Category: System

David Goldhill is a CEO. He likes Obama. He’s a democrat and generally supports government in healthcare.

But it blows his mind that an entire industry is blind to prices.

After his dad died from a hospital-borne infection, Mr. Goldhill started a quest; improve healthcare in America.

His wrote “How American Healthcare Killed my Father” for the Atlantic.

He researched, debated and lectured on healthcare.

Then he wrote a book: Catastrophic Care: Why Everything We Think We Know about Health Care Is Wrong. Malcolm Gladwell calls it

“A devastating and utterly original analysis of what has gone wrong with the American health care system. Read it, and take a deep breath.”

Why bother with US healthcare?

Everyone knows Canadian Medicare is better…and different, right? Canadians love not being American.

But for healthcare, we share something critical: invisible costs.  Patients and providers never know the price of care. Not that it’s not free; just too scary for us to know the real cost.

• In the US, insurance companies pay.
• In Canada, governments pay.
• Patients access care with no concern for cost.
• Doctors provide care with almost no concern for cost.

To this, the choir bursts into “O Canada!” And Canadian Doctors4Medicare enjoin with, “Hallelujah! Hallelujah!”

Catastrophic Care – Highlights

• Surrogates administer and pay for care. Third parties (insurance companies and governments) never care as much about prices as 1^st and 2^nd parties (patients and doctors).

• Medicare presents moral hazard – do extra work ‘because it’s covered’.

• “But if patients were served like customers, wouldn’t that create waste in advertising and promotion?“ Marx said the same about toilet paper; how wasteful to have more than 1 brand!

• Lower administrative costs do not indicate success. With waste, waiting and quality concerns, low admin costs indicate rationing or negligence.

• Insurance/government-run systems have no meaningful financial discipline.

• Cost based pricing never works. ‘Costs’ just get artificially raised.

• We’re fixated on insurance, static rules and unknown prices. We are overconfident in our ability to set prices.

• The healthcare system makes us feel like paupers – a result of a system without customer accountability.

• We follow a path of dependence. We limit reforms to existing structures.

• We try to cover too much.  It’s dangerous to the whole system.

• Surrogates, regulators and special interest groups resist new ideas.

• Stakeholder interests control government’s agenda.
  • Creative destruction becomes impossible; incumbents’ interests become stakeholders’ interests.
  • Business eliminates whole industries to improve customer service (e.g. longshoremen disappeared with ‘container’ shipping).
  • Governments never eliminate a stakeholder.

• Goldhill offers a thought experiment: Could we spend healthcare dollars differently? He leverages ideas from Singapore to offer a plan.

If you only read one healthcare book this year, try Catastrophic Care: Why Everything We Think We Know about Health Care Is Wrong.  Mr. Goldhill writes well. Other than a few totally US-centric sections, Goldhill shares problems and solutions that apply to Canadian Medicare too. He does not promote a totally privatized, laissez faire, market-based system.

I’d love to hear what you think of it!

 

Doctors admire medical experts. Physicians appreciate the sacrifice needed to learn and maintain clinical knowledge. Doctors spend thousands listening to medical sages.

As practicing physicians, we often crave the certainty of sage advice. Dozens of effortless decisions we make each day with patients seem insignificant compared to the advice of a world-renowned medical expert.

Policy makers know this. At least the smart ones do.

While lesser bureaucrats whine about physicians obstructing policy, savvy politicians call in the sages.  They trump physicians’ practical, every-day knowledge with experts’ opinions and data.

Indeed, good evidence should direct progress. Every medical student knows that (aka “The school-boy fallacy”).

How it works:

• Politician directs bureaucrat to draft new policy.
• Bureaucrat solicits an expert imprimatur.
• Policy assumes the glow of Asclepius’ Rod.
• Policy drives new process.
• Politician gets re-elected.

Medical Experts

Experts ascend through academia by conquering a tiny sliver of clinical care.  For example: the distal nephron, or the neonatal distal nephron.

Experts see fewer patients than their eminence suggests. They sashay across stained linoleum in grand university hospitals surrounded by swarms of trainees and lesser humans. They expound on clinical, political and metaphysical puzzles with worn familiarity. At conferences, experts advise regular physicians on clinical care while calling with equal authority for policy and legislative change.

