The most important issue to the average American right now is whether Lindsay Lohan will receive a longer jail sentence than Paris Hilton did.

Meanwhile, Big Medicine is spending hundreds of millions of dollars to lobby against making major changes and most politicians are taking their money.

If the average American was smart, well informed, and able to critically evaluate media stories to separate fact from BS, the US health care system would be on the "radar screen" and we would have a prompt solution (hopefully single payer). But the average American is not smart, well informed or able to intelligently digest media hype. Therefore, politicians will continue to mumble about health care, lobbying firms will keep it off the front burner, and the average American will continue to buy lottery tickets and continue to make "America's Got Talent" the number one show on television.

God Bless America.

Jeff:

The Democrats want Universal Health Care or Single Payer, neither of which is a practical solution in the short run. The Democrats need to focus their attention on some short term remedies that can begin to decrease the costs of some of the drivers of health care. They can start with tort liability reform, which carries with it two drivers - direct costs to the insurance companies in a tort claim, and huge direct expenses to doctors in the form of malpractice insurance. Eliminate the enormous financial risk that malpractice presents, stop all the petty lawsuits for "bad outcomes" (as opposed to actual malpractice), and you could reduce the basic cost of medical care by 10%, especially in fields like Obstetrics, Neurosurgery, CardioThoracic surgery. Second, they could stop Big Pharma from direct advertising to the consumer. You have no idea how much pressure this puts on doctors to write prescriptions for marginally useful improvements to old drugs. New does not necessarily equal better. Advertising costs to big pharma are worth investigating as a driver of overall health care costs. Prescription drug prices are completely out of control.

Those two things alone will help alleviate some of the costs of medical care. There is, of course, a third major variable and that is American attitudes towards health and wellness. That will require a seismic shift in culture.

Perhaps a bit of subsidy to train more doctors might help too. More incentive for medical students to go into primary care as opposed to specialty care would go a long way. We've got a supply/demand imbalance (see cultural attitudes), as well as an expectation imbalance (see cultural attitudes, medical malpractice costs).

Universal health care is not the panacea people hold it out to be. Ask the Brits, for example. Single payer is not the panacea either.

Disclaimer: I am a progressive, but I'm also married to a doctor (a specialist) and have myself been involved in one way or another with the medical community for more than 20 years. I live with it every day.

Although I agree with mrfearless47 that we have a litigious society and that the cost of malpractice cases and the insurance doctors must pay to protect themselves, I am curious where the 10% cost reduction in overall care figures come from. That seems impressively high.

I am in complete agreement for the ban on direct advertising to the consumer. I have questioned and hated ads telling you to "ask your doctor about..." ever since they first came out.

Until we get to single payer universal health care, the very least we could do is to provide a modicum of preventative care to EVERYONE. At least let's start with covering all kids (even if we have to use tobacco tax to fund it). The cost savings (for which I wish I had statistics close at hand) I think would rival if not exceed those mrfearless47 claims tort reform would accomplish.

Universal healthcare and single-payer aren't panaceas, but what in the world do you think job-based healthcare is? Do you really think America's system is better than every other developed nation's? I doubt the Brits we are to ask would agree. America's healthcare system is an unplanned accident. It arose out of the WWII wage freeze, when employers couldn't raise pay so they created new employment benefits like health insurance to recruit and retain workers. Job-based healthcare is not a healthcare plan. It's a lack of a healthcare plan.

Although I agree with mrfearless47 that we have a litigious society and that the cost of malpractice cases and the insurance doctors must pay to protect themselves, I am curious where the 10% cost reduction in overall care figures come from. That seems impressively high.

I am in complete agreement for the ban on direct advertising to the consumer. I have questioned and hated ads telling you to "ask your doctor about..." ever since they first came out.

Until we get to single payer universal health care, the very least we could do is to provide a modicum of preventative care to EVERYONE. At least let's start with covering all kids (even if we have to use tobacco tax to fund it). The cost savings (for which I wish I had statistics close at hand) I think would rival if not exceed those mrfearless47 claims tort reform would accomplish.

Will any of these folks talk about how Medicare is gonna bankrupt us in the end? The health care discussion needs to go beyond just reform of the health care system. Bulk purchasing or group purchasing legislation over the past several years is just a re-packaging (in the long run) of an unsustainable system. We'll need to reform our decision making as well.

senator wyden was talking back in january of legislation that he drafted to provide health insurance for all americans.

"http://wyden.senate.gov/media/speeches/2007/01162007_Healthy_Americans.html"

does anyone know if anything more has been done with this? i saw him speak about it at a townhall meeting, and while i was left with questions, was generally impressed with his presentation.

I agree on prescription advertising, although it's probably a tangential issue to the topic at hand. Another huge issue is drug research tainted by drug manufacturers. Now we have whole new diseases being defined explicitly to sell more pills, advertised on television to cure your restless legs or eroding esophagus. Who cares if your esophagus is self-healing?

Mr. Fearless47:

"They can start with tort liability reform, which carries with it two drivers - direct costs to the insurance companies in a tort claim, and huge direct expenses to doctors in the form of malpractice insurance. Eliminate the enormous financial risk that malpractice presents, stop all the petty lawsuits for "bad outcomes" (as opposed to actual malpractice), and you could reduce the basic cost of medical care by 10%, especially in fields like Obstetrics, Neurosurgery, CardioThoracic surgery."

***Oregon, despite elimination of recovery caps, has a lower rate of payouts than 42 other states; without caps, malpractice insurance premiums have dropped in Oregon. This, from insurance literature:

http://www.insurancejournal.com/news/west/2007/03/15/77774.htm

***I think before you start condemning people to "shoulder their own burdens" from medical malpractice, perhaps doctors should start cleaning up their own house. Remember Dr. Jayant Paytel?

http://www.kaiserpapers.org/orewashst.html#patel

***The beauty of the American justice system is consequences of negligent behavior are determined by juries who make reasoned decisions based upon the facts of each particular case (and many of whose decisions are frequently reduced on appeal). I'd much rather trust 12 of my peers to determine the financial damage to me of someone else's negligence than legislators and congress-critters who are so cozy with big insurance and big pharma.

Randy2

Jeff Allworth:

This feels like one of those transitional moments in American history when the pendulum of politics stops swinging one direction and heads back the other way, like 1932 and 1980.

Bob Tiernan:

But Jeff, the majority in 1932 believed they were electing the more conservative candidate, based on FDR's campaign platform and speeches.

Bob Tiernan

Blue Note:

I for one am sick of people who blithely cast the blame on the American people for being "not smart, well informed or able to intellectually digest media hype." Perhaps you have sufficient spare time in your life to fully inform yourself about every important issue facing America. If you do, you are blessed, and keep up the good work. Most Americans, however, live in two-worker households, are single parents, face care-giving obligations for older family members, or have other obligations that distract them from political issues. (This doesn't even include the extreme distaste for politics most citizens now feel.)

The mass media has undergone concentration of ownership in conservative (sometimes radically conservative) ownership that has both turned news operations into profit centers and tilted coverage in glaringly partisan ways. The great marketplace of ideas that was American is a distant memory as the thousands of small newspapers, independent radio and TV stations and independent magazines has disappeared. We all swim in a sea of carefully controlled information.

Lindsay Lohan? Paris Hilton? American Idol? They flood the media. Even Olbermann, who is almost a lone voice for progressivism on television, wastes one-third of his show on this tripe. (And who knows, perhaps the reason he has the show at all is because he devotes significant time to "serious criticism" of Idol or celebrities.)

A single mother may struggle to pay for the emergency room visit her young girl had, but rarely has time to ponder the niceties of national health policy. That doesn't mean that people are stupid. That is an indictment of the direction our economy and society have taken under Republican rule, and demonstrates the greater burdens ordinary Americans carry every day.

The LTV retiree who asked the best question at last night's debate confronted the Democratic candidates with the reality. How many of them had an answer that is both a legitimate solution and was expressed in language that the average citizen can directly apply to his or her life?

This next election cycle could bring great changes, but not if we write off the American people as stupid or uncaring.

This is my first posting on this site, but I feel obligated to use my real name if I am going to criticize another poster.

I married a wonderful Canadian gal and inherited a great family up North in Vancouver and Victoria. We visit them 3-4 times a year and I can assure you that of the many adults I have talked to up there NOT A SINGLE PERSON is happy with the Canadian health care system. Most of them loved it early on but time has passed and the disenchantment is growing.

Doctor shortages (especially specialists), BIG delays in receiving CSCANS, MRI's, and other diagnostic tests, and the big back log of what the Government deems "optional" surgeries is fueling the middle class movement to move back the something close to the US model.

The wealthy don't care.....they can pay for the treatment they want and get it when they want it...in the states.

There are areas where we can certainly look at for cost savings (tort reform being the major one) but any move to Universal healthcare run by the government will be a disaster.

Right on the nose Pdxskip. My fiance grew up in Calgary. She tells me the same thing.

There are a number of people who have questioned whether tort reform would offer as much savings as claimed. Citing Oregon data does not exactly address the NATIONAL problem. Do you have any idea how much it costs to insure a single obstetrician for malpractice? A neurosurgeon? Or any other physician who deals with serious medical issues. The basic problem is that many ambulance chasing tort lawyers have convinced their clients that any bad outcome, including those listed as possible on the informed consent every patient signs, is an example of medical malpractice. We wouldn't need to reform the tort system if we could add another administrative/legal hurdle for tort lawyers and their clients to clear before permitting cases to go to trial. Put in a panel of experts to mediate the case and determine whether the outcome was unexpected and the result of malpractice, or whether it simply was a "bad outcome". A baby born with birth defects is an example of a bad outcome. It has nothing to do with the skill of the obstetrician, yet malpractice claims are filed all over the country for just these very things. A neurosurgeon is routinely sued for the deaths of patients during or after brain surgery. Despite all possible precautions, patients do die during or after brain surgery. It is a bad outcome, not evidence of medical malpractice.

Tort reform does NOT limit the patients' rights to sue; it merely limits the damage size of the malpractice claim.

If you're interested, the typical malpractice premium for an obstetrician averages about $100,000 per year. Who pays for that premium? Neurosurgeons see malpractice insurance running about $125,000 per year.

Finally, there is practically no relationship between the cost of malpractice insurance and the size of the claims or awards. The malpractice equation is built out of two components: perceived risk (number of claims per capita), and performance of the insurance companies' invested premiums in the equities market. Given that the last three or four years have been pretty good years on Wall Street, it doesn't come as a surprise that malpractice insurance rates are down. When rates go up, the insurance companies blame the risk aspect. When rates go down, they never bother to mention that the risk hasn't changed intrinsically; it is just that they can afford to underwrite the risk for less money because their capital is doing better in the markets.

As for the figure of 10%, I can't put my finger on where exactly I read it. I believe it came from one of my wife's medical journals in an article by Health Economist Uwe Reinhardt of Princeton and as I recall, he factored in all the direct costs of malpractice (insurance premiums to doctors, payouts to patients), and the indirect costs (in the form of higher medical costs to individuals and to insurance companies) as well as the shortages that are created when specialists like OB/GYN decide that it isn't worth it to see OB patients any more. Interestingly, nurse midwifes, and PAs who often see the same types of patients as OB docs, experience an almost 0% malpractice rate? You have to wonder why that is. I'm not even certain, to be totally honest, whether they're even required by law to carry medical malpractice insurance.

Ignore this issue at your peril. Also, think about this. The countries with Single Payer or Universal Health care do not require doctors to carry medical liability insurance, because the system is set up to make mandatory arbitration by panels of experts the only way to establish any sort of "malpractice". And the awards, when given, are miniscule. Fewer doctors, longer working hours, less access for everyone, outs for the affluent who can afford top-up care, concierge medicine, if you will. If you think that's the solution, go for it. Then try to fill positions at the medical schools without also subsidizing the training costs of every physician working. Can you say, far more expensive than the present awful system, with outcomes perhaps no better. Especially if we don't have a sea change in the behavior of Americans to go along with it. Doomed to fail without some personal responsibility too.

Disclaimer: my wife is NOT a specialist in any of the areas mentioned above.

P.S. The Jayant Patel case is so anomalous as to not be worthy of mention. The layers of blame in that/those cases are so thick that one can hardly fault his last American employer. They were lied to and misled by all his previous American employers. And most of the patients who demonstrated harm were compensated as best Kaiser could. They, too, were victims in this case. He is the exeception -- a true sociopath who deserves the death penalty, not simple banning from practicing medicine.

<blockqutoe>If I were a Democrat running for office this year, I'd be hitting this point first in every speech. </blockqoute>

I would argue that Edwards is making health care a central issue in his campaign, as a part of the wider issue of poverty. This is one of the many reasons why I am supporting him.

Blue Note is only partly right - Yes, the average american is somewhat stupid, but that stupidity leads one to accept all the ubiquitous drivel of propaganda that is spewed towards them to the point they parrot ideas (ones they really do not undersdtand) to others without thinking about the consequences of the spewed rhetoric they babble. The result is that they believe what they are told to belive - not to believe what they think.

It is just like a computer sometimes - Garbage in, garbage out. This is why the R's became sucessful in what they did for many years - they knew how gullible the avearge american is and took advantage of it, and people like me and bluenote became 'dangerous' because we can think for ourselves.

The only way we can get health care to be a major hot button issue is to encourage all of us to think for ourselves and actually encourage the Marketplace of Ideas to develop and not to parrot our leaders endless drivel of propaganda. garbage.

"Germany has private health care, but it's private non-profit health care. I could go for that. "

HAHAHA!! You think people are going to go to school for 10 years NOT to make any money?

Leslie....I'm not sure who you were talking to up in Canada but I've been involved with scores of Canadians for 30 years.

What they want is the quality of the US healthcare system with insurance premiums paid by their government. What they abhor is the rationing taking place.....my wife's uncle had a sudden swelling the size of a ping pong ball on his shoulder. His physician asked for a CSAN....and he received one 4 1/2 weeks later. 4 1/2 WEEKS!!! That led to a biopsy.....11 days later. The he was assigned to an ocologist.....2 1/2 weeks later he finally got in to see the oncologist and he wanted an MRI....He got one 3 1/2 weeks later after the oncologist kept raising hell. 11 weeks....and then they finally scheduled surgery for 3 weeks later followed by chemotherapy and a round of radiation.

His prognosis is dim. His oncologist blames his outlook on the "inherent delays in our system"

I actually think that health care is a central issue, especially in Oregon. The cost of health care (esp. prescription drugs) consistently ranks second or ties with education funding for most important issue with voters. I think the fact that Edwards, Obama, and Clinton have health care plans 16 months before the election demonstrates this is an important issue. The only reason that a lot of people haven't retired in this country is because their employer provides health insurance and they couldn't afford it otherwise.

Randy2- medical liability insurance premiums have only dropped in Oregon in the past two years AFTER skyrocketing 100-200% (depending on specialty) between 2000 and 2004. While it is a "drop"...8% down over 2 years compared to 100-200% up over 4 years is "a drop in the bucket". Second, mrfearless47 is spot on re: Patel. He exploited the law and was a butcher. Plus the legislature closed the "loopholes" that he found this session...so your point is definitely a red-herring.

mrfearless47- while I agree with most of what you say, I have to nit-pick because details are important. Medical liability reform is necessary not because claims are 10% of health care spending--they aren't. Because of a litigious society, no non-econ damages caps, no pre-screen panel, etc. doctors practice more defensive medicine, which is 10-20% of health care spending. Premiums and payouts are .5% of health care spending.

