Tough Decisions Concerning Medical Care
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Tough Decisions Concerning Medical Care
Our society has become so prosperpous and our technology has become so effective
that we have reached an unusual dilemma. My mom was raised on a farm in the
depression and there was a great equalization in medical care at that time.
Everyone got basically the same medical care as none of the procedures available
were very expensive or very effective. While doctors of her time had gone beyond
leaches and bleedings, they still didn't have any effective treatments for many
of the common ailments, resulting in everyone being at risk for numerous fatal
ailments. Not a very pleasant situation, but certainly equitable.
Today we have developed procedures which are very effective but also very
expensive. I estimate that in the average Americans lifetime, they will earn
about two million dollars. Now we have procedures that cost $500,000 or even
$1,000,000 with new and more effective (and expensive) procedures being
developed. The problem is that with price tags like those is that we clearly
can not afford such procedures for every person who might benefit from them.
People just don't produce enough to be able to pay for such procedures if they
are provided for everyone.
Further, none of these procedures really save anyone's life. We are all going
to die at some point in time and these procedures only have the potential of
extending our lives for a few years, perhaps 5, 10, or even 30 years, but
the gain is always limited. However, since we can no longer afford to provide
the best possible procedures to everyone, we need to consider how best to
allocate our limited medical resources for the greatest and, perhaps, more
just, benefit to all.
In light of limited resources, if we can only afford a limited number of
procedures, it would make sense to apply those resources where they would have
the greatest effect. Foir example if there was a procedure that could extend
my life for ten or twenty years or my son's life for thirty or forty years,
it would be better applied to my son in light of limited resources.
While people of my generation and my
parent's generation decry the cost of getting the best possible medical care,
they forget that the procedures which are now available weren't available in the
past and there is no reason we should expect to have access to procedures
which cost so much more
than procedures used in the past. In this new environment we must address the
allocation of limited resources, a new problem which was avoided when there
were never such expensive procedures.
This process is greatly complicated in the U.S. where medical expenses are
largely paid by insurance companies with the premiums substantially paid for
by employers (at least in the past). The drivers of our ever increasing
medical expenses are:
insurance companies who get increased profits as they are a percentage of
the expenses; the higher the expenses and premiums the higher their profits,
hospitals who have to have the latest equipment to attract doctors and
patients, but then have to insure that the equipment is used often in order to
pay for it,
lawyers who need to hold doctors and insurance companies liable for their
mistakes but also raise the standard of level of care that is required with
ever increasing claims for any 'bad outcome',
doctors who need to make enough from fees to pay off their student loans
and liability insurance, but with restrictions on the amount of fees, this is
most often done by performing more services (mostly tests) which require little
of the doctor's time but provide more income
pharmaceuticals who need to raise the revenue to cover the high research
costs (substantially driven by the most thorough requirements of the FDA, but
also driven by the cost of ever increasing quality of care from liability
suits) as well as ever increasing marketing costs as pharmaceuticals compete
for the doctor and patient driven prescriptions with neither really being
concerned about the total costs which are borne mostly be the employer who has
little say in the selected prescription (even though they bear the cost).
I personally estimate that liability costs effectively double the cost of
medical care in the U.S.. It is not just the cost of the actual liability payments,
but also the cost of defending against such suits and the inevtiable mark up of
insurance companies. Further, the threat of liability suits has an ominous
effect on the whole practice of medicine. Doctors will now simply order
a huge battery of tests rather than trying to diagnose. Even if a test is
not justifiable from the point of view of expense and liklihood of providing
helpful information, better to order the test than risk a later suit because
the test was not ordered. Further, as doctors and hospitals get a percentage
of their income from each test, the best way to pad their income is to order
lots of tests, the costs of which are borne by insurance companies initially,
but then by the employer and finally by all of us (but with the patient not
able to control the cost or feeling the iminent cost).
This combination of groups and industries, all of which benefit from ever
increasing medical costs, would seem to be unstoppable except for the fact that
this unstoppable force is increasingly running into an immovable object of our
limited resources (we can't spend more resources on medical care than we
produce). It will be interesting to see how the burden of paying for medical
care is eventually returned to the individual (where it always resided before
the confusing factor of employer sponsored health plans). It is not clear
how the limited resources will be reflected back into limits on available
health care.
One obvious solution is the socialization of all medical coverage. Once
the government is paying for all medical expenses, the government will be
forced to recognize its limited resources and enforce limited health care. The
problem is that most governments have not done a very good job of allocating
medical care resources in a very efficient fashion. It is not that certain
life saving procedures are disallowed, but rather they limited so that
many (and in some cases most) people die waiting in the queue for the procedure.
It is unlikely that this sort of lottery (whoever lives longest wins the
life saving procedure) is the most efficient form of allocation of medical
resources, but at least it has a certain sense of justice (no preference is
given to anyone).
I myself would like to see more control given to the individual to choose the
level of medical care which they choose. This could be done by reforming the
income tax laws such that all employer paid medical expenses are reported as
income to the individual (the original reason for employer sponsored medical
plans was to avoid restrictions of pay raises in WWII and later to provide
income tax free bonuses) but all medical expenses paid by the individual are
exempt from income tax. This would put the choice of quality of medical back
on the individual who could make the tough decisions of how much is enough.
To further enable the individual to make correct decisions, I would recommend
that every form of medical insurance be required to list limits on liability
and limits on care (just how much they will spend on an annual and / or
lifetime basis). They could be as high as the individual chooses, but this
would allow each individual to decide what level of care they are willing to
pay for (which is really the same decision as with socialized medicine except
for the fact that people can hope to have someone else pay for their medical
care, a strategy which is probably not very effective).
This is particularly important as one of my sons, my brother and numerous
friends of mine are existing without medical insurance, largely because it is
too expensive for them to afford. Further, they go to great lengths to avoid
going to the emergency room as they are working and solvent, and the expenses
of the kind of medical care available in hospital emergency rooms (including
the subsidies through care provided to those who don't have any form of medical
insurance and who have no hope of ever paying the costs of their care). Sadly,
because my brother pays his bills, he can't even get that form medical care.
Of course if my brother is able to survive somehow until he can qualify for
Medicare (age 65, not that far off now), he will then in his old age be
able to receive the most expensive
treatments even if they have minimal impact on his life expectancy. It seems
so wasteful to spend large amounts of money in a person's last year of life
(as is common now) with such a low quality of life. Wouldn't it be better
to recognize that a person is approaching the end of their life and make the
end easier (hospice care) and instead spend the resources on younger people
who are working and productive and have the potential for more substantial
improvements in the length and quality of their life.
I would love to see basic medical care at affordable prices without
the needless expense of liability suits and supporting those who can't pay
their bills. Basic medical care wouldn't need to be provided by a doctor,
it could be a physician's assistant or nurse and still be so much better
than the total absence of care which is forced on so many working people.
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This page was last updated on October 29, 2011