Experts populate ‘expert panels’ tasked with health system improvement. But are they the experts we need?

Healthcare Experts

Healthcare needs a different kind of expert to direct policy. We need expertise on practical, everyday provision of medical care. Only front-line physicians know that.  Front-line physicians care for dozens of undifferentiated patients every day. They run small businesses. They are used to being wrong, to being humbled by patients.

Front-line, community physicians are true experts.  They need to play a central role in policy development.

What do you think?  90% of physicians provide only front-line care. Should they have more say in healthcare?  Or should we strengthen proclamations from central authorities?

photo credit: wsj.com

Why fuss over medical tourism? Can you believe what you hear?

 Medical tourism “…will lead to the end of medicare” Doris Grinspun, Executive Director of the Registered Nurses’ Association of Ontario, told the Toronto Star.

Dr. Meili of Canadian Doctors for Medicare argues that tourism will steal resources from Canadians. “No one should be able to jump to the front of the queue…”

Minister of Health Eric Hoskins said medical tourism generates around $13 million per year and uses no public money.

That doesn’t matter to Andrea Horwath, NDP leader.  She insists that “There’s no way people should be able to pay to get services ahead of everybody else.” (same link as above)

The Ontario Nurses’ Union (ONA) calls for a ban on medical tourism.

Many insist it’s un-Canadian for anyone to be allowed to purchase care in Canada. Even if queue jumping is untrue, medical tourism undermines our delicate system of rationing, oversight and regulation. How could hospitals pursue something so stupid, so heinous?

Why Medical Tourism?

1. Canada has empty operating rooms.

Operating rooms are only open 0800-1600, Monday – Friday.  They close in the evening and overnight, all weekend, on stat holidays, and during summer ‘slow-downs’ except for occasional trauma or emergency cases.

Some hospitals don’t even have money to keep ORs open Monday – Friday (OR closed to stay on budget in Orillia).

2. Canada has unemployed physicians and surgeons.

Canada invests 12-15 years of training into surgeons only to leave many unemployed (see CBC News and Globe and Mail).

3. Canadian hospitals cannot fund current needs.

Hospital budgets cannot keep up with demand (More Hospital Downsizing – Toronto Star). Administrators use parking taxes, franchises and fundraising for revenue. They must comply with arbitrated raises in salaries but keep budgets unchanged (so they lay off new hires). They ‘close beds’, cut services and leave renovations undone. Finance committees deny requests for new physicians to help over-worked consultants because new physicians mean more demands on hospital labs, x-ray and beds.

Unused facilities + unemployed surgeons + hospitals in debt = medical tourism

Medical tourism uses otherwise empty operating rooms and surgeons thankful for the chance to work. It helps foreign patients and rescues hospital budgets. Medical tourism seems a prudent solution to desperate times.  Even without financial pressures, medical tourism helps patients and provides funds to help more Canadian patients.

No one argues Canadians should wait while tourists purchase care.  That’s insane and does not happen.

Passion and Spin

Grinspun, Meili, Horwath and ONA don’t protest worker’s compensation (WSIB) patients paying for services outside of Medicare. They never protest patients paying for medical supplies, drugs, physiotherapy, long-term care, optometry, or any other necessary service.

They just hate patients paying for medical care.  They hate it because it changes their fundamental relationship with government.

Government controls healthcare. Medical tourism raises a tiny challenge to the idea that all services should be determined, delivered and controlled by the state.

Unions control hospitals in Ontario. They bask in a >90% unionization rate compared with a 16% rate in the private sector (ONA in 142 hospitals of 145 public hospitals in Ontario) (71% unionization rate in public sector overall). They know tax funded hospitals can’t fail. But privately funded hospitals risk insolvency weakening union leverage. Medical tourism raises a tiny threat to destabilize the hegemony.

Ideology

Even a whiff of medical tourism threatens Medicare ideologues.

What do you think? Are there enough tourists to warrant all the fuss? Even if it could challenge Medicare to change and grow, would that be a bad thing? Why does the left-wing NDP hate medical tourism so much?

photo credit: macedonia-timeless.com