A recent post over at the Advice Goddess regarding access to health care caught my eye. Like many such posts, there was a brisk repartee in the comment section on the topic of fixing our daunting health care access problems. Many of the comments were knowledgeable and informative; some, as is always the case, were idiotic or pedantic. One comment in particular, however, caught my eye, posted by a fellow from the liberal side of the political spectrum. It was a rather lengthy screed, which is excerpted here only in part:
I notice that people who enjoy making reflexive attacks on any and every possible change in the current system have this one thing in common: They love to mock the idea of preventive medicine. …
One other point that isn’t being made by the right wing: The number of students accepted by American medical schools was increased substantially about a third of a century ago (partly by the opening of more campuses by state schools), and then was held static. Some attribute this freeze to pressure from the medical lobby (it creates an artificial scarcity of doctors). We should increase entry level spots in medical schools by fifty percent or so (i.e.: what we did in the ’70s etc), and open many more spaces in nursing schools. Curiously, the federal government could cover the tuition of every medical student in the country for a small fraction of what we spend on medical care in total, and it would solve some serious problems for the rest of us by taking the financial bind off the entry level physician…
Of course none of this is all that hard to figure out. The major paradigm shift occurs if you stop thinking about medical care as the exercise of market place free enterprise in which doctors compete to make the most money, and instead view it as a public necessity.
Now, my intent is not to beat up the poor fellow; he is, after all, a liberal, and therefore possessed of a profoundly misguided understanding of human nature and motivation, and a strong inherent (and incoherent) proclivity for finding in government the solution to every imaginable problem. He is more to be pitied than censured. But his comment prompted me to begin thinking about some of the more common medical myths; those axiomatic convictions which seem to drive every discussion about healthcare policy, and show up in virtually every comment section on a health policy-related post. This particular gentleman’s comment mentions at least two such myths, and therefore provides lush green fodder for a rambling rumination on my part.
So here you have it: Some of my very favorite medical myths, time-tested truisms redolent with pertinence and pathos, but replete with error.
1. The healthcare system will save money and lives if we will only focus on preventive medicine.
Like all such truisms, this one actually has a grain of truth. There certainly are areas of healthcare where preventive medicine — best defined as measures taken by physicians and patients to prevent disease or detect it early– are clearly beneficial.
Some examples which come readily to mind are prenatal care, where careful management of maternal nutrition, blood pressure, blood sugar, and other parameters can have a significant beneficial effect on the health of the baby; pediatric immunization; and screening for early detection of diseases with significant long-term morbidity, such as hypertension, lipid disorders, and diabetes.
Beyond such areas, however, the idea of preventive medicine rapidly gets into the realm of wishful thinking, appealing largely to those who believe that doctors make money by keeping you sick, and that organic spinach keeps you healthy (a little e.coli is good for you, after all…).
Take, for example, the idea of an annual physical exam. This is widely perceived by patients as an important measure of preventive care, but is an almost entirely worthless exercise. It makes the patient feel better, but completely lacks in evidence of substantial long-term health benefits. Screening tests for cancer are another such area, which not only provide a false sense of security when negative (since many false negatives occur), but also pose a significant risk of their own. This risk arises from the fact that all such tests have a substantial false positive rate, which when multiplied across a population while looking for relatively low-incidence diseases such as cancer, generate an enormous amount of unnecessary cost and potential health risk chasing down abnormal tests in patients who do not have cancer. I have discussed this at somewhat greater length in a prior post on PSA screening.
Of course, the other thing which preventive medicine stresses are lifestyle issues: exercise, weight loss, smoking cessation. It should go without saying that there may be one or two individuals on the planet who do not know that you should exercise regularly, lose excess weight, and stop smoking. There may be also one or two folks alive on the planet who have successfully followed such exhortations for more than a week. So how’s that preventive medicine approach workin’ for ya? Oh, and when your preventive screening finds your blood pressure could drive a steam turbine; or that your blood has more sugar than Coca-Cola; or that your arteries look like Crisco from your sky-high cholesterol — guess what you’ll be told: lose weight, stop smoking, get to the gym. That’ll be $100 bucks please, pay the receptionist on your way out. Stay healthy, now!
2. Rich, greedy doctors are bleeding the system dry,
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3. The AMA restricts the number of doctors trained to ensure shortage and maintain physician incomes.
Well, like many myths, there may be a tiny grain of truth here: There no doubt are a few doctors who drive up healthcare costs by gaming the system; in the medical field, we call these fellows “crooks.” But the harsh reality is this: physician reimbursements make up only about 10 to 15% of total healthcare expenditures. If you can figure out a way to get physicians to work for nothing (and there appears to be a strong interest in this subject among insurance companies and government), we would still have an extremely expensive healthcare system sucking up a huge numbers of dollars. The insurance industry alone may consume as much as 40% of the healthcare dollar, with their burgeoning bureaucracies, intrusive regulation, and 7-figure CEO incomes.
Oh, and the “AMA-is-keeping-the-lid-on-the-number-of- doctors-to-make-their-incomes higher” theory — popularized by the otherwise astute Milton Friedman — is nothing more than an economist’s wet dream. It assumes, first of all, that healthcare is a free, competitive market; it is anything but. In fact, it much more resembles Soviet state industry: micro-managed, price-controlled, and utterly anti-competitive. The AMA has trouble figuring out which shoe to put on their foot in the morning, and borders on being an utterly incompetent professional organization — which is why fewer than half of physicians are even members. One could only wish that they had some influence on physician income, and reimbursements; they are worse than irrelevant to the profession. Oh, and they have no say on the admission to medical schools, by the way. I have discussed this rather foolish but surprisingly popular theory in a previous post.
