How much is a good doctor worth?
Sometimes I worry about the future of medicine in this country. We hear more and more often about the panacea of "socialized medicine," or "universal healthcare," but what most people don't realize is that we already have it and the extent to which it adversely affects our lives.
EMTALA guarantees that any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If he is, then the hospital is obligated to either provide him with treatment until he is stable or to transfer him to another hospital in conformance with the statute's directives.
In practice, at least partially because of the litigation crisis in this country, what actually occurs is routinely far more involved than a simple medical screening examination. The full services of the hospital are often brought into play regardless of the ability or desire of a patient to pay for their care. Guaranteed entry into the system plus fear of litigation = universal healthcare, enforced by the government. That is socialism, pure and simple. Worse yet, EMTALA is an unfunded government mandate, which makes it even more intolerable and unreasonable.
But wait....there is more! Every adult over 65 is eligible for Medicare, the government socialized insurance program. If a hospital or physician agrees to accept Medicare payments, then they become obligated to follow the extensive and restrictive guidelines and payment schedules stipulated by our government. And the prices are strictly fixed. This is the worst form of socialism: the most talented and experienced physicians in the country receive the same payment for each given "relative value unit" of service as those who are inexperienced and barely competent.
The jerk with the horrible bedside manner who you can hardly understand and who rushes you through your visit receives the same payment per encounter as the kindly concerned physician who takes his time to listen to you. Whether you come to the ER at noon or 3 am, the payment is the same. Pretty scar or ugly scar....same payment. Good results or no improvement....same payment. Nice office or strip center....equal under the law. Welcome to assembly-line medicine.
And even worse, the insurance companies use the Medicare RVUs to set their rates, so everyone is socialized. If the government told all restaurants that they could only charge $10 for a steak dinner, whether they were Golden Corral or Smith and Wollensky's, what do you think would happen to the quality of the dining experience? Is that really what we want our country to be like?
I wonder if we somehow were able to revert back to a free market system of reimbursement whether the overall costs might decrease, and whether patient and physician satisfaction might improve. It seems like even with the amount of socialized medicine we have now that few are happy with the situation. I think that increasing socialism further is not likely to help.
UPDATE: Crisis in the Emergency Department, via GruntDoc.
UPDATE #2: The Choice: A Longer Life or More Stuff, via DB's Medical Rants
EMTALA guarantees that any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If he is, then the hospital is obligated to either provide him with treatment until he is stable or to transfer him to another hospital in conformance with the statute's directives.
In practice, at least partially because of the litigation crisis in this country, what actually occurs is routinely far more involved than a simple medical screening examination. The full services of the hospital are often brought into play regardless of the ability or desire of a patient to pay for their care. Guaranteed entry into the system plus fear of litigation = universal healthcare, enforced by the government. That is socialism, pure and simple. Worse yet, EMTALA is an unfunded government mandate, which makes it even more intolerable and unreasonable.
But wait....there is more! Every adult over 65 is eligible for Medicare, the government socialized insurance program. If a hospital or physician agrees to accept Medicare payments, then they become obligated to follow the extensive and restrictive guidelines and payment schedules stipulated by our government. And the prices are strictly fixed. This is the worst form of socialism: the most talented and experienced physicians in the country receive the same payment for each given "relative value unit" of service as those who are inexperienced and barely competent.
The jerk with the horrible bedside manner who you can hardly understand and who rushes you through your visit receives the same payment per encounter as the kindly concerned physician who takes his time to listen to you. Whether you come to the ER at noon or 3 am, the payment is the same. Pretty scar or ugly scar....same payment. Good results or no improvement....same payment. Nice office or strip center....equal under the law. Welcome to assembly-line medicine.
And even worse, the insurance companies use the Medicare RVUs to set their rates, so everyone is socialized. If the government told all restaurants that they could only charge $10 for a steak dinner, whether they were Golden Corral or Smith and Wollensky's, what do you think would happen to the quality of the dining experience? Is that really what we want our country to be like?
I wonder if we somehow were able to revert back to a free market system of reimbursement whether the overall costs might decrease, and whether patient and physician satisfaction might improve. It seems like even with the amount of socialized medicine we have now that few are happy with the situation. I think that increasing socialism further is not likely to help.
