Having been a physician now for 16 years, I have had a first hand view at the variety of healthcare reforms and regulation put into place over that time. Most recently, the Affordable Care Act has been at the center of our attention, but it is by no means the only thing the government has done over that time.
Today, President Trump and the Republicans are working to repeat the Affordable Care Act, and possibly replace it with something else (Something Great if you listen to Trump.) I have mixed feelings about this. I think that the ACA did some good things, but also got some things wrong. At its fundamental core, by forcing all people to buy healthcare through a private insurer (albeit through a government funded network), it was trying to create universal coverage. Unfortunately, the ACA struggled to get healthy people who would pay more than they consumed to enter the system, thus creating a system where there were often more claims than premiums.
A middle aged man named called Joe decided in mid life that he would become a doctor. A former boxing instructor, Joe felt compelled to learn medicine to help his fellow man. Already in his 30s, he worked hard to develop the prerequisite education to enter medical school, which he did in the late 1990s.
I met Joe in my first year of medical school. He was a very bright guy and had a great sense of humor. He was a bit different than most of us, and not just in age. I remember him asking me once “why would we use anti-hypertensives to treat hypertension. I mean, if a person’s blood pressure is that high, maybe that’s what their body needs it to be at!”. I remember thinking it was a strange way to think, given that allopathic medicine pretty much presumes that letting the body do whatever it will may not actually be the best course for long term health.
Joe did reasonably well through the first two years of medical school. In his third year he had moderate success, and sometimes struggled with having a different outlook on what medicine should be that the attending physicians that were instructing him. Over time, this became a bigger problem, and Joe eventually made the decision that being an allopathic physician wasn’t what he wanted to do for the rest of his life.
A reader recently send me this graphic on the costs of healthcare, which is interesting in many ways.
Created by: Medical Billing and Coding Certification
Some of this diagram I agree with, and some I do not, or at least what is implied by the information contained therein. Overall, the diagram is correct – American’s can’t afford healthcare. At least not the kind we try to provide. However, I don’t feel that the diagram really addresses why Americans can’t afford healthcare in an accurate way.
Last year I wrote about a few strategies for decreasing costs in the operating room. Since being in fellowship operating many days per week, I’ve come up with a new idea, this time a bit more radical.
In Freakonomics, Leavitt and Dubner posit that in all things, human beings respond to incentives. If you want to understand human behavior, all you have to do is identify the incentives that drive them, be they emotional, financial, or social. In that vein, I wonder what incentives drive us to spend so much money on healthcare, and to waste resources when they need not be wasted.
I found a potential answer in another book, Chris Anderson’s “Free: The Future of a Radical Price” In this work Anderson investigates how an economy is affected when the marginal cost of production of a good approaches zero. Specifically, he investigates the economy surround digital goods, that while costing resources to develop, have a marginal cost of zero to produce and distribute. He proposes that in such a system, it is quite natural that the price of such goods will eventually approach zero, and if it doesn’t, the goods will be routinely stolen rather than paid for.
The corollary to this idea is the concept of optimal use of a resource when its cost is zero. That is, if one gets a real benefit from the use of a resource but it costs nothing whatsoever to use it, what is the right way to use that resource? Anderson suggests that the correct course is to use that resource to its maximal extent, and even to waste it without thinking despite diminishing returns. Read more…
A while back I published a bit about how to get insurance appeals approved. So here’s a specific example. This regards a young woman who delivered her first infant and was having trouble breastfeeding. After discharge, her physician recommended home lactation consultation services, which her insurer denied as not medically necessary. The patient’s policy did cover “skilled” medically necessary home health service , but not “custodial” care, defined as care meant for ongoing maintenance or assistance with daily living.
So here’s an answer to that (nonsense).
For the last 12 months, I have worked for a federally funded hospital. When I came to this hospital, I immediately noticed that the GYN surgical equipment was very outdated, most likely because the primary focus of the hospital until fairly recently had been the care of men. Wanting to bring hospital up to snuff, I requested about $100,000 worth of new equipment, including a hysteroresectoscope, new hysterectomy clamps, uterine ablation equipment, a laparoscopic morcellator, and a modern laparoscopic power source. When I put in the order for these things I was assured that we could get these things in short order, as the hospital had upgrading GYN surgery on its priority list.
As time went on, the equipment never arrived. It was held up in committee. It needed further approval. We needed more competitive bids. After further investigation, it seemed that the hospital just didn’t have enough money to do anything non-critical.