WhiteCoat

Dr. WhiteCoat Goes to Washington

Sorry about the sparse posting lately – have been away in Washington at an ACEP conference

Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference.

I attended some excellent lectures about leadership.

  • Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions.
  • I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional.
  • I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for.

There were other lectures about how health care reform fell short and some possible options for the future.
One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference.

And I went to legislators’ offices.
The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff.
I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input.

I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer for him. We sat there for 45 minutes talking. Below are some of the things we discussed.

“What do you think about the SGR?” He asked.

  • Honestly, I don’t think they should fix it. Nobody cares about it right now. All they know is that they can keep kicking it down the road until it becomes a big enough problem that someone is forced to fix it. The only way to deal with the issue right now is not to fix it. Cut payments to physicians. Let most of them drop out of the system. Let the patients who depend on Medicare be stuck without medical care. Almost immediately, the AARP will pay for a bunch of buses for all the grandmas and grandpas with their pink hair and canes with the tennis balls on them (probably my own mother included) to go to Washington and demand a fix. Only then will legislators realize that the current system is unsustainable and unfixable. We can’t patch this system and expect that it will continue to work. We must focus on starting over and creating an entirely new system that will be sustainable in the future. And a side note – if you try to create another system without extensive input from physicians, it will fail in the same manner that the current system is failing.

“Do you think that the AMA represents the views of physicians across the country?”

  • Not really. I believe there is a lot of attrition from the AMA and know of many physicians who have dropped their membership. At the same time, membership in specialty societies is growing. ACEP is a perfect example. ACEP’s membership is going up, not down.

“How would you make the health care system better?”

  • Patients must have more skin in the game. Right now many people think that the value of the health care they receive is their $20 copay. You can’t get work done on your car for that much. A plumber would laugh at you if you told him that was all you would pay him. But, in practical terms, all a physician visit is worth is $20. That mindset has to change. $20 per visit won’t even keep the lights on.
    There is a tremendous demand for high technology and for extensive testing that is often low yield. That is because a majority of patients have no direct responsibility for paying the cost of the testing. There is no incentive for patients not to want a test and there is no incentive for a physician not to order the test. In fact, with the push toward “patient satisfaction” as a basis for reimbursement, the incentive for physicians to order extensive testing will only increase. If patients don’t have skin in the game, costs will continue to rise no matter what regulations are put in place. I guarantee it.
  • The only instance in which patients and physicians work together to decrease costs is when patients have to pay out of pocket for their medical care. If a patient’s medication goes off formulary for their health plan, the patient goes to the physician to find an alternative or to get the physician to request an exception from the insurance company. If a physician would like an MRI on an patient’s back after the patient was injured at work, the patient will not get the exam done until worker’s compensation agrees to pay for the test. This is what we need – patients need to be responsible for the costs and physicians need to help them determine what they really need and don’t really need. If patients want a low yield test, no problem – but they have to pay for it out of their pocket. Let them have ten low yield tests if they want. The only one who bears the cost of the testing is the patient.
    Homeowner’s insurance doesn’t cover the cost of someone mowing your lawn and it doesn’t cover the cost of your kid breaking a window.
    Auto insurance doesn’t cover the cost of oil changes or fixing your tire.
    Why should health insurance cover routine medications and routine medical care? It shouldn’t.
  • Health savings accounts have to become an integral part of our culture. Use the money in those accounts to pay for routine health care costs. Make money in the accounts tax-free to encourage people to use them. Allow patients to carry some of the money in the accounts over to future years, but require that they spend at least some of the money in the account each year to encourage people to engage in preventative health care practices. Family practitioners could drop all their insurance plans and could all go “cash only.” No insurance hassles. Money at time of services. They’re happier and more productive. More people go into family medicine. Patients get seen quicker. What a concept.
  • Mandatory insurance isn’t fair and it probably isn’t Constitutional. You want everyone to pay into the system, increase taxes in an amount proportionate to the amount you’ll need to provide for medical care and provide the care at government-run hospitals for free. You don’t have to pay for an insurance policy, you have to pay 5% more in taxes. In return, you have access to health care at any VA hospital. Include county hospitals if you need more access. Will the care be the best available? Probably not. Will everyone get a same-day appointment? Not likely. Will everyone have access? Absolutely. Do this and you could eliminate much of the costs that are currently wasted on insurance companies.

“What do you think still needs to be included in the health care bill?”

