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

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?

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.”

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.

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.