UPDATE: Crisis in the Emergency Department, via GruntDoc.
UPDATE #2: The Choice: A Longer Life or More Stuff, via DB's Medical Rants
Living in a society that spends a lot of money on medical care creates real problems, but it also has something in common with getting old. It’s better than the alternative.
It’s easy to be against high costs, and it will no doubt be hard to come up with a broad health care solution. But the way to start is by acknowledging that an affluent society should devote an ever-growing share of its resources to the health of its citizens.
posted by scalpel at 9:49 AM
20 Comments:
I cringed when I heard the VP of nursing at my hospital refer to psychiatric services as a "product line." I hear you, and I feel your frustration.
I think this would be a great post for Grand Rounds.
I'm not really frustrated. I appreciate EMTALA in a sense, and I get some satisfaction taking care of all comers. I make a good living, and I am not worried about trying to reap a windfall.
I just don't think our country can continue to afford to pay for platinum-level care for all. Once a technology becomes available, it becomes the "standard."
If we truly believe that everyone should have the right to receive medical services regardless of ability to pay for them, then is it really necessary to offer the same level of care to the homeless guy and the CEO? Right now, we do (to some extent).
You can't walk into Smith and Wollensky's and expect to get a free dinner, but there are various other places the poor can eat for cheap. Yet at hospitals around the country, people show up repeatedly for thousands of dollars of free medical care at the expense of the paying customers, delaying their treatment and increasing their costs.
There has to be a better way.
the perversity (as I said in my book) in the current system that pays the same for a given service without regard to the quality of that service is that it discourages excellence. And it de-selects from going into medicine those with the sort of work-ethic that says if I work hard and provide excellent service, it'll be recognized. It's the only profession where this is the case. A lawyer who has shown excellence in his/her field gets a higher fee than one who hasn't. Not so in medicine. And it's not about the money, per se. It's about a sense of recognition of the extra effort and better outcome.... lacking at this point.
Right on! Thanks for writing about this. You are challenging the underlying (false) assumption of most (socialists) who are talking about the "healthcare" crisis these days: That everyone has a right to healthcare. Your food analogy is correct. It would be illegal to prevent someone from buying food; that doesn't mean that everyone in the country has the right to a steak by the best Parisian chef. If the government tried to enforce that concept, they would soon find both steaks and chefs so rare that no one, rich or poor, would be able to get one.
I hope someone gets this concept through to the federal government before the quality of healthcare in this country is completely destroyed.
Dude, don't knock Golden Coral's steaks until you've tried it. I happen to think that it's swell for the cheap price. Where else can you go and get to eat all the steaks you want? And the veggy offerings is unsurpassed. No other restaurant offer more variety of veggies than Golden Coral. When I'm too lazy to cook, I bring my kids there. They love it. Of course I would have to pay the following day by running an extra few miles.
I fully appreciate the type of dinner that is available at Golden Corral. It's affordable, and it's pretty good. I don't think that Americans should be forced to settle for "pretty good."
Socialism decreases the quality of everything it touches. P.J. O’Rourke once said, "if you think health care is expensive now, just wait till you see what it costs when it’s free."
P.J. Again: "if you think that Public is an altar to worship at, put the word “public” in front of these words and tell me how you feel: Restroom. Swimming pool. Transportation."
http://www.ejectejecteject.com/archives/000057.html
I am a Medicare patient, or I was when I was rushed to the hospital with a broke hip after an accidental fall recently. Though retired for 10-plus years this was my first time to seek/need medical care because I put much effort into taking care of myself.
The entire experience was a revelation. The nurses and the surgeon, and all the staff, were simply wonderful -- professional, obviously competent, yet very kind. Probably they had to do a lot of extra tests because I had no timely medical records available, but they did tell me I'm in 'excellent' health.
I'd like to say that people talk about Medicare as though it were a welfare program like Medicaid. It isn't. I paid big bucks into it for a lifetime. What is true is that Congress has turned SS tax funds into a welfare source and general money bag for purposes it was not originally intended. I don't blame medical providers for despising it.