I realize that this is really a health care thread, so I'll say my peace here and then shut up.

First Blue Note, and now Eric J. "Yes, the average american is somewhat stupid ...." This is supposed to be a website dedicated to the advancement of Democrats, or at least progressives, a party and an ideology meant to protect and empower the people. Does this disdainful, superior tune disturb no one else?

Just what kind of stupidity do you mean, Eric? The person who works on my car engine has to deal with computer controls, master mechanical skills and have significant diagnostic skills. The nurses who cared for my family in times of need have years of training and experience in medical science and still find ways of helping people when they are most vulnerable. Are these the somewhat stupid americans you describe? What makes them stupid? Do they enjoy the wrong TV shows, see the wrong movies? Do they, God forbid, enjoy NASCAR?

For myself, I have been fortunate enough in my life to get 8 to 9 years of post-secondary education, and have been a professional for almost 20 years. I also had a major part of my life when I have been a creative artist. Does that qualify me for the elite in which Blue Note and Eric J. apparently exist? I don't think so. I'm still the kid from the logging town who worked in the truck farm fields, in the saw mill and in the woods. I am the young man who served in the US military (which, through the GI Bill, got me all that fancy education). I am the older man with a wonderful wife and child, a dog and two cats, and a yard that needs a lot more work.

Somehow, I don't feel that I stand apart from "the average american." When I talk to "those" people, I hear intelligent, thoughtful, concerned people trying to make better lives for themselves, their families and their communities.

It seems that I don't know the secret handshake for this elite. I don't think I want to know it. I do know that many people (those other people, you know, "the average american") have long been alienated from the Democratic party because they perceive it to be a party of an elite, made up of academics, professional politicians, and those who don't have to face the struggles of everyday life. The Republicans captured many of those Americans by mouthing slogans and putting on shows of concern using the language of the average American. Democrats have an opportunity to recapture those voters, as well as a whole new generation, if we speak their language and respect them.

kari, glen, thanks for the update on wyden's healthy americans act.

as far as the issue of tort reform goes, it should be mentioned that the cost of defensive medicine plays a significant role in driving up healthcare costs in this country.

ER physicians routinely runs more tests than they need to adequately diagnose patients, strictly in order to cover their hind ends when it comes to the risk of malpractice suits.

giving CT scans to the majority of patients who go to ER's is ridiculously inefficient, but as long physicians stand to lose everything if they don't, and it costs them nothing to do the extra work, they'll continue to do it. and the costs get absorbed into the system, driving the cost of healthcare up for everyone.

JTT writes:

"mrfearless47- while I agree with most of what you say, I have to nit-pick because details are important. Medical liability reform is necessary not because claims are 10% of health care spending--they aren't. Because of a litigious society, no non-econ damages caps, no pre-screen panel, etc. doctors practice more defensive medicine, which is 10-20% of health care spending. Premiums and payouts are .5% of health care spending."

I made that assumption, as does Uwe Reinhardt. It's included in the "indirect costs" of malpractice. I just didn't say it in quite the articulate way you state. Nevertheless, you make my point more clearly than I do. Thanks.

mrfearless47 may I suggest that you take a look at this study by the GAO on this issue. This study along with some other that they have done offers some interesting information. I would use the word data, but since we are stupid I won't do that. Take a look at the numbers for Dade Co., Florida and compare those with Minnesota. 2002 cost are $201 thousand for Dade Co and $17, 000 for Minn. I think the question as to why the variance is a resonable one to ask.

Add to that there was nice article in the N.Y Times recently about the income of docs here in the U.S. as compared to Europe. U.S docs get paid a lot less. Shouldn't both issues be on the table if we are to discuss cutting costs?

Then we need to discuss why the Europeans have more access to such services as midwives than do expectatant mothers here in the U.S. What role does that play in health care cost as well as infant mortality.

Another issue to ask about is the large amount of funds, I think it is about 30% of medicare dollars, that go to people in their final year of life. Why and how to reduce this.

Here's another for you to chew on. Europeans do far less surgery than is done here. What role do this play in the relationship to costs and life expectancy? Who is getting the better deal?

According to a study published in the New England Journal of Medicine in 1991, about adverse results from the Harvard Medical School the number of people that die from medical errors is significantly high. This same study was used to support the Inst. of Medicine report a few years ago that put the number of death nationwide at 44,000 to 98,000 from medical errors annually. If that is correct then there are probaly 500 to 1000 in Oregon each year, but the numbers reported by the docs don't come close to this figure. Why?

It was interesting when I asked the state's medical examiner's office about this. Frankly the answer was about is interesting as I have ever heard.

Licensing also play a role in driving up costs (see midwives)because it drives out the competition.

As I recall the AMA also has a role in how many medical schools there are, thus how many docs graduate annually.

That's just for starters. And I am sure I could go on for a number of issues.

<h3></h3>

Oopsie! made a couple of malpractices. Here's the study I left out www.gao.gov/new.items/he00005.pdf

And I wrote "Add to that there was nice article in the N.Y Times recently about the income of docs here in the U.S. as compared to Europe. U.S docs get paid a lot less." Actually American doctors get paid a lot more. Much, much more.

"Huh, that's funny. I lived in Canada for four years--a year in Ontario and three in BC--and I never ran into a Canadian who wanted the American model of health care. "

Well, here's one who wanted private medical insurance, at least that is what he is telling the Supreme Court of Canada:

http://www.cbc.ca/news/background/healthcare/

To quote:

"Access to a waiting list is not access to health care," two of the justices wrote in their decision.

. . .

The cause:

"Once upon a time, there were few complaints about lengthy waits for treatment. It was a time when the federal government provided about a third of the money the provinces spent on health care.

But as government belts tightened to deal with record budget deficits in the early 1990s, complaints about access to health care increased. The federal government drastically cut the amount of money it transferred to the provinces to cover health-care costs."

I like the idea of national health care since it allows corporations to save a lot of money and the arbitration instead of malpractice, but politicians running anything scares me.

M.W. writes:

"And I wrote "Add to that there was nice article in the N.Y Times recently about the income of docs here in the U.S. as compared to Europe. U.S docs get paid a lot less." Actually American doctors get paid a lot more. Much, much more."

Yes, I read that article and every single letter that followed. Guilty as charged. But, think about this: my wife's malpractice insurance costs $105,000 per year (down from about $115,000 two years ago). My wife graduated from medical school in 1984 from a public university on the East Coast with $60,000 of medical school debt. Medicare reimburses her for less than her actual cost of delivering her care, so someone else is paying extra to subsidize the cost of her staying in practice. So, I'd suggest that you factor in those costs, one of which is recurring to your comparisons. Also, the mechanics of dealing with 25 different insurance companies is hardly cheap and patients expect the doctors' offices to do the work. Somebody's got to pay for all that. The overhead in today's US doctor's office is terrifically high. Moreover, my wife is in a specialty that is highly technology driven. In fact, without technology my wife's job would be impossible by today's standards.

I could go on forever about your comments about "medical errors." I could also go on about the issue of extra tests, more surgeries, etc, but they all share a common theme. In gutter language it is called "cover your ass". No physician wants to get sued. There is no penalty for doing too few tests or procedures or surgeries. The more you do, the more you're insulated from the spectre of liability for a "bad outcome".

Last Sunday my wife was on call. She left the house at 6 a.m. and did not return home again until 10 p.m. She did about 55 cases and procedures. Of those, she told me that only about 6 were actually necessary to do out of office hours. The rest could have waited until Monday, or didn't need to be done at all. But the ordering physician doesn't care. He/she wants to cover him/herself. My wife has learned that resistence is futile. My wife gets paid extra every time she comes in (she's in a salaried partnership). She figured out using Medicare reimbursement figures that her practice would be billing more than $100,000 for her day's work. Only about $10,000 of that was actually necessary. It doesn't really matter to her. She's paid by the hour, not by the procedure when she's on call. There is virtually no incentive for her to do anything because her take from that $100,000 is miniscule compared to all the technical overhead, extra technicians, nurses, and clerks, not to mention the amortization of the technology (3 CT scanners, 5 MRI machines, 15 ultrasound suites, a couple of angiography suites, etc).

And the capper in all this is that nearly every physician tried to discourage the unnecessary procedures and encourage the patients to see their regular doctor. Every patient refused and wanted the issue resolved NOW. Since "customer service" is a major driver in health care - believe it or not - every single one got their way.

Americans have become accustomed to getting their way in health care. They won't accept delay, they won't accept rationing, and they want everything that is possible done right now, not tomorrow, not next week.

My favorite recent story is the night my wife was called in to do a CT scan on a DEAD patient because the family refused to believe the patient was dead and would not leave the ER. This, despite the fact that the patient had terminal cancer and was expected to live only for hours. My wife asked the oncologist (at 2:30 in the morning) what the CT scan was supposed to reveal. His answer: "Christ, I don't know. Maybe they're looking for a second opinion from a machine." All I could think of as my wife was grumpily getting dressed to go in was of the Monty Python "Dead Parrot" skit.

You want some clues about American health care: spend a day walking with my wife. You'd get some really good ideas about why it is so expensive in short order. Too bad HIPPA won't let this happen. Perhaps those really glib about health care reform might be a bit more circumspect when throwing around 1991 data.

mrfearless47 - may I recommend that you consider submitting a guest or regular (health care) column to BO? I've really enjoyed reading your perspective on the (delivery) system and med-liability reform, and I'd love to see more.

"Germany has private health care, but it's private non-profit health care. I could go for that. " HAHAHA!! You think people are going to go to school for 10 years NOT to make any money?

Well, actually, Germany doesn't seem to have a shortage of doctors, so.... yes, I do think so.

There is the question of medical debt vs. pay in this country, where education isn't free... but I'm pretty confident that this can all be sorted out. I don't consider doctor's pay to be the biggest stumbling block between our current dysfunctional health care lack of a system, and the universal health care system that we so desperately need.

JTT: Thanks for your compliments. I wish I could commit to a guest column or a regular column. Unfortunately, I've got my own blog on a totally different subject that is even dearer to my heart, so I have to save most of my energy for dealing with that issue.

I do pop in here and do occasionally get into it with people about health care. I've eaten, slept, and breathed that subject since the day my wife went to medical school. It didn't take me long to figure out where the problems were and you won't find too much disagreement on my perspective from most doctors.

I for one am sick of people who blithely cast the blame on the American people for being "not smart, well informed or able to intellectually digest media hype."

I guess that includes me among the people jim loy is sick of. But perhaps we can be a little more specific when we talk about the American people which includes a whole range.

As jim loy stated to defend some people, they are working two jobs and don't have time to study issues. In such cases, they can be forgiven for not being more knowledgeable. Nevertheless, they remain ill-informed.

There is another group raised to be consumers and enjoy their hedonistic life styles. No sympathy there.

Other groups buy into one philosophy or religion or another and accept what would-be pundits, preachers or other snake oil salesmen sell them without question or intellectual curiosity. No cigar for them either.

Some of us have time to spend three or four hours each day listening and reading about issues. If we are open to what we hear and read and despite what we already know, we learn that there is still much more that we don't know.

All Americans - that includes us - have more to learn - some more than others. So perhaps the most important need today is greater knowledge in history, people, politics and citizenship.

"Do you really think America's system is better than every other developed nation's?"

Name me another country people go to when they need specialized health care and they want the best.

"But a Canadian who asks for private health care insurance and a reduction in waiting lists is not the same as asking for an American system."

OK, so the solution is to make everyone wait for needed health care. I think you miss the point. Why not subisidze those without medical insurance and have the gov pay the premiums since we already pay welfare and have OMIP, it can be done.

My point is, like Canada, this would start out cheap and then govt would overstaff and underdeliver and keep raising prices.

mrfeerless47 writes: "I could go on forever about your comments about "medical errors." I could also go on about the issue of extra tests, more surgeries, etc, but they all share a common theme. In gutter language it is called "cover your ass".

Please do go on about my comments regarding medical errors. I would appreciate being enlightened on that issue.

And as for the CYA let's not forget that a number of docs have been charged with Medicare fraud.

I'd suggest a phased roll-in for having Medicare cover other classes of people. Start by closing the VA hospital system and have Medicare cover veterans hassle free.

Dump part D and have any healthcare reform go hand in hand with tort reform.

In the meantime, i think we should spin a wheel with any number of European systems on it and adopt whichever one comes up until America has its collective head surgically extracted from its arse.

MW asks:

"Please do go on about my comments regarding medical errors. I would appreciate being enlightened on that issue."

While I would be the first to admit that medical errors do occur - my wife being the victim of two herself - the vast majority of "medical errors" are caused by medical staff (nurses, aides, physical therapists, medical interns, residents) not following the doctor's specific orders. A goodly percentage of them involve misgiving drugs, prematurely removing sutures. The occasional doctor error involves mislabeling the side of the body (leg/arm/ear) that is bilateral upon which surgery is to be performed. Sometimes that occurs because an anesthesia nurse will ask the patient what side of the body is supposed to "fixed" and the patient responds correctly but the nurse is, of course, looking at the patient in such a way that the patient's right is the nurse's left. Doctors do this occasionally. Finally, there are cases of doctors' notoriously poor handwriting being impossible to read and nurses improvising rather than calling the doctor. Electronic medical records are taking care of this.

Most patient medical errors occur in overcrowded hospitals with large training programs. This isn't an excuse; it's a fact. All the hospitals are working extremely hard to correct this, and more frequent audits by JCAH (Joint Council for Accreditation of Hospitals) has made hospitals far more vigilant about such. The error rate at my wife's hospital has dropped more than 45% in the past two years due to a program of extreme vigilance.

Medical errors are unpleasant, but only a small percentage involve permanent harm or death. You think they don't occur elsewhere in other systems? It is impossible to run an error-free environment.

The Harvard Study was published in 1991 and their estimate of errors, while looking large, was actually a very small percentage of the patients treated in the study.

I think that the electronic medical record (privacy concerns aside) will reduce dramatically the number of such errors as, for example, there are computers in every operating room in major hospitals today. Surgeons call call up xrays, CT, MRI, and ultrasound studies as well as radiographs of biopsies and everything else. This allows them to double-check everything before beginning the cut down for surgery.

That's all I have time for now. Hope this helps.

America has become a place where hard-working Americans can end up sick and destitute simply because our system favors big insurance, HMO, and pharmaceutical companies over people.

And that is a losing message. It defines the issue in terms of justice, fairness etc. that appeal to the Democratic base. Most people don't care how much money those guys make as long as they get good health care, when they need it and at a price they can afford. The case for universal health care is that everyone, their kids, and their parents and grandparents will get health care.

The mistake proponents of universal health care make is getting dragged into a debate about how, rather than whether. Candidates just need to be hammered on "Do you support universal health care?" And if the response is "How do you pay for it?", the answer is "We have a system now, its called the emergency room. It is very, very expensive. And we all pay for it with our medical bills."