  • Malpractice reform. The AAJ has talking points stating how direct medical malpractice costs are an infinitesimal amount of total medical expenditures in this country. The statistics are true, but are only half of the story. The AAJ states that instilling fear in medical practitioners is good for medical quality of care. That fear drives defensive medicine. Defensive medicine accounts for hundreds of billions of dollars in indirect medical costs – at little gain to the system. If lawsuits improve quality of care, then the trial lawyers have failed. They’ve been suing doctors for decades and mistakes are still being made. The only thing that seems to go up is the size of the judgments. We can’t sue our way to better health care. Yes, I said that and yes the assistant laughed. I think he even wrote it down on his pad.
  • Damage caps are a tricky subject. Capping a patient’s damages at $250,000 isn’t fair to the patient, but neither is making a doctor liable for a $60 million judgment. There has to be some reasonable limit to damages, but even those limits won’t decrease the physician fear of being sued. [I actually agree with Matt on this point – in almost all cases, caps don’t save physicians money, they save insurance companies money – but if insurance companies go out of business, hike rates, or stop offering coverage because of a $60 million judgment, physicians will have a more difficult time finding coverage and won’t be able to practice. There has to be a happy medium].
  • Like it or not, we will likely need to provide some type of limited liability protection to certain providers if we want to increase the numbers of those providers. Few physicians like being on call at hospitals because they know that they probably won’t be paid for the care and that they are highly likely to be sued if anything goes wrong. We have to ask ourselves whether we value the ability to find a physician to care for us in an emergency more than we value the right to sue that physician if anything goes wrong. Which is more important to us: Perfect care or available care?

We had other discussions, but this post is already getting too long.

You naysayers want my ideas? Here they are.

Now try to show me how they won’t work and come up with some better ideas.

43 Responses to “Dr. WhiteCoat Goes to Washington”

  1. Matt says:

    So after you got done with presenting some good ideas and some false choices, did you get a feel for which way Washington is headed?

    Kudos to you for being proactive, even if somewhat misguided.

  2. Matt says:

    ” but if insurance companies go out of business, hike rates, or stop offering coverage because of a $60 million judgment, physicians will have a more difficult time finding coverage and won’t be able to practice. There has to be a happy medium]”

    This is a delicate argument for you to make, btw. You’re effectively arguing that insurers should have some kind of guarantee of profitability so we’ll have them and thus have doctors (according to you). The problem with that line of thinking is that it’s a big slippery slope. If we’re going to guarantee profitability of one industry, where do we stop?

    And why even have the middleman of the insurer? Why not just move the cost of malpractice to being paid by the government, and eliminate insurance execs and such and that overhead? And for that matter, since oftentimes that liability coverage is going to pay back the government, why not just have the government be wholly responsible?

    You don’t crack the door to government intervention and it stays cracked. It gets swung wide open. So you may well get your protections, but the government’s going to ask something in return. You can’t say we have to have limited liability so there will be doctors in the ED, and then expect the government to not demand a certain number of physicians in the ED in return. You guys have a tendency to be specific in the proposals that favor you, but vague in what you’ll give in return. That’s not how it typically works.

    • WhiteCoat says:

      Nice Mattuendo. Who said anything about “guaranteeing profitability”? I’m commenting on my perceptions of cause and effect. Change the laws and make insurance companies go away and there will be different incentives and disincentives to practicing medicine under those circumstances. You are twisting things and trying to put words in my mouth.
      I agree that eliminating the middleman would save costs. That’s another choice we have to make as a country. Insurance companies can be liable for negligent decisions. Governments usually can’t. It’s easy for governments to make laws about what insurers should cover because it’s not the government that is paying for the testing/treatment. Being a provider and an insurer would create a monopoly where care could be denied with potentially little recourse for patients.
      Are the cost savings worth the restrictions? That’s not my call. Maybe it would create a secondary insurance market like they have in the UK.
      Your logic in last paragraph doesn’t make sense. Like saying “we are going to limit the liability of IRS agents. Now we demand to know how many people agree to be an IRS agent and what you’re going to give us in return.”

      • Matt says:

        “Who said anything about “guaranteeing profitability”? I’m commenting on my perceptions of cause and effect. ”

        Picked up some weasel word techniques while you were there I see. Well, good sir, what was the point of your comment if not to say that insurers need to be solvent so we’ll have docs.

        “Change the laws and make insurance companies go away?”

        I didn’t say change the laws at all. I just disagree with you that we should give companies in the risk business insulation from the very risk they insure based on some vague promises of access to physicians.

