Health Care: Good Reading

[drscott]

Hat tip Greg Minkow's blog: long but rewarding Atlantic article on health care reform. They killed his father, and the bill was $636,687.75.

Comments

[txkink.livejournal.com]

A very good and detailed read though I think there are some questions to a few of his assertions.I do agree that hospital acquired or nosocomial infections are a travesty in this era, but I know our infection control officers at my hospital are like storm troopers about hand-washing.

I agree that there are many financially motivated doctors who benefit from ordering procedures, but I cannot understand how anyone can line their pockets by ordering lab tests. Now I work at a government funded county hospital for a salary, meaning I get nothing extra no matter what I order or do, but I don't know how any doctor could get extra money from lab tests. Every lab we order goes through the submission process to insurance carriers or covered by the tax-supported fund for uninsured patients. Maybe it can be done in the private world somehow but I would be surprised to find out how they do it. The financial and legal repercussions for trying to cheat Medicare and insurance companies would dissuade most doctors from even trying.

The line about doctors in Dallas versus small-town Oregon might have some other explanations (as a doctor working in Dallas). The way I read him, he seems to imply that since Dallas is a larger city it would have more specialists (agreed), but he again makes it sound like these specialists are ordering unnecessary tests to pad their wallets. As I see it, the specialists are necessarily in larger cities because they can't support even a small practice in more rural areas but also many of these specialists work at major medical schools which are also located in major cities, not rural ones. Because of this we get referrals from all over the region meaning some of our sickest and most complicated cases may not be Dallas citizens at all. These patients are also those requiring the most complicated and expensive diagnostic tests and treatments. I'm a psychiatrist but our unit has the reputation for taking patients with both severe mental illness and severe medical issues including dialysis. We've had calls from as far away as Kansas City looking for admission for such patients. I would guess that in the Oregon town he mentions that these more complicated and difficult patients are transferred to larger cities because they can't handle such cases. Another issue on the same subject is that Dallas has at least one if not more Level I trauma centers, again meaning that smaller cities and towns with severe trauma cases send all their patients to Dallas. Our heliport at Parkland often looks like a scene from M.A.S.H. with helicopters coming and going. Maybe this is an oversimplification on my part, but that one issue struck me as more complicated than he might know.

[dr-scott.livejournal.com]

You're referring to this comment, I think: "Most physicians, meanwhile, benefit financially from ordering diagnostic tests, doing procedures, and scheduling follow-up appointments. Combine these two features of the system with a third—the informational advantage that extensive training has given physicians over their patients, and the authority that advantage confers—and you have a system where physicians can, to some extent, generate demand at will."

About diagnostic tests particularly, many people think they are ordered in excess as a CYA maneuver, which helps protect against malpractice suits. I think you're right that it's less commonly directly beneficial to the doctor, though there are apparently places (I'm thinking of Florida) where it's not uncommon for the doctors to own some part of the test facilities, for example for MRIs. This is a Sunbelt phenomenon, mostly, and I suspect it's much more prevalent in retirement areas or places where the population is unsophisticated and fails to question whatever the doctor says.

I think his point about specialists is more that they are highly compensated, while generalists are not well paid for talking to patients, taking histories, doing coordination work, and being patient advocates. The spending stats may not be based on pateint residence but on location of facility, which might wel lessen his point as you say - referrals and travel for complex cases would then tend to make areas where specialists practice more apparently costly. But I think that other studies have shown that it is true that specialists do generate their own demand to some extent, with otherwise similar urban areas showing widely varying costs.