Leslie Carlson writes:

"Kari asked for some stats to back up Canadian satisfaction with health care services. Here are some, from Statistics Canada, rated for each province by Canadians who have gone to the doctor in the last 12 months. From this data, it looks like 80-85 percent of them are satisfied with the care they are getting."

How relevant are those statistics to us? Canadians have been living with the National Health Service for a long time and have not experienced the cafeteria style American system. In addition, both the ethnic and cultural diversity in the US compared with Canada doesn't translate well. Look how well HMO care went over in the US? That should give you a clue how much Americans care about having choices, no explicit rationing, no waiting, etc. Americans are, generally, very impatient medical consumers and our expectations are very high.

If you surveyed Americans with health insurance, you'd probably find similar satisfaction rates. The problem is with the uninsured. An alternative to employer-based insurance would be useful, but that doesn't necessarily imply universal health care or single payer. A vastly improved Medicare system with a higher Medicare tax rate would enable all Americans to get basic health care, but it won't be cheap, and reimbursement rates will have to be improved before hospitals, clinics, and health providers will buy into it. Moreover, something has to be done about malpractice and all its consequences and sequelae, and something needs to stop big pharma from direct advertising to end users.

Better national regulation of insurance providers would also help. Most health insurance providers also provide many other insurance products. I'd bet they'd accept more regulation on health insurance rates IF they could continue their other insurance businesses without ADDITIONAL regulation.

Sin taxes could also help.

What we have to face is that any significant change to health care will come at considerable price: tort reform, regulation of big pharma advertising, better regulation of health insurers, elimination of job-based health insurance, significantly increased Medicare taxes and premiums, and taxes on products that have have no benefits and total detriments to health - e.g. tobacco and liquor. And when you've managed that, you've got to get people to completely wrap their minds around the idea that there is some degree of personal responsibility for maintaining one's own health. The evidence is strong that people with health insurance abuse the system significantly by demanding unnecessary drugs, tests, operations, and the doctors live in daily fear that if they don't provide this useless service, they'll eventually face some litigation for it. Resistence is truly futile. People also have to accept that death in the natural outcome of life. You can only do so much at the end of life. More attention should be given to comfort and palliative care and less attention paid to patients and their families who demand heroic measures for a patient in the end stage of their life, regardless of cause.

It is easy to glibly assert that Canadians are satisfied with their health system. Most of them don't know any other. Those who do often buy top-up insurance that permits them to obtain care in the US. Ever consider doing a survey of how many Canadian nationals get medical care in the US. Do you think the Canadian Prime Minister gets his care rationed in the same way Joe Blow gets his care in Windsor, Ontario (actually, Joe probably crosses the bridge into Detroit and gets his care there under a top-up or individual plan).

I just don't think that people who advocate for this kind of radical overhaul of the US healthcare system understand how entrenched our system is in almost everyones' eyes. Radical change will fail; only gradual change can possibly work.

It is easy to glibly assert that Canadians are satisfied with their health system. Most of them don't know any other.

But I think the polls show most Americans are dissatisfied with our health care system. Most of them don't know any other either.

Kari write: Because health care providers lose money on Medicare. The government refuses payment - paying a less-than-full percentage of the bill. As a result, privately-paid health care essentially subsidizes Medicare health care.

Oh, Kari, et tu? You are parroting the AMA's talking points. I expect this from Mr. Fearless, whose wife is a doctor, but not from you. It is a lie. Or more charitably, it is AMA spin designed to put pressure on Congress to increase physician reimbursement under Medicare.

See recent GAO report for more info on Medicare physician payment and access problems (or lack of access problems).

Regarding tort reform, Mr. Fearless acknowledges that medical payouts have very little impact on malpractice insurance rates. Given that, why would capping payouts lower the cost of malpractice insurance? And with any cap, there are some seriously injured people (injured through pure negligence, like Jordaan Clark at OHSU) who will have lifetime medical costs that are higher than the cap. How can you advocate for such a system?

Finally, quoting malpractice insurance rates of $100,000+ without also quoting doctor salaries is really misleading. Five years ago, the median physician salary was over $200,000. Median, not average, so it's not being pulled up by the million dollar salaries of some specialists. If a neurologist is making $400,000 a year and has to pay $120,000 for malpractice insurance, my heart isn't bleeding for her.

as far as tort reform goes, the problem of doctors practicing defensive medicine, and thus driving up healthcare costs for everyone, is a real one. it's not just the price of malpractice insurance, it's what the threat of malpractice does to standard medical protocols that is the killer.

having a panel that would screen for frivolous lawsuits, as i believe john edwards suggested, would be a good start. another suggestion is to have a national board that would approve standard protocols for doctors, so instead of running every single test available, they would only run the tests called for in the protocol. with the legal standing that the following of protocols grants immunity from malpractice suits, overseen by aforementioned screening panels.

the way we are doing it now is ridiculous, as mrfearless has attested.

Miles writes:

"Regarding tort reform, Mr. Fearless acknowledges that medical payouts have very little impact on malpractice insurance rates. Given that, why would capping payouts lower the cost of malpractice insurance? And with any cap, there are some seriously injured people (injured through pure negligence, like Jordaan Clark at OHSU) who will have lifetime medical costs that are higher than the cap. How can you advocate for such a system?"

Capping payouts would prevent the insurance companies from using the pretext of high payouts as justification for raising insurance rates. The major driver of malpractice rates are: risk and reward. The risk derives from the nature of what the doctor is routinely exposed to in the course of his/her practice. The reward is based on stock market and other investment returns on premiums. If you place caps on non-economic damages (we're not talking about capping medical damages as in the Jordan Clark case, which derives from a peculiar indemnification system unique to OHSU and has nothing to do with what I'm talking about. Tort reform doesn't go after anything in that realm), you expose the true reason why malpractice premiums go up (and rarely down) and will make it harder for insurance companies to justify the premiums they're charging.

As to your later point about the relationship between doctor salaries and malpractice costs, the neurosurgeon is a rare case where the malpractice costs are lower than expected relative to salary, whereas in other areas of medicine (OB/GYN) the relationship between malpractice costs and salaries are much more dramatic. OB/GYN physicians average around $225,000 in annual gross salary. With malpractice premiums, nearly HALF of their gross income is given over to the insurance company. By getting out of the OB side, the malpractice premium drops by about 75%, while the additional GYN patients continue the doctor's base salary. Consequently, there are fewer and fewer residencies in OB, more doctors quitting OB practices, and medical students choosing almost anything but OB to do their residencies. Thus, being an OB patient today is more risky than ever because it is so difficult to find a doctor, keep a doctor, and be supervised by a doctor in the delivery room. As I said before, many of the allied health professionals have little, if any, medical liability insurance. If you go to a nurse midwife working without physician supervision -- there are many of these -- who ya gonna sue for a "bad outcome"?

Remember that training doctors is very expensive and doctors sacrifice at least 10 years post-graduate earning power while completing their training. That post-graduate training is time-consuming, expensive, and pays a pittance. Did you know that Board Certified medical fellows (post-residency) earn around $35,000 annually and work about 90 hours per week during the one or two years of this training. So: 4 years college + 4 years Medical School + 1 year internship + 3-6 years (depending on specialty) residency + Board Certification + 1-2 years fellowship training finally equals "attending physician". In many cases, these "attending physicians" spend another 4 - 6 years as salaried employees before possibly obtaining a partnership at which time the "big bucks" finally start to roll in. My wife was 40 years ago when she finally started earning "big bucks" and was 43 before she made partner. This gives her an effective working life of about 17 years during which she can pay significant malpractice insurance, work 75 - 80 hour weeks with every decision she makes potentially exposing her to exhausting, draining, and debilitating malpractice litigation. I am proud to say that in my wife's 17+ years as an attending physician, she has NEVER been named in any malpractice litigation. She's damn good at what she does. But how would you like to wake up every day and know that decisions you make can literally make the difference between life and death.

You'll get no traction from me on physician salaries. Most physicians work harder than about 70% of the US population and most burn out relatively young. They earn every dime they make.

Jeff Allworth siad:

But the greatest rationer BY FAR is the US, where 45 million aren't even on the rolls and many of the other 250 million find they're not adequately covered.

Bob T:

That's not an example of rationing.

Where'd you get that talking point?

Bob Tiernan

WOW! This thread is still going strong!

You socialists wear a guy out!

"WOW! This thread is still going strong!

You socialists wear a guy out!"

Actually, I think there are far fewer "socialists" than you count, unless you can't read or understand.

Ross Williams opines:

"But I think the polls show most Americans are dissatisfied with our health care system. Most of them don't know any other either."

If you look at those polls carefully, what they show is that most americans WITH HEALTH INSURANCE are, in general, satisfied with their health care system. What they are dissatisfied with and fear is losing benefits partially or completely. A genuine concern, but a different matter than pure dissatisfaction.

since today is my day to follow mrfearless around & add postscripts, let me just throw in another wrinkle to the OB malpractice insurance problem.

rural areas in the U.S. are having a real crisis in healthcare in that there is a decided OB shortage, due to the high malpractice premiums.

i doubt i need to explain why it is a problem for a given segment of a population to not have access to any obstetricians.

it would be interesting to find out how much of an issue this is in eastern oregon, in fact. i can imagine there are some communities that may be a few hours' drive (at least) from the nearest OB office.

I want to clarify a statement I made earlier. Nurse midwives, physician assistants, and nurse practioners do carry, but are not required to, liability insurance. However, in Oregon, Nurse Midwives are supposed to be supervised by a licensed OB. If there is a bad outcome, it is the supervising OB who's got the deep pockets and so he/she will be sued. So, when you drive the OB out of practice, or prevent them from wanting to go into that practice in the first place, you're effectively also limiting the amount of Nurse Midwifery care available too. Many midwives practice without OB supervision, but if they don't carry liability insurance, they're dangling out on a tightrope with no safety net. All a lawsuit will do is bankrupt them and put them out of business.

If you don't think this shortage is real ask anyone in rural areas of the US, anyone in the heavily populated rust belt cities. Spend a few hours with the Annals of Obstetrics and Gynecology. Besides getting a few tips on GYN self-surgery, you'll learn about the very real shortage of OB docs all over the country, in residency programs.

Finally, to put an exclamation point on this problem. Why would anyone voluntarily choose to take on $200,000 medical school debt to enter a field that may pay an average salary of $225,000 and have $100,000+ annual malpractice premiums? Those malpractice premiums aren't simply window dressing. They reflect the real risks of complications of prenatal all the way to post-natal care. Every patient is a potential malpractice case one bad outcome away - a ticking time bomb. Little wonder this an area severely undersupplied. It will take a lot more than salary increases to improve the supply of OBs.

You'll get no traction from me on physician salaries. Most physicians work harder than about 70% of the US population and most burn out relatively young. They earn every dime they make.

Physicians, on average, make more than 98% of the US population. No one can objectively look at the US healthcare system and argue that physician salaries aren't a big part of the overall problem. I love my doctor, I want my doctor to be comfortable in his life so that when he is in the office he can focus his full attention on me and my problems. And I don't mind rewarding doctors for the hard work they put in to become doctors. But $200,000+ median incomes? $400,000+ for run-of-the-mill specialists? $1 million+ salaries for top specialists?

See this NY Times article for more. The AMA is the same as every other special interest group in America. They are desparately trying to maintain the wealth of those in the medical profession -- at the expense of the rest of us. How many of the 45 million uninsured could be covered by a $50,000 reduction in average physician salaries?

Miles writes:

"See this NY Times article for more. The AMA is the same as every other special interest group in America. They are desparately trying to maintain the wealth of those in the medical profession -- at the expense of the rest of us. How many of the 45 million uninsured could be covered by a $50,000 reduction in average physician salaries?"

Yawn. I've read the NY Times op-ed piece and have discussed it with dozens of people. My wife doesn't even belong to the AMA, hates the AMA, and doesn't listen to what they say. That said, can you say "supply and demand" - the very basis of a capitalist system. And why should physicians be remunerated less than trial lawyers, corporate CEOS, middle management at half the local tech companies. Tell me how much education and experience these folks have to deserve their salaries. Do they wake each morning worrying about what evil will lurk in their waiting room today, and go to bed every night wondering, tossing, and turning about whether he/she made the right call in that very complex set of films just read. I can't tell you the number of times my wife has gone into her hospital in the middle of the night to recheck a case that she had read earlier in the day. She couldn't sleep until she was sure of her earlier call.

I think the animus towards physician salaries is both misdirected and counterproductive. In general, we have too few physicians serving way too many patients right now. Cutting physician salaries won't solve the shortage, it will exacerbate it, and it won't even make a small dent in the cost of medical care.

Final personal example. My wife had very complex and dangerous spine surgery some years ago at UCSF - one of the spine meccas. She had some post-surgery complications and ended up in the hospital for nearly 3 weeks and had a second surgery. The entire bill for this ordeal came to just short of $1,000,000, all but a tiny bit of which was covered by her insurance. But, for reasons we've never understood, we got a copy of the bill, fully itemized including all the professional fees involved. The surgeons fees, the anesthesiologists fees, the ICU docs fees, the CCU doc fees all came collectively to just under $80,000. The remaining $900,000 fees were all technical, support staff, nursing, parts, drugs, sutures, bandaids, bed charge, meals, physical therapy, durable medical equipment. So, out of a roughly $1 million bill, 8% could be directly attributed to actual physician costs, out of which all the physician group expenses will come. Take out physician salaries out of the equation altogether and I doubt you'd cut health care expenses more than a few percent -- and you'd have no doctors. If you cut doctors salaries by 25%, I'd challenge you to find more than 1% savings in the overall cost of health care.

It's a bogus argument anyone practicing doesn't need the AMA shilling or lobbying for them to understand why this is the case. The AMA's job is to perpetuate the AMA; few doctors I know see it as representing their interests.

Here is where the threat of a lawsuit may have saved my life:

I was diagnosed with a spinal cord tumor in 2003- I was referred by my PCP to a local neurosurgeon who was in private practice. The Dr. looked at my MRI and told me that he really would like the experience in doing my surgery ( he had never done a spinal cord tumor surgery before, spinal cord tumors are quite rare ) but that in doing so, he would make me a quadraplegic. He told me that he didn't have the liability insurance available, and without saying good bye, he promptly walked out of the room.

This incident caused me to ignore my Drs. referral, and to look around and find my own neurosurgeon. I went with OHSU ( I know, they have a liability cap ) but they really cared, did a great job, and I will challenge any of you to a foot race.

Dr. X would have really like to collect that paycheck, and he would have done the surgery, but he KNEW he would have botched it. If he had a liability cap, he would have given it a shot just for the heck of it.

Regarding how stupid the US is, just because Lohan and Hilton are on TV, that doesn't mean that is all anybody cares about. I think that this is the TV telling you what is important, but the number of network viewers is always decreasing-
 I think people are tuning out because they don't care. Just because it is on TV doesn't mean anybody gives a crap about it.

JEFF A....."You also gave an inadvertent "tell," Skip. In referring to us as socialists, you reveal your conservatism.