        “. Being a provider and an insurer would create a monopoly where care could be denied with potentially little recourse for patients.”

        Or for physicians, for that matter, when you apply it to the other side of the physician-patient relationship. That’s what happening, although I think you’re missing it.

        “Are the cost savings worth the restrictions? That’s not my call”

        Except you went up there to advocate for a specific savings benefit. So you, like every other voter, do make the call.

        “Your logic in last paragraph doesn’t make sense.”

        Only to someone who is used to asking for things but giving nothing in return like yourself. The point is clear. You say we have to have liability protection or we won’t have physicians. That’s not a new claim from physicians, and you can and do apply it to everything you want. What you never actually say though is how many physicians we get if we DO give you what you want.

        It’s great lobbying work, because most people never ask the question. But you and I know what you’re doing, don’t we?

      • Andrew says:

        “Only to someone who is used to asking for things but giving nothing in return”

        Isn’t that the definition of a malpractice lawyer?

      • C. Lewis says:

        Having never replied to comments on this website, I’m just hoping this comment lands in the right spot.

        My comment is in response to what Matt said about health insurance companies being in the “risk business”. I would like to point out that the ability of health insurers to properly risk-adjust their premiums has been severely limited in most states (guaranteed issue, community rating) and will be eliminated in 2014 by the new health law. At that point, insurers will become public-utilities and yes, you do have to give such companies insulation (guaranteed profits).

        Whitecoat pointed to auto and home insurance as examples of real insurance. To this list I’ll add life insurance. In all cases, some form of risk assessment takes place and individuals are assigned a premium. Premiums can be affected by the way your actions, e.g. lots of speeding tickets will increase your auto insurance premium. Life insurance typically expects a blood and urine sample, personal medical histories, and a signed statement that you will avoid reckless behavior (sky diving, motorcross, etc). Unlike health insurance, life insurance is typically a long term contract. Think of the incentives insurers would have to keep people well if they were committed to them for longer than a year?

        Until we bring these principles back to health insurance, I don’t expect to see any cost savings. Quality of care will suffer as long as third party payers (including the government) are the ones determining what care people should and should not receive.

      • WhiteCoat says:

        “But you and I know what you’re doing, don’t we?”

        More classic Mattuendo. Keep it up and pretty soon “mattuendo” will show up on Google searches. You’ll be famous. Mwuuuuuuhahahahaha.

      • WhiteCoat says:

        C. Lewis –
        Welcome, and I wholeheartedly agree with your comments.

      • Matt says:

        “Isn’t that the definition of a malpractice lawyer?”

        No, a malpractice lawyer puts hundreds of hours of time and hundreds of thousands of dollars into the typical case they try. And their client, who they’re really the agent for, has generally given quite a bit in suffering for whatever they receive.

      • Matt says:

        “My comment is in response to what Matt said about health insurance companies being in the “risk business””

        Did I say health insurance companies? I think I was referring to malpractice liability carriers. You’re spot on with regard to health insurers, C. Lewis.

      • ERP says:

        “Mattuendo” LOL.

      • Matt says:

        More on the Faustian bargain made by health insurers:

        http://www.theatlantic.com/business/archive/2010/05/health-insurers-and-their-faustian-bargain/56898/

        It’s likely going to turn out similar to the Faustian bargain physicians made 30 or so years ago with LBJ. Although at least physicians had a few decades of making quite a bit of money off of it. I don’t think health insurers will get that long before the spigot gets shut off.

  3. Matt says:

    “If lawsuits improve quality of care”

    Love that false choice, by the way.

    • WhiteCoat says:

      Another Mattuendo.
      Your opinions different than the AAJ in the liability-quality connection, there counselor?

      • Matt says:

        I’ve never seen the AAJ say that, but if that were their position as the goal of a lawsuit, they’d be wrong. It may in certain circumstances be a tangential benefit, but the goal of a civil lawsuit is generally to recoup the damages of the plaintiff.

        BTW, do you know what an innuendo is? You might want to get a dictionary. It’s a great little phrase that you got there, but I think you’ve fallen in love with it a little too much and are misusing it.

      • WhiteCoat says:

        Apparently you have to drink more Kool-Aid. You didn’t seem to denounce the AAJ’s opinion back in December very much, did you?