I've written my representatives in Congress demanding that Medicare payments to doctors be INcreased, not DEcreased. After I got out of the hospital, I paid each bill -- ambulance, emergency doctor, radiologist etc, etc and my surgeon -- the same week I received them. Sensible people set aside funds for emergencies. Supposedly that is what Congress was doing with the tax payments sent in for SS.
With all the bureaucrats employed by the SSA, it could make timely payments as well.
The idea of the gov't deciding on 'merit payments' for doctors boggles the mind. They haven't enough brains even to pay their bills on time.
Sorry for the rambling. I'm royally aggravated.
The concepts of Medicare and Medicaid are valid to me, but the implementation of both could be improved. I see way too many able-bodied people on Medicaid (welfare) or Medicare (disability).
If a woman is going to have a child and circumstances force her to seek Medicaid benefits, I think she should be required to stay on mandatory birth control (depoprovera, unless contraindicated) as a condition for receiving welfare benefits. If she cannot support one child herself, then she shouldn't have more until she can support them. Alternatively, she can have all the kids that she wants, but without government assistance.
And why shouldn't physicians be able to "balance bill" above what Medicare pays? I fully agree with the concept of reducing government spending, but Medicare reimbursement is already too low. Why should the fact that government insurance exists preclude physicians from charging as much as they desire on the open market for their services? Some physicians already don't accept Medicare patients at all, and that trend is likely to increase. Wouldn't it be better to let physicians balance bill rather than turning away those patients altogether?
The problem is that the public has been conditioned over many years to believe that anything from the government is 'free', especially if it's from the federal government.
There is not one. single. segment. of the population that doesn't believe its necessay 'entitlement' to government support supercedes everyone else's claims.
"There is not one. single. segment. of the population that doesn't believe its necessay 'entitlement' to government support supercedes everyone else's claims."
Not true. I would give up every dollar that I have ever put into the Social Security system up until this point (which is probably more than most people pay into it during an entire career) if I could just get out now and invest my future savings for myself.
mon dieu, you people are all smoking tasty crack, you know that?
Have you got to the point where you somehow think it's 'impossible' for everyone to recieve platinum standards of health care, in return for nothing more than paying taxes, or living in a place where it's recognised that not all are created equal?
Should, for example, the mentally ill or physically incapacitated be getting cheap government steak while you stuff yourself on sirloin? What if you suddenly got cancer and had to stop working? Where's your sirloin-feeding income going to come from then, when you apparently seem to need it most?
Until recently, I lived in a country where health care was free. FREE. Read it and weep for the past. Everything. The government enforced prices on medications so that pharmaceutical companies couldn't fleece patients, your bills went straight from the doctor to the government offices, the mother with two kids and a mortgage got the same care as a CEO. Both the good doctors and the rotten doctors had to go through the same audits and accreditations, and if you didn't do your homework before you picked one out, you were an idiot. Bad doctors just sank. Good ones swam.
This isn't socialism. This is a government taking care of its citizens. That is why you pay your taxes.
"From each according to his ability, to each according to his need," eh, comrade?
I think that part of the problem is that pricing is not transparent in medicine. No where else would you 'buy' something without knowing the price first. Example: My son needed a (non-emergent) MRI of his knee. Doc suggested one MRI place, but we had been previously to another. I figured I'd just go wherever it was cheaper. Only I could not get either place to tell me their price! (Something about 'confidential' price arrangements with the insurance company.) So I called the insurance company. They said they could not tell me their 'allowed' price for either MRI place and that I shouldn’t worry about the price because the service was covered. (Yeah, after my deductible and then with a co-pay!) So we just went where we'd been before. When I got the explanation of benefit form (after the fact), the billed and allowed prices were listed...not sure why it was so difficult to obtain this info up front.
Good point. I don't even know exactly how much each service costs our patients. The ER facility fee for a basic visit is $210 for a basic visit like a sinus infection, $650 for a more involved visit like getting IV fluids, or over $1000 for a comprehensive visit where critical care stuff gets done. That doesn't include the physicians fee, meds, or suppllies, that's just the "facility fee."