Jeff...that is a complete crock and exposes YOU as a being a narrow minded totally afflicted radical. I suspect you are one of the black hooded zombies wandering Hawthorne Blvd, taking a coffee break from your blogging.

I have been a registered Democrat since 1963 and an active player in party issues for most of that 40 plus years. I admire much about the so called "progressive" movement but continue to be amazed that whenever a moderate Democrat or Liberal Republican espouses something your far left azz doen't agree with they are given the dreaded "conservative" label. Guys like you who are intolerent of a diversity of opinions within the party are in fact hurting the party.

Do us mainstream Dems a favor. Go work for the Green Party.

mrfearless...I didn't mean to infer that most of the people posting here are socialists. Quite the contary. Mostly Liberal Democrats, some moderates, and yes...a few off the wall far left, socialists. It only takes a few of those to stir things up and enliven the discussion. I enjoy talking to them over coffee much more than this venue. They're a kick in the pants!

Raul:

You did exactly what an informed patient should do, and by doing so you had what sounds like a terrific outcome. Congratulations.

If you look at those polls carefully, what they show is that most americans WITH HEALTH INSURANCE are, in general, satisfied with their health care system.

I am not sure what that proves. Sure, many people who have health care are satisfied while they have it. The issue with universal coverage is just that - people aren't satisfied with the system of health care, unlike Canadians who are. And I suspect the difference is the lack of security. All over the United States there are people holding bake sales to help pay for their neighbors medical expenses. We need to do something about it.

mrfearless47...

regarding your calculations of what an obgyn makes...it looks like the average salary of $225,000 is about right, but I don't get what you're saying about the $100,000 malpractice cost. It appears like you're trying to say that is paid out of the "gross salary" of $225k leaving an obgyn with a mere $120k. Thats not right is it? Dr's don't figure out all their costs except for their malpractice insurance and call that their gross salary do they? Don't they figure that cost into their overhead like everyone else?

But I'm getting sidetracked...

I agree with the original post that health care is going to be the major domestic issue, if not THE biggest issue, in the next election, because more people will come to believe, if they haven't already, that they and their families are vulnerable to losing their coverage. Businesspeople understand It effects our economic competitiveness and our ability to maintain wages and a healthy workforce. And retirees recognize that it effects our ability to afford health care and social security for them.

Ross Williams: You've made my point. The issue isn't the quality of health care, its the issue of its availability, and threat of possible loss either through price or loss of employment, or loss of future insurance. You tell me that 80 - 85% of Canadians are happy with their health care; I tell you that probably the same percentage of insured americans are happy with theirs but are afraid of losing it. I'm not arguing that fear of the loss of health care is an issue; I'm arguing that it is a different issue than the one we've been talking about.

Robert Harris: Malpractice is an individual cost, not a group cost. The aggregated group cost may be paid out of partnership gross income, but this, in turn, affects the bottom line of partners in the group. It takes more out of the net, from which partners draw their income. But practices, because of the way surveys are constructed, typically report salaries of physicians before group expenses are amortized across the group. Ask your local physician about his/her net (in this case, before taxes, after group expenses and partnership costs) salary. You'll get a different answer than the surveys post. The number is lower.

"Tort reform" isn't the answer.

Certainly not "the" answer, but part of a solution IMHO. And it's not only the premiums, the litigation and the payouts... It's the incentive to over-treat that also is taxing the system.

Disclaimer: much to my mother's joy, i married a doctor.

I'ld like to thank everyone who contributed to this thread. It is rare to find an intelligent debate on the internet. Especially one that so closely touches on one of my research interests.

Since I'm Canadian, I am going to resist giving detailed advice on what the members of this list should advocate for, but I will toss in my own two cents about a few things, specifically:

The basic structure of the Canadian health system is,

Canadian public opinion re: the structure of the system,

Its relationship to values,

People paying privately for treatment in the US as a sort of escape valve,

And what I see as the single biggest problem facing the US health care system.

First off what Canada has: We don’t have one system we have several. Each province runs its own show within a very lose federal framework. If they obey five general principles they get substantial grants. If they don’t obey the principles they can be fined (though the fines are often trivial and more meant to make a political point than to actually punish). The principles are universality (all permanent residents must be eligible for coverage), portability (coverage must be good whether the resident is at home or in another part of Canada), comprehensiveness (all medically necessary services provided by physicians, hospitals and diagnostic tests as defined by the province must be covered), public administration (the province must have a publicly managed not-for profit system for insuring people), accessibility (services must be reasonably available in terms of timeliness, geography and no fees can be charged at point of service). After that everything is up for debate. Some provinces insure things others don’t. Some provinces have premiums for health insurance, some have a dedicated portion of income tax, some fund it 100% out of general revenue. Some provinces have regional authorities that directly manage facilities, others (such as Ontario) leave that in the hands of charitable and not for profit corporations. Some provinces have aggressive programs to contract out care to for-profit firms (who provide treatment at no cost to the patient). One thing that is constant is that MDs are predominantly private and bill the provincial insurance schemes for their work, whether in their office or a hospital. They are not employed by the provincial governments. Some work on straight fee for service, others have different compensation, such as capitation. A lot of stuff is not covered and that is why most families have supplemental insurance for things like drugs, medical supplies and devices, dentistry and non-medically necessary stuff (such as private and semi-private rooms in hospitals). Low income families and seniors usually have public coverage for those things. As in the US marginal workers and entrepreneurs are the least likely to have this private coverage.

Second off public opinion: A few years back Matthew Mendelsohn did a meta-analysis of polling data on Canadian health care. He found that Canadians were well aware of the issues and options and had reached a considered opinion that our system works best for us. Canadians may want reform but not wholesale change. You can read the study on the website of The Commission on the Future of Health Care in Canada which commissioned the study. To date I have not seen anything that would lead me to believe that Mendelsohn’s conclusions are no longer valid. What is important is that Canadians did not just support the system because of the care they felt they were receiving, but because it resonated with their values, specifically that high quality health care is a right, and as a right ought to be available to all regardless of location or socio-economic status.

I myself tested something similar with a study of attorneys in the province of Alberta. Attorneys are a relatively political informed group (so they know the issues), they are also a relatively prosperous group (the sort of people who could theoretically benefit from market-based care as they can afford it and would be attractive risks to insurers). Finally Alberta’s government has been among the least supportive of the present health system and has regularly sought to undermine it. The people I surveyed nevertheless overwhelmingly endorsed the present system. Most felt they would not get better care if privately financed care for medically necessary services were introduced. What turned the majority in favour of the present system into a landslide was a sizable portion which supported the present system even though they felt they would get better care if privately financed care were introduced for medically necessary services. I found decent evidence that these people based their support exclusively in the values promoted by the system. You can read that study "Canadian Medicare is there a Potential for Loyalty: Evidence from Alberta" in the Canadian Journal of Political Science 2005, Volume 38(2).

This relationship of support for the system to values is why I am hesitant to give detailed advice to Americans. Let me just say whatever plan people develop, it had better fit the values of your society or it will never gain traction and might positively hurt you politically as the losers will fight back and whip up the fear of those who think they might be worse off as a result of your reforms.

As an aside let me quickly point out that the idea that scores of Canadians sneak across the boarder with private insurance to get medically necessary elective surgery is bogus. Although I have heard some radio ads for this sort of coverage (in the Greater Vancouver Area, but no where else) I have not found a major carrier that provides it. In other words, it is not a huge business or the Aetna’s of the world would be in on it. In fact most private insurance for what we call “extended care” the stuff provincial plans exclude, specifically refuse to pay for out of country care other than that which is related to an emergency (heart attack, broken arm, etc. on vacation or business trip). A couple of years back some researchers did a study of billing recorders in hospitals near the Canada US boarder and could find little or no documentary evidence that there was a transboarder trade in elective surgeries. See SJ Katz et al. “Phantoms in the Snow: Canadians use of Health Care Services in the United States,” Health Affairs May/June 2002.

Finally, the reason the above noted sort of insurance is hard to find relates to what I see as the single biggest problem with the present system for financing US health care. It sucks as a business! In fact many Americans with private sector coverage for health costs don’t even have health “insurance” any more. What they in fact have is employer financed care which is “managed” by an insurance or similar firm. The insurance companies bailed on providing insurance and decided to focus on managing benefits as the risks in providing health insurance are just too unpredictable to accurately price in a way that will make the product both profitable and affordable to clients. Some one in this thread made reference to the Chaoulli decision of the Canadian Supreme Court. This case involved a man on a wait list in Quebec who wanted a private alternative (Quebec is a province which specifically outlaws private insurance which competes with the public plan). The Court ruled Quebec’s limits on private insurance violated its own provincial bill of rights. Most scholars say such bans probably violate the national Charter of Rights too but the Court did not rule as such in this case. Yet in spite of this massive victory for private insurance, not one major firm (i.e. one with the financial resources to make a major market in the field) has since stepped up and said: “okay, its legal we want to provide private health insurance that will compete with the public plan.” Instead they are more than happy to stick to providing “extended” care (the stuff provincial plans don’t pay for) and emergency coverage for travelers to and from Canada because these things are easier to make money insuring.

So that’s my little contribution. In sum health care for medically necessary care sucks as a business (and we don't even have your tort problem up here in Canada as judges not juries decide damage awards). Whatever you choose to do make sure it resonates deeply with the values of your society or people will not be willing to sacrifice their own interests. I just you hope you get it together before GM and Ford go bust and trigger a meta crisis in your health system. Apologies for the length of this post and I hope you don’t ban me from the site for running on so much.

Cheers
DC

Someone wants to know what will gather voters around the Dems? The Democrats have had nearly 7 years to find the answer to that question. Meanwhile, I wrote this good intentioned comment the other day, on a recent post of Kari's. I didn't get an answer. Not one. It's no joke, though I did ask a friend if I seemed just too naive to merit a response from the high thinkers here at blueoregon...but Jeff's post here makes me suspect apparently not. Here's my comment:

"I've always voted Democrat...across the board. Part of the consistency of my voting purpose was a memory of Democrats who really made a difference, part of it was simply a vote against the GOP....who frankly scared the sh-t out of me, a small business owner who always knew I was in for a bumpy ride whenever the Republicans were in charge.

It seems here at blueoregon most of the talk is about elections, and getting as many DEMS in office as possible. Well we did that last Novemeber, and I just don't see much change or improvement....especially at the national level. This FISA fiasco has really and truly opened my eyes, and disillusion is the sad result. My votes, my core beliefs are not being represented. And I feel so let down. Not only have the DEMS in DC failed to start to unravel and repair the damage of the past 7 years, they have now actively added to the travesty. I am stunned.

There is not enough talk about platforms....if I have to vote for the lesser of evils I'd at least like to know what the Democrats' goals are once we give them leadership roles. And can I count on them to follow through once the election is over? Or will it be just more empty promises, forgotten once they take office?

Can any of you here please define Democratic goals for me? I know you can't please everyone, so spare me the ambiguous platitudes. I really want to know where the Democrats are going with this power about to be given to them. I am asking in all seriousness and with respect....and don't think I am singular in my confusion and disappointment. There are a lots more like me out here, and we all vote. What do DEMS stand for these days?"

And if anyone cares what I think will gather voters around the Dems, yes health care coverage is a BIG BIG issue for me. But the Dems also must create a policy of wise, even frugal, spending of my tax dollars, or get the government out of my pockets. I want to see American taxpayers start getting some true representation and benefits in return for their tax contributions. And that includes NOT wasting billions and sacrificing lives on senseless wars, AND creating laws that stop big business from raiding our pocketbooks too....banking and credit companies, insurance companies, et al. And when we elect Democrats I expect to see them fervently and ceaslessly work to restore our Constitution to pre-Bush condition....and not stop until the job is done.

Get a platform! Grow some balls.

To MCT and Dan Cohn:

A hearty thank you for your very interesting, useful, and provocative contributions. They made my day.

mrf

I'm not arguing that fear of the loss of health care is an issue; I'm arguing that it is a different issue than the one we've been talking about.

Its not just a fear, many Americans already lack health care. The issue of universal health care has almost nothing to do with the quality of care people will receive. That is a red herring.

People in Canada are mostly satisfied with both the care they receive and the system that provides it. People in the United States are often dissatisfied with both. The fact is that the US system is broken and it should have been fixed 30 years ago.

MRF writes: I think the animus towards physician salaries is both misdirected and counterproductive. In general, we have too few physicians serving way too many patients right now. Cutting physician salaries won't solve the shortage, it will exacerbate it, and it won't even make a small dent in the cost of medical care.

According to the BLS, there were over 567,000 US physicians and surgeons in 2004. If we currently have a physician shortage, how many do you think we should have? The idea that people are having a hard time finding doctors is a fabrication designed to scare the American people into increasing the already exorbitant salaries that doctors receive. There are cases of rural areas that have lost an OB/GYN or primary care physician, but these cannot be used to argue for a change in national health policy towards doctors. The isolated cases need to be addressed, but they have no bearing on the overall supply of physicians in the US.

You claim that cutting physician salaries will exacerbate the (nonexistent) shortage, but that only makes sense if doctors are entering the field in order to become rich. I hope that's not the case, but if it is, it's better for those people to find something else to do. It's ridiculous to argue that doctors, with their heavy student loans and malpractice insurance costs, are bordering on insolvency. Doctors, on average, are extremely wealthy, and there are plenty of bright, talented individuals who would be happy to enter the field of medicine even if they only earn $200,000 instead of $250,000.

As for the cost of physician services, according to CMS we spent $421.2 billion on physician services in 2005. That represents about 20% of all health spending, and it clearly needs to be part of any effort to control health costs. If the 500,000+ physicians each took a $50,000 pay cut, that would result in over $25 billion in yearly savings. For reference, the Senate bill to cover 4 million uninsured kids costs about $7 billion a year, so yes, $25 billion would go a very long way towards universal coverage.

Finally, I don't understand the point of you arguing against the AMA. Whether you think it's a good organization or not, your arguments are in lock-step with theirs. Doctors (and their spouses) should not be in charge of national health policy any more than hospital administrators or insurance execs. All have a significant financial interest in the current system.

[Just to be clear, I really don't have any animosity towards doctors in general or the fact that they're prospering under the current system. There are other areas besides physician payments that I would reform first. But it is impossible to get real health reform if we exempt a large segment of the industry just because we think they're good people.]

In the '70's I recall so many ob/gyn's left the field because of soaring malpractise insurance they couldn't pass on to their patients, so many of whom could ill-afford fee hikes. Those doctors I knew personally were both angry and heart-broken, as they had spent decades in practice. These were honorable, highly-skilled physicians who made their decisions with reluctant practicality.

Ironically, advances in medicine is to blame, in part. For example, my own ob/gyn said patients were suing doctors who could not keep alive their wildly premature fetuses. They had grown to expect miracles because so often "miracles" were achieved. Rather than play Russian roulette with their financial futures, many ob/gyns dropped out of obstetrics.

I can't imagine the situation has improved much over the years for doctors. As prior posts here suggest, the patients want what they want when they want it. And I sense there is yet huge resistance to "socialized" medicine.

That's why I am eager to see what happens to Sen. Wyden's universal healthcare plan, and how seriously it is taken.

But it is impossible to get real health reform if we exempt a large segment of the industry just because we think they're good people.