        Innuendo: “An innuendo is a baseless invention of thoughts or ideas. It can also be a remark or question, typically disparaging (also called insinuation), that works obliquely by allusion. In the latter sense, the intention is often to insult or accuse someone in such a way that one’s words, taken literally, are innocent.”
        Seems like the definition fits to me …

      • Max Power says:

        Punitive damages are more than just “recouping damages” they are by definition designed to “punish” the offending party. They came into play w/ an automaker (Ford, I believe) was involved in a class action lawsuit for knowingly selling an unsafe vehicle. Actual damages were cheaper than the cost of recalling the vehicles. Punitive damages were added, so that Ford (and future big companies) would think twice before being deliberately negligent again.

        So, yes, punitive damages against physicians, etc. are designed to prevent them from slacking on their quality of care.

      • Matt says:

        “one’s words, taken literally, are innocent.”
        Seems like the definition fits to me ”

        I imagine that to you it does. Your version of English and the dictionary only rarely cross paths, though.

        And I’m not a member of the AAJ, but I have repeatedly said that argument was a weak one. Sorry I didn’t say it in that particular link – I know how short your memory is. Saying lawsuits don’t improve medicine is like saying physicians are responsible because my drain is clogged.

  4. “Health savings accounts have to become an integral part of our culture.”

    Not as currently implemented, they don’t.

    I did one of these for one year. I used it for co-pays, prescription meds, and some medical equipment (CPAP, eyeglasses) that I pay for off-insurance.

    I had started the account by guessing $2600 in such incidental expenses, knowing that was on the low side. I ran out, pretty much as expected, in september. Then I started to get the paperwork from the HSA administrator. Every last one of my claims was denied, please provide more documentation. For payments to my local hospital for an X-ray after a road accident, please provide justification. For co-pays to my physician, please provide justification. For mail-order refills of my blood-pressure meds, please provide justification.

    From my co-workers, I find out that this was routine – it seems part of the dance for the HSA administrator to pushback on individuals, in the hope that they’ll give up. Digging up documentation and justifications for several dozen transactions taking place up to a year before didn’t appeal to me, so I dropped the HSA and bit the bullet on re-making the entire HSA amount taxable that year.

    Adding useless paperwork is hardly the way forward.

    • JustADoc, says:

      Are you sure you had a HSA and not a FSA. People with HSAs tend to not have co-pays as you are responsible for the first dollar the 3000th dolar and then your insurance pays everything above that. Your HSA and your insurance are not actually even linked.
      Your HSA is also your money. There are rules about it having to be used for healthcare before age 65(after that it is essentially an IRA).
      With a FSA any money not used returns to the company so it is in their interest to argue every penny as any penny not spent is income for the company.

    • Andrew says:

      That’s part and parcel of medicine. Its why doctors are forced to hire multiple assistants to track patient records and claims, while spending hours documenting every medical decision, hours which they are not compensated for. The alternative is a lax regulatory system, like Medicare, which allows for millions of dollars in scams.

      Under the current system, either you pay the cost, the doctor pays the cost, or the entire risk pool pays the cost. I think that’s what WhiteCoat means by making HSAs an integral part of our culture. There could be a whole profession of freelance medical assistants helping individuals navigate the bureaucracy, similar to accountants. Or maybe after a little exposure, consumers such as yourself could demand a more succinct, user-friendly system for filing claims.

      HSA’s are windows into the world of medicine. If you don’t like what you see, don’t just close the blinds and walk away. See if you can do something.

  5. Doc99 says:

    Great Job, WC. Perhaps after the November elections, you’ll be visiting legislators and not just their aids.

    • Doc99 says:

      I meant AIDES lol. My Freudian Slip is showing.

    • Matt says:

      Why would the November elections change anything? Republicans had far more power than Democrats have for the last two years from 2000-06 and did exactly nothing on the issue. Except pile on more debt.

      As long as you physicians keep going to the government to solve your problems, you’ll keep having the same problems.

      • Doc99 says:

        It’s not about D or R. This year, it’s about the anti-incumbent “Vote Row No” sentiment around the country. Entrenched politicians have become an entitled class who’ve forgotten the fact that they work for the people, not vice versa. November may well truly be a game-changer.

      • Matt says:

        I hope you’re right.

  6. Classof65 says:

    Thank you for sharing your ideas and opinions on health care reform with us.

    I understand your stance on HSAs, however I really would like to do away with insurance companies altogether. I would prefer to pay higher taxes than to have to fight with insurance companies for every penny. I currently have health insurance that I pay for directly and the premiums are money thrown down a hole. It’s BCBS with a high deductible and even with chronic conditions, my medical costs rarely exceed my deductible. However, I am afraid to drop the insurance in case of a catastrophic illness. With the high deductible I am definitely aware of the price of my medical care and I have no prescription coverage so my meds cost me nearly $800 a month. Give us a public option, please!

