Monday, June 22, 2009

What is Necessary?

Atrios nominates her for Wanker of the Day. In her interview with Obama administration health officials, Dianne Sawyer asked:

What percentage of American medicine then do you think is doctors doing unnecessary tests because they're caught in some cycle of unnecessary testing?

From personal experience I would say, yes, doctors definitely do order unnecessary tests. Rather than use their expertise to diagnose and treat, my doctors seem to rely more and more on tests, most of which end up being either inconclusive or merely confirm their suspicions. Morever, family and general practitioners tend to refer all but the most ordinary (i.e. safe) diagnoses to specialists. These are just two ways that healthcare costs are being needlessly jacked up.

Well, not needlessly. Needs are being met, just not the needs of the patients.

I have too many examples to choose from to demonstrate my argument, so I'll focus on two. Recently, I broke a toe. I knew it was broken as soon as I hit it. And I also knew there was nothing a doctor can do for a broken toe, but I went to the doctor anyway, because the pain made it extremely difficult to walk.

{Sidebar - This is another example of wasteful medical spending. I have to see a doctor to get a pain pill. The doctor has no way of knowing, other than personal experience, whether I am telling the truth. If a doctor can tell if you're lying, surely a pharmacist can, too. Why can't I just go to the pharmacy and buy a pill?}

Arriving at the doctor's office, the first thing they did was take an x-ray. Did they need to do an x-ray for a broken pinky toe? No, common medical diagnosis procedures can determine a broken toe without the need of an x-ray. The doctor wrote a prescription for naproxin and refered me to an orthopedic doctor. Against my better judgment, I went to the orthopedist, who confirmed my broken toe and gave me a shoe to wear which, thankfully, provided enough relief to allow me to walk. "Gave" isn't exactly correct, as I just got a bill for $18 for the shoe, and a note saying this did not include the cost of the doctor visit. He also told me not to take the naproxin and gave me a prescription for Tylenol 3.

My GP could just as easily have given me a shoe to wear, or sent me to a medical supply store to buy one, but no, they had to refer me to a specialist. Why? I honestly don't know. Why did they need to do an x-ray? I don't know that either, but being the conspiratorial sort, I suspect doctors do these things: a) to increase the size of their bills {it's all about size}; b) they get referal or finder fees when they make appointments with specialists on behalf of the patient.

Second case - My wife had a sore throat and visited her GP, who took one look at her throat and immediately refered her to an ENT, arranging an appointment for her that same afternoon. The ENT took her through two follow-up visits before we got the first bill, which showed that the cost of using this little endoscope to look into her sinuses was $200 a nostril, and they used it on both nostrils each time she visited. Since her first two visits were in November and December, and her third visit in January, we didn't meet the $1,000 per year deductible for either year and had to pay full price. This was in addition to the cost of the doctor visits, plus the other procedures, including a head CT, for a grant total of over two grand out of pocket. All of this expensive medicine led to... (drumroll, please)... a prescription for an antibiotic which the GP could have prescribed for the cost of the original $25 copay.

Now call me crazy, but when you can put $2,000 in your pocket, instead of $25, which medical procedure are you going to follow? Doctors are human. In addition to practicing medicine, they are in a business designed to produce a profit for the owners. If I go to a doctor and pay him $85 to look at my toe, he can take that $85 and tell me its broke. Or he can take that $85, plus $125 for an x-ray, plus whatever referal fee he gets from the specialist, who will tell me it's broke and charge me $250 plus $18 for one ugly shoe.

What would you do? He's a doctor. By cultural definition, doctors are rich. Unless he's the second coming of Jesus Christ, he didn't go into medicine only for humanitarian reasons. He also went into medicine because it pays well. And the better he can make medicine pay, the more often he can take the wife and kids snorkeling in Aruba. That is just the way the world works. Everybody wants some.

So what is the solution? I don't know. If you start cutting back on doctor fees, or not paying them for all the little extras they tack on to the sticker price of a visit, you're going to see fewer doctors coming out of medical school and more doctors retiring early. But at the same time, things can't keep going the way they've been going. Doctors must be willing to make some sacrifices. After all, the next time I break my toe, not only will I not be seeing a specialist, I won't even be seeing my GP. I'll be using my $18 shoe. Fool me once, can't get fooled again.

Moreover, the above two examples are made possible because of health insurance. Do you think our ENT would be able to charge $400 every time he stuck his deal up your nose if most (or many) people didn't have insurance that would pay for it? If your insurance pays for something, do you even look to see how much it cost, much less complain about it?

Insurance is a big part of the problem. Because we have insurance, the monetary impact of a doctor's visit isn't immediately apparent, just as financing a $22,000 car for 72 months feels like a better deal than coughing up $35,000 for a $22,000 car. Nobody has that kind of cash laying around, but enough people can afford $400 a month to keep the car companies in business. Well, until recently. If GM and Chrysler really wanted to survive in the free market, they would lower their prices. But bailouts and bankruptcy are better than deflation. Deflation is the beast that dare not speak its name on the doorstep.

But if you don't have insurance, or you can't get financing, new cars and doctor visits are not even available to you. Good luck with that.

If there weren't financing, a $22,000 car would cost you about $8,000, because that's the most anybody could realistically charge for a car bought with cash. Same with houses and furniture and appliances and groceries. Financing, in the form of credit cards, car loans, mortgages and insurance, makes high prices possible.

Medical care is a basic human need. When there is a disaster, what do we send? Food, water, shelter, and medicine. Doctors need to go back to practicing medicine. They should use their minds and their imaginations and intuitions to diagose and treat, and rely less on expensive imagery and the opinions of specialists. That, and universal healthcare, will make medicine work for us again, instead of us working for medicine.

After all, think of the new car you could afford if your $8,000 a year health insurance were replaced with a $3,000 a year healthcare tax.

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