To the contrary, its impossible to get universal health care if it is tied to "reform" that takes a huge chunk out of the existing industry's pocket to pay for it.

Is it any wonder people are suspicious of "universal health care" coverage the will provide more people with the same care at less cost? A lot of people's experience tells them to run for the hills when they hear that sales pitch. Because cheaper and better rarely go together. And cheaper, better and more are like fast, good and cheap, you get to choose two.

If we want universal coverage we need to convince people their own coverage won't be reduced. And that means we have to stop talking about how we are going to "reform" the system to make it less profitable for insurance salesmen, drug companies and HMO's. Because it quickly becomes apparent that the goal isn't universal coverage, its reducing costs. And reduced costs often means reduced service as well. And people want better health care coverage, not less.

Ross Williams writes:

"If we want universal coverage we need to convince people their own coverage won't be reduced. And that means we have to stop talking about how we are going to "reform" the system to make it less profitable for insurance salesmen, drug companies and HMO's. Because it quickly becomes apparent that the goal isn't universal coverage, its reducing costs. And reduced costs often means reduced service as well. And people want better health care coverage, not less."

this is pure b.s. The goal IS to reduce costs and spread the coverage over a all individuals. The current rates of expenditure are unsustainable and you can't get to universal coverage without cutting those things you just decried will send people running for the hills. Read Mr Cohn's post very carefully because you apparently didn't get it the first time.

As for the info in your other posts, I can't replicate the info from the CMS, because I don't know what organization you're talking about. I can figure out the acronym, but there is no such agency listed in Google. But that's beside the point. We have no idea whether that figures all doctors with active licenses somewhere or all doctors still alive. Moreover, there are many doctors who retain active licenses but don't practice. Licensure is a small cost of keeping eligibility. It is $330 every two years in Oregon, $340 every two years in Washington, and $900 annually in California. My wife retains and uses two of those licenses annually, and she did her fellowship in California and retains her CA license because it was so difficult and expensive to get initially. I suspect the count of physicians and surgeons is an overestimate of the number of ACTIVE doctors.

But even more to the point, a huge percentage of those doctors are on both coasts, with far fewer in the nation's midsection. The reason for this is that both coasts are more desireable to live and doctors want to come to large metro areas on or near either coast. Salaries are lower on the coasts for that reason. Example: my wife and I were in San Diego (UCSD) doing her fellowship. I had a job in Portland that tied me here. So my wife, a native Portlander, applied only for positions in Portland. She was offered jobs at 6 different radiology practices in Portland. The salaries were highly varied, but it was the benefit array and worklife conditions that made all the difference and that determined which of the 6 offers she would take. Her starting salary (in 1990) was about $105,000 per year. Several of her classmates, who didn't care where they lived, took positions in the midwest where finding doctors (especially specialists) is actually difficult. One took a position in South Bend, Indiana with a starting salary of $650,000. That's what it takes to recruit to those parts of the country. He reasoned that he could live anywhere if they were willing to pay him that much. He hoped he could kill himself in this small practice for a few years, make and save as much money as he could, pay off all his med school debt, and then take a position on one of the Coasts. He worked there until 2000, at which time he took a position in Florida for a smaller salary (not much by then).

If you don't think there are doctor shortages, you're sadly mistaken. Be glad you're not a woman of childbearing age, even in populous areas. According to accreditation data from all the area hospitals, every single Portland hospital practice is down about 20% in available OB staff positions. There simply isn't enough supply to fill the increasing demand. We personally know 5 OB/GYN docs who have relinquished their OB practice in favor of an OB-only practice.

Primary care is another area where extreme shortages exist. There is almost no incentive right now for medical students to choose primary care. The workload is crushing, the demands from insurance companies, patients, employers, governments, medicare make the practice nearly intolerable for most. Surprisingly, ER medicine is, itself, a specialty area as are "Hospitalists". Many primary care docs are taking time off, retraining and going into these less stressful (yes, ER work is less stressful because it is all the docs do) practice areas. Medicare has made primary care unsustainable unless you do two things: (1) document exquisitely and using very precise coding exactly why the patient is seeing you. And you're dead if you sequence the history incorrectly. Either you'll get underreimbursed, or not reimbursed at all; and (2) see patients in huge volumes, typical 4 or 5 per hour. You cannot give a patient quality care if you're limited to 10 or 15 minute encounters. The demand for care is unceasingly increasing and the practice situation is a direct cause of such high physician burnout and turnover. Again, my wife's group - a multispeciality one-stop shop - currently has 40 open positions in primary care. This is 10% of the total number of primary care docs needed to minimally care for the current group of paying patients, not counting the uninsured that the group takes on through the emergency room.

Gastro-Intestinal medicine currently has waitlists of more than 2 or 3 years for a patient to get a colonoscopy, unless the patient has two or more risk factors and a direct lineal relative with a history of colon cancer. That branch is 4 GI specialists short (and this is true all over the country).

Do a survey of medical schools and break down the numbers of practicing docs in the US. When you've completed this exercise, come back again and tell me there aren't systematic and national shortages in key primary care areas. I've only listed a couple. Then, take a look at the number of residents being trained in fields like plastic and cosmetic surgery, where insurance doesn't cover much of anything unless it is caused by an accident. These are essentially boutique practices earning some of the highest salaries in the field of medicine. Why? Because it is almost exclusively self-pay. We know several couples where one spouse is in a primary care field and the other in plastic surgery or dermatology. The primary care doc typically earns one sixth of what the plastic surgeon or dermatologist earns. In one case, most of the reimbursement is from insurance and medicare and salaries are very depressed and there are severe shortages. In the other case, the salaries are high, work days short, no call, and almost all the patients pay out of pocket.

While physicians don't go into practice "for the money", "money" is a consideration relative to the cost and length of training, and the practice risks. Internal medicine and family practice used to be intrinsically rewarding, but you'd be hard pressed to find a single primary care doc these days in a brutally busy practice who finds much of anything rewarding.

My wife chose specialty care for one reason: she loved medicine, but never considered herself cutout to be patient and listen to patient complaints daily. She wanted a field that diminished her interactions with patients, yet afforded her the opportunity to make a significant difference. She ended up in Radiology, which also has shortages, but nowhere near as severe as OB/GYN, Internal Medicine, Family Practice, Gastroenterology, Pulmonology.

Your numbers mean nothing. Do more research.

Ross Williams also writes:

"Finally, I don't understand the point of you arguing against the AMA. Whether you think it's a good organization or not, your arguments are in lock-step with theirs. Doctors (and their spouses) should not be in charge of national health policy any more than hospital administrators or insurance execs. All have a significant financial interest in the current system."

Whether our arguments are or are not in lock step with the AMA, they DON'T represent the views of many doctors. The fact that doctors' opinions, observations, and experience coincide with AMA's position is a coincidence based on actual data from real life. We're not talking about whether people are nice or deserving; we're talking about the reality of the system.

It is just way too bad that policy wonks like you, who work from aggregated data rather than disaggregated data can't see the forest for the trees. There could be a million doctors as far as I'm concerned but that probably wouldn't change the fact that there is a gross maldistribution of primary care, OB/GYN, gasteroenterology, and pulmonology (to name those I'm intimately familiar with) across the country. The Medicare funding program continues to reduce reimbursement rates to training hospitals; this in turn reduces the number of residencies available; which in turn reduces the number of certain types of doctors being trained. Ironically, this doesn't lead to increases in compensation for primary care doctors in areas of extreme shortages because compensation isn't typically the problem. Most primary care docs, except in a few areas of the country, are paid decent salaries. The issue is the workload, the length of the workday, the frequency of call, the amount of paperwork, the demanding patients, demanding families, burdensome Medicare requirements, constant second-guessing by administrators, etc, etc, etc. What part of that would Universal Health Care eliminate. If salary isn't the primary concern, what other incentive can you offer people to go into primary care, where new doctors have an effective shelf life of about 10 - 12 years, before they start looking for other fields of medicine to retrain in. There is a burgeoning after-market for post-residency short fellowships to bring doctors in one field up to date in another field that is less stressful. You also might be surprised by the number of primary care doctors who decide to become lawyers - we know a few of those too.

If policy wonks could actually spend time with doctors actually practicing medicine, they would have a clearer idea about what it is really like, what kinds of stuff doctors have to deal with every single day (and night and early morning), and might change the perspective about (a) whether the compensation is adequate and (b) whether the doctors' reimbursement rate actually makes up a significant cost of modern health care in the US. As I've said before, HIPPA (Health Information Protection and Portability Act) prevents this from happening, so we're left here with wonks citing rather unhelpful statistics and actual doctors citing actual experience.

Here's a fun exercise. Pretend you're a new patient. You have insurance. Pick up the phone book and call every primary care doctor in your network to find out when you can get in for a complete physical. After all, this is the correct way to begin a relationship with a doctor, not just when you get ill. Let me know what the average wait time to get to such an appointment is.

Your numbers mean nothing. Do more research.

The Centers for Medicare and Medicaid Services (CMS) is the primary federal agency that compiles data on national health spending. The Bureau of Labor Statistics (BLS) compiles data on labor in the U.S. If you think their numbers don't mean anything, then I'm not sure we can continue this discussion.

As for Ross William's post, if you're telling me that your prescription for health care reform is simply to spend more money, then count me out. How many times do we need to point out that the US spends more money for worse outcomes than any other industrialized nation?

Miles writes:

"The Centers for Medicare and Medicaid Services (CMS) is the primary federal agency that compiles data on national health spending. The Bureau of Labor Statistics (BLS) compiles data on labor in the U.S. If you think their numbers don't mean anything, then I'm not sure we can continue this discussion.

As for Ross William's post, if you're telling me that your prescription for health care reform is simply to spend more money, then count me out. How many times do we need to point out that the US spends more money for worse outcomes than any other industrialized nation?"

Thank you for the reference to CMS. I wasn't saying their numbers were worthless. What I said is that the numbers don't necessarily tell the whole story because they are not disaggregated by area of practice and area of the country, nor do we know whether they are counting only doctors with active licenses without considering whether they are still practicing or not.

As for your point about Ross William's post, my point has always been that we could spend the same amount of money and cover almost all the ininsured (through a mechanism that is, in my opinion, not entirely relevant to the running debate), by decreasing some of the drivers of current health care costs that actually do nothing to affect the outcomes of health care today. Defensive medicine is an extraordinarily costly proposition. Every unnecessary MRI costs $1500 on average. There are about 30 - 40 MRI machines (I lose count because they're going in so fast) at all the hospitals in the Portland metro area. Virtually every one runs 24/7 and schedules patients at least 18 hours every day. My wife, a radiologist who specializes in cross-sectional imaging, does about 40 MRI cases in her typical workday, and another 20 or so are done either on call or unmonitored except by technicians. Of those 60 MRIs per day, more than half are completely unnecessary, but for the fact that the patient is balky, demanding, or the doctor is too busy to fight. The fear of malpractice drives these tests. Imagine how many fewer $1500 studies would be done if doctors didn't live in fear of being sued. Another example. My wife also does CT and her medical center has 3 CT scanners running 24/7. A typical day might consist of reading 40-50 CT scans each with about 800 images. Common reason: patient comes in with worst headache of life. Instead of the doctor taking the time to find out more about the patient's history (because there are 5 patients stacked up waiting), he orders a CT scan to determine whether or not the patient has a sub arachnoid hemorrhage. During the procedure, my wife is busy chatting with the patient. During the procedure the patient tells my wife that last night he went on a bender and drank 2 dozen beers chased by whisky shooters. Now he's got the worst headache of his life. Duh. But this isn't in the history because the ordering doc doesn't have time. He orders the "right test" because he can't get sued for doing it. He doesn't have to do anything else because my wife will tell the patient that his head is fine, he just needs to get over the hangover.

These are but two incredibly common examples. Oh, and the typical cost of that CT scan is about $500 if done during the work day, and about $750 if it is done after hours and involves a doctor coming in to read it, or reading it from home via a secure VPN that is HIPPA compliant.

I am NOT advocating that we spend more money on medical care. I'm advocating that we spend the money we currently spend differently, which will allow more (if not all) patients to get basic coverage by whatever mechanism. You can't do this in an environment when patients assume little or no personal responsibility, when doctors are scared shitless to NOT do every test known to mankind, and when drug companies turn end users into advertising bots spreading "the word" in every doctor's office on the planet. "Ask Your Doctor" in drug commercials is the most hated line in medicine.

And, as to "worse outcomes". This is pretty understandable even if you factor out the people who don't have health insurance. Abuse of health insurance drives much of the "worse outcomes". People don't want to have to interrupt their day for a routine doctor's appointment. Compliance rates with prescription medication is pretty awful. Patients have side effects, don't bother to communicate with the doctor, and then stop taking the meds (unless they're narcotics and that's a different story). By the time the patient returns to the ER (remember, that appointment with your regular PCP is just so inconvenient), he/she is in far worse shape and has worse prospects of a good outcome than ever. Personal responsibility has GOT to come into play somewhere in this equation. To leave it out means that no solution will work and the whole system will implode.

I think I've made all the points I need to make. If people would like more tales from the true life of a radiologist in a large multi-specialty group, please feel free to ask. But I'm not going to engage in further repetitive debates with people who want to cite statistics without any real explanation of the meaning of those statistics. I'm not really contesting the accuracy of the numbers; I just don't know what they mean in the context of the discussion we're having.

mrf

The goal IS to reduce costs and spread the coverage over a all individuals.

I agree, but that goal isn't supported by people who already have good coverage. They don't want the quality and amount of their health care reduced in order to spread it to other people. They do want to people to be secure in having health care available.

Frankly, cost has nothing to do with making care health care universal. But people have caught on that there is a bait and switch operation here. The bait is universal coverage, the switch is cost containment for employers and government. And they don't trust politicians not to cut a lot of meat with the fat.

BTW - the rest of your response(s) have nothing to do with anything that I said.

How many times do we need to point out that the US spends more money for worse outcomes than any other industrialized nation?

You can keep pointing it out. But you need to convince a broad part of the public that you have a solution that spends less and gets better outcomes. That is counter-intuitive for most people and they suspect it is an empty promise. If your goal is cost-containment that is a different issue than assuring every person they will have access to health care.

But aside from the politics of actually getting to universal health care, I think people ignore the reality that some costs in the system are a direct result of triage based on ability to pay. Those costs will be contained regardless of the system. And once coverage is universal, it is going to be much easier to address other cost-containment issues.

Every Democratic president since Lyndon Johnson (Carter,Clinton) has been elected on the promise of universal health care coverage. We still don't have it. And if cost containment is made the focus, we will have another debacle like Clinton's.

This isn't 1994. I don't have numbers but I'm willing to bet there were a lot less uninsured Americans in 1994 and while healthcare costs were rising they weren't at the ridiculous levels they are at right now. Again I don't have proof but I really suspect all the mumbo jumbo you hear (worse coverage, long lines, worse care) about universal health care is spread by Big Pharma. I know Canadians, Brits, Sweedes, Frenchmen...not a single one of them complains about their system. I have a friend (American) who broke his jaw playing rugby in England while he was in school abroad for a year. They fixed it for free and he received care for the injury throughout the time he was in England at no cost to him. Tell me again how that system is broke?