    • Max Power says:

      Have you ever considered a high deductible low premium plan. You save that $800/ month and put it in a HSA, or heck even a regular savings account, and pay your FP and pharmacist out of pocket. That way you are covered if something really bad happens. Basically you are paying for “pre-paid” health care, without using what you are paying for and you are demanding that the rest of us pick up the cost. Should we pay for your lawn care and oil changes too?

  7. SeaSpray says:

    Good for you Dr WhiteCoat goes to Washington! :)

    I am *glad* you got the message out. I have long said they need to speak with the doctors.

    That being said ..I am very pleased with my plan and am concerned for when we will have to pay more out of pocket. We don’t abuse it, but given the medical issues that have come up ..I am so grateful we had/have it. There is absolutely no way we could afford to pay for the multiple large tests that have been done (Do you know how many thousands of dollars they cost?)and then add in all the other ones and procedures. And if you are a patient with frequent flier office visits ..20.00 is doable, insurance kicks in after deductible and then responsible for 10% co-pay on other end. Our insurance reimburses doctors quite well. But if had to be responsible for all/entire office visits to different doctors – out of pocket? You don’t keep bringing your car in to get fixed over and over again.

    I don’t want any tests I don’t need. I don’t want my doctors ordering any tests I don’t need for any reason. But I do want to be able to afford the ones *they* think I *need*, not for cya. I do want to afford to go to the doctor if needed. Specialists cost more than pcp’s and they aren’t cheap either. If you have a patient with a chronic or serious condition ..it all adds up quickly ..even with insurance.

    My decision would have to be to not get the treatment or check up until I absolutely had to… if I had a choice ..or if doctors wanted to be paid up front and not work out a payment schedule ..then wouldn’t be able to go to them. Kind of can’t get all the work done when they want to and we have been in that boat to ..prior to dental insurance and even with it is is expensive if you need a cap, etc. Or wait and then go to emergency room ..incur more costs and then you are back to square one with not being able to afford the follow- up physician.

    This really irritates me ..this whole thing. All these years we paid into insurance premiums and of course my husband’s company ..but we actually pay more than I thought. I was surprised when doing the taxes this year. I must’ve latched on to some figure at least a few years back. Anyway ..we paid in ..hardly used it until last few years and now that we need it .. it may all change. Just venting.

    I actually can’t believe that we could end up not being able to get *quality* medical treatment like we are used to.

    Am I misunderstanding all of this?

    Maybe I don’t understand the concept of skin in the game and hsa’s. I understand about shopping for the best price ..but if you don’t have the money ..you aren’t buying a darn thing.

    Oh and that is horrible …what California is doing to physicians!

  8. SeaSpray says:

    P.S. Thank you for sharing all of this. Most interesting.

    You do realize that now in my mind’s eye ..I see you as a young Jimmy Stewart? ;)

  9. Painless says:

    Of course something else to think about as one alternative.. make insurance companies nonprofit entities. That way they aren’t looking to make their shareholders the vast sums of money they are getting now. Take that incentive away from them, and they may be willing to pay claims appropriately and not dispute every little thing. Of course.. who would want to be an insurance carrier if they couldn’t make money that way? Never mind.. we’d probably end up with more med mal attorney’s. :-)
    Yes Matt, that was a dig.

    • Matt says:

      No worries. It was a decent one. Although I’m not a medical malpractice attorney, for the most part.

  10. hashmd says:

    Hey, WC

    Next time you are up there, you need to mention that Congress and the Executive Branch need to have skin in the game too. Until they have to live with what they have legislated for healthcare, they will never “get it”.

    This is supposed to be a government of the people, by the people, and for the people. They should have to feel the pain of what we have to put up with in the current and future healthcare plans.

    Whatever limitations, restrictions, controls they place on benefits provided to Medicare beneficiaries, they should have to live with as well. No more yearly colonoscopies for POTUS (unless medically indicated and put through all the usual approval hoops my patients have to go through), no MRI or CT unless approved by the Blue Cross Radiology approval process (a nightmare!).

  11. Matt says:

    This news is awesome:

    http://www.chron.com/disp/story.mpl/metropolitan/7009807.html

    Physicians have been touting the Texas “miracle” for awhile, and WC loves to say how tort “reform” is necessary for access. Yet it appears that the poor who rely on the government still can’t get access in Texas. Why you ask?