A sprained ankle requiring X-ray, splinting, and crutch training is easily around $1000 total. A chest pain workup is going to run 3 to 5 grand, the difference largely depending on whether or not a CT scan is done. That doesn't include the admission; that's just the ER portion of the experience.
As far as my physician fees go, I bill the same for incising an abscess (which takes me only 10 minutes max) as I do deciding if your abdominal pain is appendicitis or just food poisoning (which takes hours). I do not set the rates for my services....they are set by the government.
Nicole,
I know it feels like everyone here has lost their souls but I would simply argue that you are misinformed.
No matter which country you used to live in, your healthcare was not "free." People in that country financed it in the form of "taxes." I assure you of that. Under a simplified single-payer model, (where the government is the sole payer for healthcare) it is generally safe to presume that yes, the CEO and the mother both get the same quality of care. What you don't realize is that the CEOs from such countries often fly to the U.S. for the better quality care. They come here to get their important surgeries -- and they don't have to wait in line.
You've also illustrated another problem in commenting that your healthcare was "free"; you have no idea how much the healthcare service is actually costing you. Most importantly, you have no incentive to shop wisely, to get the most medical bang for your buck. Under such a model, the costs grow without a parallel improvement in quality.
I know that you hate the idea of the disadvantaged getting cheaper steak but you also have to keep in mind that healthcare, just like anything else on this earth, is a resource. We have a limited amount of resources and it boils down to how we divide up the resources. Is everyone "entitled" to a same-sized-piece, simply for being alive? Or do we divide it up some other way, according to need? According to ability to pay?
I have more to say about how you think pharmaceutical companies fleece people but perhaps I'll save that for my own blog.
I live in Canada, yes we have socialized medicine here, and I think it works pretty damm well, The Dr's in this country make a very good income, and maybe even have abit more job satisfaction due to the fact that they do not have to practise CYA medicine, and an ER doc here does not get paid the same fee for a simple suture job, versus working up an abdm pain or chest pain, not to mention if they work a weekday or weekend or dayshift versus nightshift. I work in the health field (ER and ICU) and have worked in both Canada and USA, and in my humble opinion they care pts receive are equal in both countries, there are good and bad Dr's in both countries. And as for the wealthier pts in our country going "over the border for quicker better service" if a pt truely needs emergency surgery in Canada they get it. I also think that pts in a socialized medicine situation have alittle more respect for the medical care they receive because they do not think of health care as a retail service. Sorry for the rant, just got alittle touchy about the perceived trashing of the way our country provides medical care.
Oh and by the way, biomed Tim, no our health care is not "free" we do pay taxes, the same taxes that everyone else pays in every other country in the civilized world. Those taxes cover the cost of our health care, schools, highways, and everything else a federal or provincal goverment administers
Wow, this has been a real eye opener. Who deserves medical service more? A single working mother of two who gets injured on the job, or Paris Hilton after fucking herself up on a bender?
Well, who can afford the steak?
And after all, isn't Paris worth more as a person? No one can deny that!
Hmm... appendicitis or food poisoning? Can't afford to check? Just go home and decrease the surplus population.
Whenever one of those deluded cynics tell me doctors care more about money then they do about healing the sick, I'm going to link to this article to prove how wrong they are.
We really do live in the best of all possible worlds.
I am very happy to see that the socialists who prey on the little guy's paychecks are reaping the rewards for their crime against economy.
I wish that the USA's health care system will go into socialized medicine, that way your health care system will go to hell and it will be one historic example that robbing money from the workers is a crime against humanity.
People should pay NO taxes and should pay for everything they use.
I am for a free market and I am a libertarian. Government intervention has always lead to persecution of the working class and the poor.
I think the problem is even more deeply rooted than that. Society simply does NOT work.
The only thing separating civilization from wilderness is the tie you wear around your neck.
Layers upon layers of hypocrisy is the true achievement of civilization. People still use violence and destruction to achieve their means, people still crush the small so they can go higher up the ladder.
We should have remained in a hunters gatherers economy.
Society is a failure and will eventually collapse.
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