How many times do we need to point out that the US spends more money for worse outcomes than any other industrialized nation?

You can keep pointing it out. But you need to convince a broad part of the public that you have a solution that spends less and gets better outcomes.

There is a simple and easy way to frame this issue to the American people-

We need to get rid of the fat cats who are skimming all of the money from the top. Health care should not be a for profit enterprise. Doctors should do well financially, hospitals and nurses can and should do well. Monetary compensation should go to the people who are actually doing work. Insurance companies are not playing a positive role in our health care- and every American knows it. Even those Americans that are covered ( like me ) are not satisfied with the level of service we receive, and when I factor in my costs coupled with my employer's cost, I feel that we are both being ripped off.

Insurance companies are created to hedge a risk against an unforeseen event- not to measure out our health care, and to attempt to ration it to create a higher profit maargin.

You can make the debate as complicated as you want, but the chance to not worry about health insurance, and to see a doctor when you need to and have everything covered for everybody is very exciting. Remove all insurance companies and payments, add a 2% payroll tax and administer the whole program through Medicare at a mere 1% overhead.

I think that the best way to do this is like Canada's system, the state you live in could administer the program. Most people trust their state government over their Federal government, and citizens have easier access to state reps.

There is a lot of talk about whether there is any way to cover the cost for all Americans' health care. Whether doctors fees are overblown. I believe the costs and fees and charges of EVERY component of medical care needs to be examined.

Some 20 years ago I had a surgery that kept me in the hospital for nearly a week....back in the days before HMO's and rampant staph infections in the hospitals drove people home as soon as possible, to heal in a more hygenic and cheaper environment. I had health insurance, paid for by me, but I was still responsible for 20% of the bill. A friend of mine was a head nurse in the O.R. of a large Seattle hospital. She came to visit and perused my itemized bill with a pencil, checking items (she at least knew what some of those mysterious items were!)..."I'd question this...and this...and this." And, "they can't be serious; no WAY would this cost that much!" "$8 for a Tylonol?!" You get my drift.

I think we CAN revamp the health care system and make it work for all Americans. But we have to put a stop to the general overcharging, and make it a non-profit or limited profit industry....no more of this sky's the limit pricing on something so crucial to the public's well-being. Our health shouldn't be subject to keeping the shareholders happy. We have to take big medical corporations to task, or get them out of the picture. And there will be a big fight from their lobbies. Whether we are healthy or not shouldn't be a decision made on the basis of profit and loss, or actuary tables...or the vote of MY elected representative who's accepted big money from the medical lobby. So maybe the job cannot be done until we reform campaign financing. So let's do that.

I'm from England, and I recall being there visiting when one of my relatives needed medical care, and when my Grandmother was ill and dying from cancer. The National Health was not perfect, but they made house calls when needed and gave medical care and medications that my family would not have had otherwise. There are millions of Americans who do not have even that, and they are suffering. One serious illness or medical emergency can ruin their finances for years if not for life; and that's if they are not turned away at the door. And let's not overlook dental and vision care. Even those who are insured rarely have dental and vision coverage these days. Not even Medicare covers these two vital areas of health care. Millions of Americans with their teeth rotting away....while the dentists are resorting to TV advertising.

I'm disappointed that any American would say "it can't be done". We have always been know for our "can do" spirit. No cause is more important than the good health of American citizens! It will be a massive undertaking...but isn't that what America is best at? Think big and make it happen. And think of the headway that could have been made if we had used the billions spent on war to give health care to Americans.

There is a simple and easy way to frame this issue to the American people-

We need to get rid of the fat cats who are skimming all of the money from the top. Health care should not be a for profit enterprise.

That's a great argument for the Democratic base who are already bought into the idea of universal health care. Maybe I live in a different country, but it seems to me most Americans are very skeptical of ideological solutions. That argument is a sure loser with people who don't mind people making a profit as long as they deliver the services.

As for the argument that we are spending too much on health care - how is providing care to more people going to solve that? It isn't. On the other hand, securing people's medical care is a good idea. They don't want to worry if they change jobs, get laid off or their employer drops insurance coverage. Americans are already dissatisfied with our health care system, they don't need to be convinced it should be improved. They need to be convinced you are really improving it, not saving corporations money or satisfying some ideological belief.

MRF:

I agree with 90% of what you write. What I disagree with is what you said earlier: I think the animus towards physician salaries is both misdirected and counterproductive.

But then you say: my point has always been that we could spend the same amount of money and cover almost all the ininsured . . . by decreasing some of the drivers of current health care costs that actually do nothing to affect the outcomes of health care today.

My point throughout has been that doctors and their salaries are one of those drivers. You talk about the waste inherent in defensive medicine, but what about the waste cited by the economists in the NY Times article who say that it's the piecemeal way we pay doctors that drives much of the unnecessary medical care? If we pay doctors a salary, rather than piecemeal for each procedure, this problem is solved. Of course doctors would make less, as they do in Europe, but how can you take that off the table as a cost driver?

I'm not really contesting the accuracy of the numbers; I just don't know what they mean in the context of the discussion we're having.

I think the point is that the number of doctors and physician spending is so large, you can't dismiss it as "irrelevant" to the health reform debate. Let's say you're right and we discount the number of physicians (and corresponding salary savings if they take a $50,000 pay cut) by 70%. We're STILL left with $7 billion in annual savings -- enough to cover 4 million uninsured kids. You can continue trying to downplay the role that physician salaries play in driving costs up -- and thus making health care unaffordable -- but I trust the numbers more than I trust your anecdotes.

Miles: The isolated cases [of rural areas losing doctors] need to be addressed emphasis mine

Please actually do some research before making statements that are wildly inaccurate. There is an exodus of medical providers out of rural areas to urban areas where the patient mix is MUCH more attractive. We're not talking isolated; we're talking systemic. In rural areas the proportion of population/patients is more heavily weighted toward Medicaid/Medicare/Uninsured…which (in Oregon) pay MUCH less than private insurance. In metro/urban areas, the population is much more heavily weighted to private payers. Oregon has somewhat addressed this issue by providing a malpractice subsidy for certain rural practitioners, but frankly it’s only a band-aid for a more systemic problem

Miles re: just expand Medicare A long time ago, I used to think the same thing. It’s a great simple and easily understandable proposal. Since then, I’ve figured out that it’s probably the stupidest “fix” to expanding access/coverage. Current Medicare (especially after part D) is underfunded and unsustainable. And the worst part is that the current incentives are absolutely f**ked up! Oregon has the lowest Medicare reimbursement rate. The lowest. The highest reimbursed states? Massachusetts and Florida. Why is Oregon at the bottom and Massachusetts/Florida at the top? Because Oregon has better health outcomes with the money that we spend on health care than Florida/Mass. In other words, we prioritize our Medicaid dollars on procedures that are evidence based. We’re efficient and we’re penalized for it. It’s kinda like a reverse-No Child Left Behind (instead of less money for poor performance…you get less money for better performance). I wouldn’t have as much of a problem with a massive Medicare expansion if the perverse reimbursement incentives were removed (but I don’t see that happening anytime soon…Mass/Florida have 39 votes in Congress, Oregon has 7).

Miles/mrfearless: reducing costs and expanding coverage It’s about spending the dollars that we have more wisely. Bend has 8 MRI machines; Portland has 30 - 40 MRI machines (so says mrfearless in thread above). Imaging technology is one of the most lucrative ways for a doctor or phys. group to rake in cash because of how insurance/Medicare reimburses imaging. Furthermore, the American ER is the most expensive health care on the face of the planet. That’s where the 615,000 uninsured Oregonians go for their health care. ER care is nine times more expensive than primary preventative care. It’s simple. If you’re able to afford to go to your primary care doctor and get your regular colonoscopy/pap smear/annual physical/etc. and prevent disease and treat conditions in early stages…it’s smarter, cheaper, and leads to better health outcomes. However, if you can’t afford preventative care (don’t have insurance)…you wait until something gets so bad that you have to go to the emergency room. Then it costs a s**tload more money and your chances of survival are significantly lower than if you had regular, affordable access to a primary care doc. If you can provide access to affordable primary preventative health services, you should be able to actually lower the overall cost of health care. Now, let’s talk about the office overhead in every insurance company and physician’s office that’s dedicated to billing alone. Why? Because every insurance company does billing differently. Different forms, different rules and procedures. How much money could we save in the system by using a common billing system (standard forms, standard computer technology, etc.)? Then, how much money (not to mention lives) could we save through electronic medical records? No more duplicate and unnecessary labs and films.

The frame of expanding access cannot not (and should not) be about rationing care, increasing wait times, decreasing physician’s salaries. The frame and reality we have to talk about is spending our health care dollars smarter, earlier, and rationally.

yes, but keep in mind the disparities in incomes that various doctors make, depending on their area of expertise.

as pointed out, the doctors who make the most money work in the fields where elective surgery is popular, and are largely paid directly by their patients. there's really no way to cut their salaries, as they are at market driven rates - for better or for worse.

cutting the salaries of doctors who work in fields like obstetrics or primary care is a really bad idea, because those fields are already horrifically underserved, and primary care is only getting worse. and let's not even talk about gerentology - that's a crisis waiting to happen in this country as boomers age & technology increases life expectancy.

so where does the "$50,000/doctor" come from, except from averages? that's why the statistics don't work all that well.

you can't, on average, take $50,000 off of every doctor's salary, because there's no such thing as an "average" doctor. every doctor works in an individual field, with salaries that match accordingly.

oh, and ps: it's my understanding pediatricians also get paid crap compared to other doctors. taking money away from them would likely cause problems of shortages in that field as well. what good would it do to have insured children if there is a shortage pediatricians to serve them?

Miles/mrfearless: reducing costs and expanding coverage I'm sorry I meant Ross Williams/mrfearless.

It’s about spending the dollars that we have more wisely.

Obviously that is the argument. Now, how many Americans are going to ever take the time to understand the health care system well enough to evaluate whether spending the money more "wisely" means they will get the same care, at less cost while expanding coverage to a lot of people that don't have it. Its not whether that is possible, its whether anyone will believe it.

Where is the money that is not being spent "wisely" going now? The argument seems to be that government and politicians will direct it to be spent more wisely. That doesn't pass the smell test. They are much more likely to direct it into the pockets of their campaign contributors and supporters.

Which brings us back to the central question, how do we get universal health care coverage and why haven't we got it already. And the answer is because no one is really working to achieve that. Instead they are trying to punish their political enemies (trial lawyers, greedy drug companies etc.), reward their political friends (lower health care costs for employers, government) or win some ideological struggle (capitalism, socialism, free markets etc).

People are naturally suspicious of someone who says thys support universal health care and then goes into a 15 minute diatribe about health care costs, their impact on the economy, greedy drug companies, medical malpractice insurance, tort reform, wasteful medical procedures, duplication of equipment, expensive and unnecessary procedures etc. Because none of those things have anything to do with whether everyone has access to health care they could just as easily lower costs to people who already have medical care. Its becomes pretty obvious that universal health care is just a popular wedge being used to get at other issues.

If we want universal health care we need a message that says that. And the folks that want to hijack the issue for their own purposes need to be thrown off the train.

Miles and I write (exchanging quotes):

"MRF:

I agree with 90% of what you write. What I disagree with is what you said earlier: I think the animus towards physician salaries is both misdirected and counterproductive.

But then you say: my point has always been that we could spend the same amount of money and cover almost all the ininsured . . . by decreasing some of the drivers of current health care costs that actually do nothing to affect the outcomes of health care today.

My point throughout has been that doctors and their salaries are one of those drivers. You talk about the waste inherent in defensive medicine, but what about the waste cited by the economists in the NY Times article who say that it's the piecemeal way we pay doctors that drives much of the unnecessary medical care? If we pay doctors a salary, rather than piecemeal for each procedure, this problem is solved. Of course doctors would make less, as they do in Europe, but how can you take that off the table as a cost driver?"

We don't need to put it on the table. If doctors are, as you and the NYT say, reimbursed piecemeal for every procedure, then by reducing the high frequency of unnecessary tests and procedures, this alone will reduce reimbursement to doctors.

The fundamental problem is the "fee for service" way some doctors are reimbursed. My wife is salaried and, except for call work, she receives her compensation based on completing whatever workload there is in a given day. She receives a decent, not great, salary, but she traded off the additional income in fee-for-service to work in a group that is reimbursed differently. There are some terrific models of health care delivery out there in the US already, but people have already made up their minds that they don't like that kind of care, except for those people who have it and generally like it.

I want to add a comment from an earlier thread to illustrate how off some of these statistics are. According to your sources, there are 567,000 physicians and surgeons in the US in 2004 and in 2005, you infer that physicians and surgeons raked in $421.6 billion. If I accept your numbers as facts, then I come to the following conclusion, which is most definitely wrong: $421.6b / 567,000 physicians and surgeons = $742,504 as the average salary of physicians and surgeons in the US. Since I know this to be absolutely untrue: the average is closer to about $245,000+-, there is something wrong with these figures. My guess is that the $421.6b figure includes a lot more than physician reimbursements and therefore overstates my a significant amount, the portion of money devoted to physician reimbursement. It might be the case that the average reimbursement to physicians BEFORE EXPENSES was somewhere in the vicinity of the number I've computed, but there is no relationship between that amount and the amount doctors see in their paychecks. I don't have precise numbers, but generalizing from my wife's practice (over 1000 physicians and surgeons), 75% are in primary care fields, where salaries are dramatically lower than in specialty fields. So it is impossible to believe that even in primary care the reimbursement rates to physicians, even before expenses, is anywhere near what you're reporting. I'd suggest you dig a bit deeper to find out what that reported figure actually encompasses.

To go back to an earlier point I made, my wife isn't involved to any degree in the billing for any services she renders, nor does she receive compensation that is in any way related to how much the group receives in reimbursement for her work. Radiologists are paid on a salary scale commensurate with their experience, their training, whether or not they're Board Certified, and their tenure in their current position. If the workload becomes too great, the equipment outdated, or the equipment inadequate, her partners go to the Board of the group and ask for additional positions and/or additional equipment to handle the workload.

Now, go back to an earlier point I made about my wife's $1,000,000 hospital bill for two spine reconstruction surgeries and 22 days in the hospital. Out of that bill, only 8% of it represented actual reimbursement to some of the most expensive specialists in the world - trained and double certified orthopedic spine and neurosurgeons. In that particular context, how do you squeeze more out of the team of doctors in charge of my wife's care? 92% of the money spent didn't go anywhere near my wife's physicians.

I think you're barking up the wrong tree by suggestion that physician salaries are driving the health care crisis. I think that the reduction of unnecessary procedures, by whatever means necessary, will produce a reduction in physician income as a direct consequence. This won't happen to physicians in my wife's practice, by will dramatically impact fee-for-service practices.

JTT writes:

"It’s about spending the dollars that we have more wisely. Bend has 8 MRI machines; Portland has 30 - 40 MRI machines (so says mrfearless in thread above). Imaging technology is one of the most lucrative ways for a doctor or phys. group to rake in cash because of how insurance/Medicare reimburses imaging."