    Because it seems that after the physicians got what they wanted, they now want a little more in order to fulfill their previously made promises.

    Guys, stop going to the government. For anything, even immunity from your mistakes. Even if you get it there’s a price to pay.

  12. Joe says:

    How is a patient supposed to determine whether or not a particular test is “low yield”? The doctor has an incentive to over-test (as you correctly noted), so asking the doc is out. Do you really want your patients second-guessing you when you order expensive but necessary tests?

    I mean, you already have patients second-guessing you about vaccination, right?

    I lean towards the single-payer end of the spectrum, so the problem of reducing unnecessary testing seems fairly easy: any doc who orders substantially more than average “low yield” tests (taking into account the number and types of patients they see) would receive a professional audit by an MD. The auditor would suggest ways to reduce testing; docs who can’t manage to reduce testing would have their reimbursement reduced.

    You also say that health insurance shouldn’t cover routine care. What about routine care that is a public good? What about routine care that in the long run reduces catastrophic care, saves the insurance company money, and reduces hospital overcrowding?

    As for malpractice reform, I think we just plain need to stop handling non-malicious malpractice in the courtroom. Docs who screw up a bit (as determined by a review board of other doctors) should be required to take remedial training; those who screw up big-time should lose (or have restrictions placed on) their licenses. Injured patients should be provided remedial care out of a government fund, but no punitive damages or awards for pain and suffering. Seeing a doctor, like anything else in life, entails some risk; trying to make whole those who are injured in doing so ends up drastically reducing the quality of care for everybody. Doctor liability should be limited to those rare cases when the doc commits a criminal act.

    • Matt says:

      I think all of that is exactly where we are headed. Plus I expect physician pay to decline significantly.

      • DensityDuck says:

        I love how we’ve got a lawyer here bitching about how doctors make too much money!

      • Matt says:

        You misread. I think physicians deserve every dollar I get. In fact, I think some of you seriously undervalue yourselves as you allowed yourselves to get paid in lockstep with all other physicians, regardless of skills.

        I support your ability to earn as much as the market will bear.

    • DensityDuck says:

      “You also say that health insurance shouldn’t cover routine care. What about routine care that is a public good?”

      There’s plenty of precedent for this. Many states require drivers to have their vehicles inspected every year. This inspection is performed at the driver’s expense, even though it’s notionally to ensure a base level of “health” in all vehicles on the road.

      Even without that, regular vehicle maintenance (oil changes, tire rotation, brake inspection) reduces the number of accidents; and those accidents are responded to, typically, by government personnel. Seems to me that there’s a “public good” argument that basic vehicle maintenance should be covered, and yet those costs are still borne by the drivers themselves.

      As for single-payer, it could certainly reduce costs by instituting a Schedule Of Approved Treatment and anything outside that is at the patient’s own option–and the patient’s own risk. “Well, Mister Medical Examiner, I did the Approved Treatment and the patient still died, blame the government for the wrong Approved Treatment. I asked the patient if he wanted more, but he didn’t want to pay the extra fee to cover the liabilty costs.”

  13. DefendUSA says:

    WC, Great job, but Mattuendos drive me berserk!! Argh!!
    Your suggestion about skin in the game is spot on. I think I have said it before that people think it’s magic when they make a copay and they are done. Actually most of your thoughts are worthy of consideration by those who make the laws. Let’s hope you get a call back.

  14. DensityDuck says:

    “skin in the game”: No. That isn’t the problem, actually, because people having their cars repaired have plenty of “skin in the game” and yet car repairs are still plenty pricey. (And medical patients don’t have the option to total the car and buy a new one…)

    You say “skin in the game”, but I keep thinking that what’s really going to happen is that there’ll be just as much defensive medicine, only now it’ll be used as an excuse to insulate doctors from ANY malpractice accusations–Matt’s nightmare scenario. “I think you need this test, even though your insurance won’t pay for it. But if you don’t get the test and something goes wrong, then you can’t sue me, because you Didn’t Do The Recommended Test.”

    It seems to me that the better path would be to institute a national board in the USA, similar to Mexico’s CONAMED or other such bodies, that would review prospective malpractice cases before they went to trial. Indeed, the very notion of “expert witnesses” argues against the competence of twelve general-population citizens to decide medical matters; why not just carry that to its logical conclusion?

    • Matt says:

      If we go to single payer like you suggest, much of this is moot. You want Mexico malpractice laws, give us Mexico medical prices. And physician salaries.

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