4. Tort reform will bring down medical costs by stopping unnecessary testing and defensive medicine.
This one is a favorite of conservatives and physicians alike. Anyone who sleeps less than Rip Van Winkle knows that our medical liability situation in this country is a disaster: skyrocketing premiums driving high-risk specialties out of business; physicians fleeing high-cost states for those with lower malpractice rates; increasing access problems to specialties such as obstetrics, neurosurgery, and orthopedics; spiraling overhead costs for physicians, hospitals, and clinics; and the exorbitant costs of defensive medicine, where countless tests are performed in part or whole for potential defense against a future lawsuit.
So it naturally makes sense that tort reform will ease the economic pressure, lower physician costs, and reduce unnecessary testing done primarily for medico-legal reasons. Right? Wrong.
Now, tort reform legislation has proven almost impossible to implement, so the point may be moot. But for the sake of argument, let’s pretend that legislatures — comprised as they are primarily of attorneys — become willing to pass reasonable tort reform. Let’s assume that the court system, manned by judges who are also attorneys, will not gut or invalidate such legislation, as they have routinely done. Let’s ignore the fact that attorneys contribute vastly more money to the political process — nearly a 100 to 1 disparity — than do physicians, to defeat such legislation. Let’s assume that this mythical law is a carefully-crafted statute, which limits attorneys fees, puts a reasonable cap on often emotionally-driven pain and suffering awards, mandates mediation in most cases, and perhaps a host of other widely-accepted reforms which evidence indicates can reduce liability premiums.
Such legislation would likely ease some pressures on malpractice premiums, perhaps improving access to high-risk specialties while lessening economic pressures on physicians in general. The one thing upon which it would have no impact whatsoever — the one factor in the malpractice mess which, more than any other, drives up overall healthcare costs — would be the practice of defensive medicine. And it is pure fantasy to believe otherwise.
Here’s why: the practice of defensive medicine — ordering tests with very low yield and often high cost to ward off the risk of future Monday-morning legal quarterbacking — is now fully ingrained into the health care system. It has become the de facto standard of care. We will not rip out the extra CT scanners and MRI machines installed to handle the excess load. Doctors will not stop ordering tests which have become the standard workup for a given problem, even if low-yield, for they have done so for so long it is now routine. Furthermore, you have not changed the fundamental calculus: if you order a test to protect yourself against a future $5 million-dollar lawsuit, you will not stop ordering it because you are only at risk of being sued for $2 million. Only a drastic, top-to-bottom elimination of medical torts — the chances of which are exactly zero — could bring about such a reduction in defensive medicine costs. Sorry, but they’re here to stay — tort reform or no tort reform.
5. Pay for performance will improve health care quality.
Those of you outside the health care arena may have never heard of this one, but it’s huge, and coming to hospitals and doctors near you. Like some decrepit tramp steamer, it lumbers afore with enormous inertia but no discernible destination, piloted by a faceless crew of bureaucrats intoxicated with a cannabis cloud of cost-containment fantasies.
The idea, fostered by both federal and private payers, seems simple enough on its face: if we’re paying you, we should have some say over the quality of the product we receive. Leaving aside the not-so-minor quibble that they are not the recipients of the services (their insurance beneficiaries are), this notion is filled with risible assumptions and hidden reefs which threaten to shipwreck its lofty and laudable aims.
First and foremost among the questionable underpinnings of this noble venture is the presumption that much of the care paid for by government and insurance is in fact substandard and in need of quality improvement. Of course, this assumption is almost certainly wrong, and certainly unproven — and in fact cannot be proven — as the standards by which such quality is measured have, by and large, yet to be developed. Physician organizations are scrambling to develop them (under the threat that government and insurers will establish such guidelines for them, based on economics rather than medical criteria) — an effort which is no small feat, as forcing the complexities of medicine into nice cookbook formats is daunting, if even possible.
The potential problems with this approach are legion — from physicians avoiding higher-risk or non-compliant patients who are more difficult to treat successfully; to the enormous challenges of gathering, standardizing, and transmitting quality data (including the medical information systems needed to manage it, which are non-existent); to the strong economic temptation to pay no more for quality but much less for “substandard” care; to the termination of physicians who do not meet “quality” standards — as defined by the insurers. Insurance companies are already headed in this last direction: a local carrier in the Puget Sound area recently sent out a letter to patients announcing the termination of their doctors from their provider panel, stating their care “did not meet quality standards.” The doctors’ offense? Not quality issues at all, but cost: they were not the lowest-cost providers. The defamation lawsuits are flying — but expect to see much more of this sort of thing in the future.
But the biggest risk from this looming lunacy directly relates to the quality issue it purports to address: pay for performance schemes will fossilize health care, effectively freezing innovation and stunting medical advances. Once you have regulatory specifications detailing just what is “quality” — i.e., allowable — standards of practice, and connect such standards to reimbursement, you will create a strong financial disincentive toward trying new and better ways of addressing difficult health problems.
Got a better way to treat diabetes, or cancer, or arthritis? Sorry, your approach doesn’t meet our government-approved, forever-carved-in-stone “quality standards.” “No soup for you!!”
I could go on, but I’ve been long-winded enough for now. Hopefully you won’t get fooled into believing any of these fables the next time you catch wind of a health care policy debate.