Insurance/Medicare reimbursement for imaging is actually close to the cost of delivering the service. An MRI scanner costs about $2.5 million. It has to be housed in its own building, or at least totally isolated from all other parts of the building. The cooling requirements are extraordinary. The shielding requirements are extraordinary. The machines take about 2 hours to start up and so it is more efficient to run them 24/7. A typical maintenance contract (with 4 hour response time) runs about $200,000 per year per machine. The machines typically require one or two techs to run, and the radiologists reading MRI's are supposed to have subspecialty training and fellowships in cross-sectional imaging. Storage requirements for MRI images is costly because virtually every study produces hundreds, if not thousands, of images. RAID storage fills rapidly and you've got to provide the consumers of MRI (surgeons, orthopedists, urologists etc) with a means of reading the films in their offices unless the facility provides a comprehensive PACS system that enables the radiologists to send ordering clinicians MRI's on a simple CD that can be read on a Windows-based computer.

The evolution of MRI has been extraordinary as is the volume of work on these machines. When my wife started as a full-time attending, her group was installing its first MRI machine. Last year, they installed their fifth machine. Their individual patient growth was about 30% between 1990 and 2005, the last year for which data are available. So, you can draw whatever conclusions you'd like, but somehow in that equation figure out the meaning of a 30% growth in the patient population (individuals) coupled with a 400% increase in the number of machines (and the number of studies). When my wife joined her radiology group, she was radiologist #22 in the group. Now her group has a census of 45 FTE radiologists. There are more than 500 techs in radiology alone.

Her group doesn't own the equipment and no radiologist refers anyone for any test. What the overall group is reimbursed pretty much covers their basic costs, but it is hardly a huge profit center. Moreover, reimbursement rates for many other services are actually less than the cost of delivering the service. Her department does OK and isn't in any financial jeopardy, but it helps that the group as a whole has no incentive to order extra tests for anyone. That said, the ordering pattern is crazy because resistence is futile.

In groups that own their own equipment, I suspect MRIs may be more lucrative, but these are mostly fee-for-service practices, which are far less common on the west coast than elsewhere in the country.

JTT writes: Please actually do some research before making statements that are wildly inaccurate. There is an exodus of medical providers out of rural areas to urban areas where the patient mix is MUCH more attractive.

Thanks for providing the link, but I'm not sure it tells the story you want it to tell. Yes, rural areas have fewer physicians per capita than urban areas. They also have fewer firefighters, lawyers, accountants, and CEOs per capita. Is that a problem? Sometimes, and I acknowledge that targeted programs to help are important. But any attempt to make broad health financing decisions for the state or the country based on the experience of rural America is foolish.

I would also point out that the paper you link shows that Oregon has more OB/GYNs, general surgeons, internists, and family practicioners than "recommended" by Solucient (whoever that is), which contradicts MRF's earlier post about the precipitous decline in obstetricians and the doctors who are fleeing family practice and internal medicine because of the "low" pay. Personally, though, I wouldn't put too much faith in an OHSU study on physician shortages. I'm not saying they're wrong, but they do have a financial interest in making any shortage look at bad as possible.

MRF writes: If I accept your numbers as facts, then I come to the following conclusion, which is most definitely wrong: $421.6b / 567,000 physicians and surgeons = $742,504 as the average salary of physicians and surgeons in the US.

Correct, the $421 billion number has to include physician salaries as well as all other costs related to physicians. That's actually why I didn't use the $421 billion figure to come up with the savings that could be achieved through a $50,000 cut in physician pay -- I only used the number of physicians (567,000). As I said above, even if that number is grossly inflated and we only assume 30% of those are practicing (which is way too low), we can still achieve $7 BILLION in savings every year. As for the equity issues between specialties, I'm fine exempting primary care physicians, pediatricians, and OB/GYNs and just taking $100k from everyone else.

The point of this, however, is not to delve into a statistical analysis of health data, it's simply to point out that physician salaries total way over $100 billion every year. Even a small reduction generates enough savings to greatly expand coverage of the uninsured. I don't think physician salaries are driving the health care crisis, but I do think they're a contributing factor.

I think that the reduction of unnecessary procedures, by whatever means necessary, will produce a reduction in physician income as a direct consequence.

I actually think we've reached agreement because we both want to see a reduction in unnecessary procedures. You want to do it through changes to the way we handle malpractice issues, which will reduce the practice of "defensive medicine". I want to do it through paying doctors a salary, which will reduce their incentive to order more tests on which they make more money. Both will result in a reduction in physician income, and I think that's a good thing for the health care system.

Now, we just need to tackle those damn hospital charges, drug company profits, and insurance overhead.

Miles:

I don't know what your qualifications are to discuss health economics, but I'd suggest that aside from your ability to cite a bunch of numbers and make a bunch of silly inferences from them, you don't have a clue what you're talking about. You just don't "cut salaries of any group of practicioners" by $100,000 annually. How would you do it on my wife's group where salaries are unrelated to the number of procedures they do? How would you do it in the scores of doctors like dermatologists and plastic surgeons who don't make much, if any, from insurance; virtually all their money comes directly from patients' pockets? How would cutting salaries improve access for patients?

Unless you propose nationalizing doctors, which isn't part of the Canadian model and isn't obligatory in the UK, what mechanism would do this?

Your views, which are constructed out of the ether of a few facts, don't follow logically from those facts.

Your argument has such fundamental flaws that it would take me an hour's worth of writing to begin to refute it thoroughly.

So, what IS your background in this area?

Miles continues:

"I actually think we've reached agreement because we both want to see a reduction in unnecessary procedures. You want to do it through changes to the way we handle malpractice issues, which will reduce the practice of "defensive medicine". I want to do it through paying doctors a salary, which will reduce their incentive to order more tests on which they make more money. Both will result in a reduction in physician income, and I think that's a good thing for the health care system."

Well, sort of. The problem is few specialists order any procedures. The origination of orders for extra procedures come from primary care. Federal law forbids doctors from the kinds of conflicts of interest in which an individual doctor can profit by ordering extra procedures. This does not stop doctors in one area to form a corporation that owns all the equipment for another speciality, such as radiology. The radiologists in fee-for-service get reimbursed by the number of studies they do, but they are not doing the referrals and have no direct or indirect control over the referrals.

Unless you are willing to get into the area of changing the structure of corporate law, partnership law, LLC law, you'd have no possibility of controlling doctor's income by forcing them to be salaried. Not in the US; actually not in very many places in the world. You'd have to do this for lawyers, engineers, CPAs, physical therapists, architects and any other business that can incorporate, form partnerships and pay partners WHATEVER THEY CHOOSE based on the volume of business.

It is utterly naive to think that you can force doctors to receive a "salary" as a means of reducing their salary. This is unheard of in this country, and singling out doctors and trying to force them onto a salaried basis rather than profit sharing, is much the same as trying to reduce housing costs by forcing realtors to be on salary.

This is such a silly, impractical idea that I don't know what you're thinking when you propose this.

My idea, which is quite manageable and doable - although politically challenging - could accomplish nearly the same thing without getting into such ugly territory that has no chance of ever happening, nor does it need to happen.

Thinking "outside the box" doesn't get you where you want to go here.

And, of course, even assuming your idea were remotely possible, you haven't addressed the massive disruption in accessibility to doctors that would be created by such a move. You know nothing of physician demographics, by type of practice, specialty, or anything. You don't know anything about medical school demography, residency demography. All of these factors would need to be taken into consideration to see if there is sufficient depth in the pipeline to cover the very large number of physicians trained in the 70's and 80's who could retire at almost any moment if pushed into it by a proposal like this. Their retirements are certain. Try to imagine what my wife's practice (45 radiologists with 4 open positions), would look like if 15 radiologists at or near retirement age (my wife included) suddenly decided to retire next week in the face of a $100,000 per year mandated salary cut. The workload, which right now is nearly unsustainable being down 4 hard-to-fill positions, would become impossible if her group were suddenly down 19 positions. There simply aren't enough radiologists in the pipeline to fill those positions. Reduction in demand might come, but not without tort reform; without that, demand continues to increase nearly exponentially.

As I asked in an earlier question, what IS your background aside from being an interested consumer of healthcare?

So, what IS your background in this area?

MRF, it sounds as though you're trying to turn this into a discussion about me, rather than about the American health care system. I hope that's not the case, and I would ask that you focus on what I'm writing, not on whether my qualifications make me "worthy" of your time. That said, I have a graduate degree in health policy and I spent six years as a career (read: nonpartisan) health policy analyst at the White House budget office, four years under Clinton and two years under Bush. So I'm pretty familiar with health economics and federal health policy.

You just don't "cut salaries of any group of practicioners" by $100,000 annually. How would you do it on my wife's group where salaries are unrelated to the number of procedures they do?

Let me first just point out that you're moving the goalposts. This started as a discussion as to whether physician salaries should be "on the table" when talking about health care reform. You wanted them off the table, I didn't. Now, you agree that they should be on the table, but you're attacking the lack of policy specifics in my posts. I'm happy to go there, but it's a different discussion than the one we've been having. In general, the issues you raise about access and demographics and the aging workforce all need to be addressed, but it's foolish to think we don't have the capacity to do something about it. And it's also a strawman to assume it needs to be done all at once. Policy changes could easily be phased in to result in a reduction in physician costs over a 10-year period.

As a general comment, MRF, you seem to be under the impression that there is a health care marketplace that operates under normal laws of supply and demand. Nothing could be further from the truth. Besides the fact that the prerequisites for a free market don't exist, doctors also receive a huge percentage of their fees from government programs, which include price controls. This is where conservatives get it wrong when it comes to health care: this isn't the government inserting itself into the market, this is the government appropriately regulating a non-competitive market.

Federal law forbids doctors from the kinds of conflicts of interest in which an individual doctor can profit by ordering extra procedures.

Please cite the federal law you're referring to, because this statement doesn't make any sense to me. Doctors order additional tests and procedures in their own offices all the time, and they bill for those, thus making more money. One issue that's driving cuts in the Medicare physician fee schedule is the increased utilization as a result of past cuts. Essentially, doctors are compensating for reduced Medicare payments by ordering more tests, most of which are medically unnecessary. This is pure profit motive on the part of doctors and may even result in worse outcomes.

Since you asked about my personal qualifications, let me ask you: Do you have any health care experience outside of your marriage to a doctor? Does your interest in protecting the outrageous salaries of physicians have anything to do with the good of society, or is it just to protect your own personal wealth?

miles writes:

"Since you asked about my personal qualifications, let me ask you: Do you have any health care experience outside of your marriage to a doctor? Does your interest in protecting the outrageous salaries of physicians have anything to do with the good of society, or is it just to protect your own personal wealth?"

I have a BS in statistics, MA and PhD in Biological Anthropology. I've taught in medical schools, training medical students to understand gross anatomy. I've done medical research and have 5 publications (jointly with many others) in a variety of medical journals. At the end of my career I did a lot of training of forensic scientists and chaired two academic departments at PSU.

Your experience tells me that you know "policy" but you don't understand practice. My personal connections to my wife give me insights into the actual "practice" of medicine at the street level. Health policy analysts and politicians can "study" this problem to death, but the acid test of any successful policy will be to get those on the delivery end of whatever you design to buy in. They don't take kindly to being singled out as A cause of the health care crisis. Most doctors are working damn hard and making decisions you'll never have to make.

Again, the people ordering the tests are the people down in the trenches doing primary care. Virtually all specialists order NO studies; they're the ones doing the surgery or studying the lab work, or the biopsies, or the images.

You've got your layers all mixed up in your analysis. Aside from being a health policy analyst in the Clinton White House, have you ever spent a full week shadowing a primary care physician in a large multi-specialty practice ? In the Clinton years you might have been able to do this pre-HIPPA (a monstrosity that has added incredible layers of cost to health care delivery even though its purpose is noble).

You may understand the abstract economics of medicine, but medicine is a really concrete thing when you involve the doctors as providers.

The doctors object to any substantive change because they think that policy wonks like you have their heads up their rear end. That studying numbers and reports has no relationship to the actual day-to-day workings of medical care. You're like backseat drivers with no feel for how the car is handling. You want the car to drive the way you think it should drive theoretically or based on some objective target you've set, but you don't actually know anything about any specific car.

I have a hard time taking you seriously because everything you're saying is so completely alien to the type of practice my wife is in that it doesn't compute for me. My wife makes a salary (fixed) with a few ways of making extra money for handling duty outside regular office hours and when the workload gets so great that they start having to put on extra clinics and pay rads extra to cover the backlog.

You act as if DOCTORS are driving demand of medical care. There may be some actors who do this in fee-for-service practices, but that type of practice is on the decline in the west; unfortunately not in the NE or SE, and varies widely through the midwest - least in places like Minneapolis/St Paul and greater in Chicago, Cleveland, etc.

You've not presented me with any evidence that doctor's salaries are outrageous, any more than lawyers' fees are outrageous, or realtors' fees are ridiculous. Saying something doesn't make it true. There is a risk/reward equation that makes doctors work valuable. If you don't think it merits the remuneration, have that discussion with your specialist or PCP. See whether they agree with you. They won't (or they're among the small group of near-retirement "commies" as they're called who happily take the salaries they're getting while complaining that doctors are overpaid, and actually writhing in pain if their salaries aren't increased annually for the "increases in the cost of living". In short, most doctors you argue that doctors are overpaid are hypocrites and wouldn't themselves accept a pay cut under any circumstances. We've seen this in my wife's group. The last "commie" died about 6 months ago in her group. Now there's an opening for a new radiologist who will probably enter the practice with anywhere from $150,000 - $300,000 in medical school debt and ain't the least bit interested in accepting a salary that less than the market median, and a signing bonus (because radiologists are in slightly short supply right now), and moving expenses 9 months from now.

You ascribe motives to doctors that deeply offend me. You imply that doctors order tests purely for profit. I can't speak widely on this subject, but I certainly that in my wife's group, it doesn't happen because compensation isn't structured that way.

So, you can accuse me of changing the goalposts, but my point has been consistent all along. Remove the necessity for practicing defensive medicine - this arises from tort reform. The effect of this is that many practices will be able to cut utilization dramatically and free up time and money that would enable them to care for more patients at lower costs. Obviously this isn't true for all practices, but I don't think you have any way of controlling that without getting deeply into corporate law, LLP formation, parternship agreements, and other arrangements that doctors (and lawyers and realtors and engineers and architects and on and on and on) use to structure their practices. To go after doctors and not any of the others is discriminatory.

Why isn't the number of malpractice cases filed, the number of trial lawyers, and the total amount of claims paid out in medical litigation figured out. Perhaps we should cut the salaries of trial lawyers too.

To be perfectly honest, my defense of doctors' salaries come from the good of society. My wife is too close to retirement for this to matter to her anymore. Our personal wealth is secure, our children grown, colleged, and married with outstanding jobs outside healthcare, and frankly we could "give a shit" what happens in ten years. I'm not trying to protect our personal wealth because the crap you're talking about wouldn't affect us one way or the other. But it will affect society unless society is willing to accept a whole bunch of other tradeoffs that will not generally be acceptable to get to your goal.

