currently within many health care systems around the globe, much to the detriment of the affected populations).

Anyway, thanks for your patience so far folks.

I will try to get part 4 posted within the next day or two hopefully!

Cheers for now!

…Sam