I want you in the examination room when the doctor says to a patient: you know, we can only do an x-ray of your knee because we aren't allowed to refer you for an MRI because it is too expensive and we don't want to prop up radiologists' salaries too much. So instead, we'll take this pretty ole picture which might tell us what's wrong with your knee. This means we'll be giving you aspirin or tylenol or ibuprofen because we can't enrich our orthopedists either. They would just do surgery to fix your knee. Your knee will have to heal the way nature intended it to. And when the patient starts shreiking at the doctor at 140 dB, I want you there to explain why these kinds of changes are needed and why all of society will benefit from her sacrifices. It will only hurt if you laugh.

Sorry. You may be a good health economist, but you're a lousy study of the actual practice of medicine.

Miles asks:

"Please cite the federal law you're referring to, because this statement doesn't make any sense to me. Doctors order additional tests and procedures in their own offices all the time, and they bill for those, thus making more money. One issue that's driving cuts in the Medicare physician fee schedule is the increased utilization as a result of past cuts. Essentially, doctors are compensating for reduced Medicare payments by ordering more tests, most of which are medically unnecessary. This is pure profit motive on the part of doctors and may even result in worse outcomes."

I will cite the statutes as soon as I can locate them. They appeared in a lengthy memo to my wife's group after they were passed by congress.

You make out that doctor's are crooks, a truly offensive idea. You make out that doctors' have conflicts of interest, an equally offensive idea. Sure, there are a few rotten apples in the barrel, but to swath tar over the entire medical generalization as odious as yours is offensive in extremis. But even if it occurs far more frequently than you suggest, you have no authority or control of how partnerships treat their group income, any more than you have any control over how baseball teams divvy up their profits at the end of the year, how lawyers divide up the spoils after winning a big case, how architects cream off the pot after charging the city of Portland a fortune for designing the tram. The list could go on forever.

For a progressive, you sure are a discriminatory bastard. Doctors: public enemy number one! You've probably got this poster on your wall. Kill a doctor, claim a prize.

The fact that you were a health policy analyst with the Clinton administration helps me better understand why no reform came out of that administration. That you stayed on with the Bush administration for awhile explains why the issue has died a slow death. What part of the message: you are barking up the wrong tree don't you understand? What part of 92% of the costs of health care don't come from physician billing.

As I've said repeatedly and I'm not going to back down, you're a policy wonk. Policy wonks don't have a clue about how the game is played: they've got no skin in the game. Until you have personally participated in the delivery of health in the US, you have, in my mind, no idea what goes on where the rubber meets the road. When you've spent some considerable amount of time in and around doctors and their patients and their patients families and everyone's demands, you have no right to sit back and pontificate about how wholesome it would be if we just took a knife and stabbed it in the back of all specialists by rigging the system to result in a $100,000 salary cut mandated by the government. You'd obtain savings all right, but at the cost of a significant decline in the number of doctors willing to practice under those circumstances.

Bottom line: as long as doctors are expected risk their life and livelihoods everytime they deal with a patient in the current environment, they are entitled to every penney they're currently making.

Doctors: public enemy number one! You've probably got this poster on your wall. Kill a doctor, claim a prize.

This is sort of over the top, isn't it? Look, Mr. Fearless, my only point throughout this discussion is that true health care reform is going to require sacrifices from all those who profit from our current, broken system. That includes hospital administrators, insurance execs, drug manufacturers, patients with cadillac health plans, and doctors. That's my point, nothing more, nothing less.

You act as if DOCTORS are driving demand of medical care. . . . You ascribe motives to doctors that deeply offend me. You imply that doctors order tests purely for profit.

Of course they do -- you've already agree with me that doctors drive utilization! Your entire argument about tort reform and defensive medicine is based on the notion that doctors control at least some health utilization. If doctors didn't have the ability to order unnecessary tests, your argument falls apart. The fact is, they order these tests for defensive purposes, and also for profit purposes. I'm not saying this means they're evil, it just means they're human. Why do doctors ask patients to come back to the office in 2-3 weeks for a follow-up for a minor ailment, rather than call them and see how they're doing? Because if they come in, they bill for another $90 consultation.

You're a policy wonk. Policy wonks don't have a clue about how the game is played: they've got no skin in the game. Until you have personally participated in the delivery of health in the US, you have, in my mind, no idea what goes on where the rubber meets the road.

The irony of this is that it could be written by any major health care stakeholder. I've heard the exact same argument from drug companies (after all, they provide miracle drugs that save peoples lives), hospital execs (after all, they save peoples lives every day), and insurance execs (after all, they provide security and protection from financial ruin to millions of Americans). Should we really let doctors, drug companies, hospital execs, and insurance companies make decisions for the rest of us about our health care system? Of course not. We need to talk to them, take notes, and then make an objective decision about the best path to take, regardless of who the winners and losers are.

Bottom line: as long as doctors are expected risk their life and livelihoods everytime they deal with a patient in the current environment, they are entitled to every penny they're currently making.

This is a truly radical position: Doctors are entitled to however much they make, regardless of the impact it has on society. Bullshit. You fail to see the moral implications of your position, which is that millions go without health care so that doctors can take in $200,000, $300,000, or $400,000 a year.

You've not presented me with any evidence that doctor's salaries are outrageous, any more than lawyers' fees are outrageous, or realtors' fees are ridiculous.

According to the Bureau of Labor Statistics, lawyers median salary is $95,000, and realtors median salary is $36,000. According to "career profiles" on the Princeton Review website, the average salary for a trial lawyer after 10-15 years is $127,000. Once again, median salary for doctors is over $200,000. I challenge you to find another profession, outide of professional sports, with that kind of median salary -- not just a few at the top who make millions, but where the top 50% of the profession are in the top 1% of income earners.

I've said before that there are other sectors of the health care industry that I would go after first. But if you think we should exempt doctors from our reform efforts, then you're not very serious about reform.

One additional point:

I would also refer you back to an earlier post where you talked about increasing personal responsibility for one's health and health care. I couldn't agree more. But let's be honest. . . if people had an incentive to pay more attention to their health care, they would certainly not pay doctors what they're getting paid. The reason doctors rake in the salaries they do is because very few directly pay for services. If we really had a free market, doctor salaries would plummet because there is no way I'm paying $120 for a 10-minute office visit to look at a sore throat that I've had for a week, plus another $60 for a strep culture. If people actually had to pay that amount, doctors would either drop their fees (and their salaries) or the public would demand that nurse practicioners and other "lesser" providers be allowed to do most of the primary care that is now currently done by doctors. Thousands of docs would be out of work in a heartbeat.

re: salaries of doctors. PCP physicians order 90%+ of all tests. They are the lowest paid physicians of all. Specialists do the tests and make the money. No doctor I know, and no practice I'm familiar with, gets kickbacks from the specialty groups for referring patients for the specialists services. Every doctor I've talked to who's in PC tells me quite earnestly that they'd gladly give up ordering many unnecessary tests if they didn't have to be concerned about tort liability. They would also be far happier to be able to exercise their training more by spending more time per patient and seeing fewer patients in a day. So if PCP make up 70% of all doctors and they are the gatekeepers for patient care, and they are the one's whose butt's are exposed in the first instance for a bad outcome (as are all the doctors in the chart related to the whatever litigation the patient's contemplating or filing), how exactly do we get to fewer unnecessary tests EXCEPT by removing the exposure to unnecessary malpractice litigation? Cutting the salaries won't do it (oh wait, you've exempted those guys/gals so we have 70% of physicians immune from your remedy, and we'll focus on the 30% of the bad guys who actually order few or no tests because they don't see patients without referral from PCP).

I don't think any doctor I know would care one iota if patients took personal responsibility. They would sing for joy at the reduction in unnecessary office visits. But you'd have to change the nature of the relationship between nurse practioners and physician assistants and untether them from supervision by primary care physicians because none of them can write prescriptions without physician endorsement. That's both state and DEA law.

We're not that far apart. You want an outcome that I don't disagree with except for the mechanism. I see plainly and explicitly imposing cuts on doctors salaries as discrimination against one profession to the exclusion of all other professions that earn their living in related ways. I'm saying that the by product of making another change in the way medicine in practiced will achieve the result you're looking for without making doctors "a target" directly.

As for doctors going out of business in a heartbeat, you might be right, but for all the wrong reasons. The one's who are holding 6 figure debt and upfront practice costs will be forced to stay; those large numbers of docs who earned their degrees in the 70's & 80's are close enough to retirement that they can walk away and continue to draw retirement benefits, and work part time whenever cash is a bit short as a "locum tenens". What will really happen is that the training of future doctors will take a nosedive and when current doctors retire, there will be fewer and fewer physicians trained to take their places. And that will, in turn, drive salaries back up and the demand will exceed the supply.

I hope you never have a serious illness that requires the attention of multiple specialists.

Me, I hope I die from a massive stroke, or a massive coronary infarction. The place I'm most scared of is the hospital - not the doctors - but everyone else. And that I know from first hand experience - both mine and my wifes. And all these experiences were in what anyone would regard as the A+++ premium facilities. If these are that bad, god help us what less compensated facilities get. It is really frightening in there.

We're not that far apart. You want an outcome that I don't disagree with except for the mechanism.

Agreed, we're looking at the same end goal but with different ways of getting there. I actually hope Blue Oregon has a post sometime on tort reform and medical liability issues, because it's an issue where I think progressives could really move the ball forward. I'm sympathetic when I hear the complaints about malpractice insurance premiums and the culture of fear that doctors live in when it comes to malpractice. At the same time, I have yet to see a tort reform proposal that's anything but a conservative attack on trial lawyers, who we all know support Democratic candidates. Most of the proposals are designed to shield doctors from responsiblity even for extreme cases of negligence.

One thing I'd like in return for any malpractice reform is the mandatory reporting of medical errors and mistakes by doctors and hospitals. If we're going to cap payouts or reduce premiums, the government should require health care providers to report all mistakes -- not to punish, but to learn from them and figure out ways to avoid them in the future.

Miles writes:

"One thing I'd like in return for any malpractice reform is the mandatory reporting of medical errors and mistakes by doctors and hospitals. If we're going to cap payouts or reduce premiums, the government should require health care providers to report all mistakes -- not to punish, but to learn from them and figure out ways to avoid them in the future."

You'll get no arguments from me there or any doctor I know. We just have to agree on what constitutes a "mistake" or "error" and we'd be in perfect harmony. We have to find a way to distinguish the "sponge left in after closing", from baby has epileptic seizure for no explicable reason. One is an error or malpractice, the other is a "bad outcome". Nurses giving a patient 1 gram of a drug where the order is for 1 milligram is a big error. A patient being given Dilaudid when the chart explicit says in big handwriting, NO DILAUDID, is a medical error caused by nursing staff or tired residents (this actually happened to my wife. Without my tireless advocacy, my wife would have been institutionalized rather than getting the correct pain medication). We didn't sue, but a team of nurses and residents found themselves on the receiving end of a nasty tonguelashing from me.

I'm glad that this thread has continued.

Miles: Why do doctors ask patients to come back to the office...

Most physicians want to follow up with you if they prescribe a new medication or after a change in lifestyle. I've never been to the doctor suffering from a minor condition (allergies, cold, infection) and had him ask me to schedule a follow up appointment...only if I'm not doing better after a few days or I have an adverse reaction. Some good medical practices will actually have an NP or PA call a patient a couple of days after a visit to follow up. I guess I just don't see doctors as money-grubbing SOBs...I mostly see them drying to serve their patient's needs.

...have yet to see a tort reform proposal that's anything but a conservative attack on trial lawyers

I don't think that all the proposals out there are attacks on trial lawyers. What about a pre-screen panel? What about a semi-governmental physician's liability pool (i.e. like SAIF)? What about liability protection of physician's personal assets? Trial lawyers currently hold all the cards (at least in Oregon where we have almost no protections for doctors). Unfortunately, it's a win-lose situation for lawyers-doctors, and as a result we haven't gotten any reform in Oregon. As a Democrat I hate to say it, but with trial lawyers as significant funders of the DPO (and with the Gov as a former trial lawyer)...I just don't see tort reform coming anytime soon.

the government should require health care providers to report all mistakes

As for reporting, Oregon already has launched a voluntary system of reporting medical errors and adverse outcomes called the Patient Safety Commission. It's only been up and running for a little over a year, so I think we need to give it some more time before we consider making it mandatory. Plus, I guess I'm a little confused by what you think making reporting mandatory will do? Act as a fuller resource for peer-review? or act as a central database for trial lawyers to sue the pants off doctors?

I guess I'm a little confused by what you think making reporting mandatory will do? Act as a fuller resource for peer-review? or act as a central database for trial lawyers to sue the pants off doctors?

Mandatory reporting is probably only possible if we first put malpractice reforms into place. It's a quid pro quo: We insulate you from excess liability, you agree to report all mistakes and errors.

Such a database would be hugely beneficial to improving care. Most (but not all) medical errors can be corrected through better safeguards and processes. For instance, requiring two people to sign-off on the amputation marking, or anti-bacterial hand wash in every room, or mandatory rest periods for staff working over 10 hours. The problem is that hospitals are so afraid of malpractice suits, they try to correct mistakes internally. If hospitals could share information more freely on a community-wide or regional basis, they could more easily compare best practices, figure out which safeguards really work and which don't, and probably save lives.

The Democrats need to focus their attention on some short term remedies that can begin to decrease the costs of some of the drivers of health care.

We're too far behind the rest of the world for that. If death rate is any indication of the quality of a health care system, we pay more to die younger than over 40 other nations.

So with an eye on outcome, let's design a health care system that seeks perfect health for everyone. It will be very easy to tell how well we are doing - everyone's health will be considered and accounted for in our quest.

My wife and I haved worked as hospital nurses a combined 40+ years. I lived in Canada for 6 years, and my wife lived in Holland for 25 years. This is what I know to be true:

(1.) No one either of us has ever met in Holland or Canada has told us that they would prefer the medical system of the U.S.

(2.) We both stopped working in acute care in the U.S. because our increasingly for-profit system is dangerous for patients and for health care workers.

(3.) Most of the doctors I worked with were honorable and hard working. The pressures they endured were unbelievable. If anyone deserves to make $200,000 a year, it's doctors, and primary care physicians need a raise, for sure.

(4.) We need single-payer, universal, non-corporate health care now. There are all kinds of ways to do this, including many of the suggestions offered on this thread. There is no reason to assume that educational expenses, malpractice schemes and location bonuses can't be a part of this, and arguments to the contrary are irresponsible.

(5.) Single payer systems can be set up to create policy boards that require outcome-based research, thereby continuously refining medical practice in ways that raise our poor current outcomes and decrease costs at the same time. The idea that insurance companies are necessary for this is ridiculous.

(6.) Like Mitt Romney's and Arnold Schwartzenegger's plans, Wyden's gift to his corporate buddies aims to provide a cash cow for the insurance industry. Wyden's proposal actually requires employers to terminate their existing health coverage, destroying the employer-provided insurance system with nothing to replace it.

(6.) Sign up for Dr. Don McCanne's (Physicians for a National Health Program) "Quote of the Day": http://two.pairlist.net/mailman/listinfo/quote-of-the-day

Dr. McCanne answers all of the claims of the health industry trolls who have been jamming this thread.

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