Government Intervention in Medicine

[FM75]

Background

My mother is very ill. I took off work today, to leave to visit her in a senior rehab center, a 90 minute drive for me. The medical and family issues involved are not relevant. But her condition, and the information available to her family caused my brother, a board certified endocrinological surgeon, to cancel his appointments for the rest of the week, and begin a 5 hour drive yesterday to visit her as well. His concerns were that the care and the information we had gotten from our brother and sister-in-law (RN and newly licensed LPN) did not really make sense - details irrelevant to this post.

 

Government Intervention and Background

I have no medical training other than basic first aid and some self instruction on wilderness medicine. My brother has not only practiced medicine, but he taught medicine as a professor in a university, and also has had a management role in surgery at a VA hospital. He is reasonably computer technologically savvy - for an MD - maybe even for anyone not in computer software industry.

 

Does this scare you?

Given his VA background, it was natural that at some point today, we had time to discuss something other than the medical issues facing our mother. He no longer works in the VA, but I asked him about what his take was with the current controversy (for lack of a better description). He allowed that it was common practice - eventually - that the policy of a time limit between request for treatment and actual treatment, led naturally to a distortion of reality. Patients with a complaint, for which the backlog exceeded policy, would have "delayed entry" into the system. This mechanism, via "political natural selection", became widely known, and in his opinion was likely "universally practiced". He also mentioned that there were delays, in some cases, due to patients not being able to meet on the scheduled (perhaps delayed) dates. So far, this may seem like a management problem? To be fair, this practice became well known to the top level management of the VA.

 

It gets worse

The VA had a computerized system built in the early 90's to track patient histories. It was DOS based (most bridge players used computers in that era). It eventually was DOS running under Windows. This version did not really get any "smarter". But it gets still worse (IMO and his). The VA decided that they needed extensive data. They mandated that all of the doctors in the system get "training" for analyzing possible mental issues - psychological and social. They also required counseling on smoking cessation, drugs, and even what firearms the veterans had in their homes (I am not making this up!). This training was not specialization specific. For example, the same "course requirements" existed for surgeons, family practitioners, etc. So there was not a 30 minute course for surgeons on smoking cessation, and a longer course for GPs, etc. Darwin and government got the expected result. Soon the "test answers" became well known.

 

It ain't just the VA

Once the lawyer/regulator gods got the religion, it started leaking into Medicare. HIPPA - originally all the data was aggregated - in compliance, of course, with regulations prohibiting personally identifiable information. The next step is auditing, by the government,. the information provided. Can you audit without personal information? Now the whole idea is moving into medicare. Does a surgeon who operates on organs in the endocrine system have the time to counsel on smoking cessation - to check that box to get reimbursed? Is the ownership and possession of firearms, by individuals presumably highly trained on how to use them by our government, germane to surgery on their thyroids?

 

Opting out

Unsurprisingly, you can expect doctors to "opt out" of medicare. At the VA, a doctor could only treat 12 patients in an 8 hour day! Even if it were not financial, would you want to limit the use of your expensive knowledge and expertise to treating only 12 patients per day (40 minutes per patient) because of paperwork?

[mike777]

"

Unsurprisingly, you can expect doctors to "opt out" of medicare. At the VA, a doctor could only treat 12 patients in an 8 hour day! Even if it were not financial, would you want to limit the use of your expensive knowledge and expertise to treating only 12 patients per day (40 minutes per patient) because of paperwork

 

Sure why not? I have a family, I have love ones, I am getting older, I love bridge, choices...and I get to spend 40inutes with patients including computer time.

 

 

Either you want open competition or you don't.

 

----

 

 

btw what docs work only 8 hours a day?

 

As some point I may need to hire a smart computer, clerk type guy/gal to handle the computer stuff. I know my local doc does. fwiw my local doc also has hired a super nurse to handle much of my routine illness stuff, she is great and I love her. She follows up with phone calls, etc. She has some sort of fancy nurse title and is great.

[barmar]

I think it's been at least 5 years since I've talked to the actual MD at my GP's office. I think it's always a Nurse Practicioner or Physician Assistant. But I haven't been there for anything serious, just annual checkups and minor aches.

[hrothgar]

Few quick comments:

 

1. I don't understand the supposed relationship between the amount of paperwork that needs to be collected and the number of hours that Doctor's have available to see patients. I was just down at my Dr.s last week for an annual physical. The person signing me in wasn't the phone checking me for a hernia.

 

2. It's well documented that the highly privatized US system provides a worse quality of care at a higher cost than virtually any other developed country. FWIW, the government run VA system is typically rated at providing much better care than the private market. (The current scandals involving the VA involve wait time rather than care once people enter the system).

[blackshoe]

When I first started going to the VA for medical care, ca. 1996, the VA hospital in Buffalo was rated one of the top ones in the VA system. Now it seems to be fifth from the bottom. Of course, I don't know how such things were measured, then or now. I do know that I've had good care from this VA region (the hospitals in Buffalo and Canandaigua and the clinic here in Rochester) - although in the last year or so they seem to be having trouble scheduling me for a colonoscopy and letting me know when it will be. And changing an appointment, or getting in to see the doctor when you don't have one, is virtually impossible, but I doubt that's unique to the VA.

 

The one thing that does bother me about VA policy has to do with the walk-in bit. Basically we're told that if we need to see a doctor, and we don't have an appointment, to go to an Emergency Room. Not why they're there, is it? :(

 

I don't know how many hours he normally works, but the last time I saw my (VA) doctor, about six months ago, he looked like he hadn't slept in a week.

[Cthulhu D]

It makes total sense for doctors to ask their patients about smoking, this has been effective at making people stop smoking, which in turn is a highly successful healthcare measure.

 

Really the only thing that can happen with government intervention in healthcare is that it becomes cheaper and less poor people die. See: Every wealthy OECD country vs the US.

[mike777]

It makes total sense for doctors to ask their patients about smoking, this has been effective at making people stop smoking, which in turn is a highly successful healthcare measure.

 

Really the only thing that can happen with government intervention in healthcare is that it becomes cheaper and less poor people die. See: Every wealthy OECD country vs the US.

 

 

 

If true you make a powerful case.

 

 

The concern is that govt healthcare inhibits innovation and creativity. That central govt control of health care inhibits competition which leads to stagnation. The concern is govt health care does not allow for failure and competition to replace failure.

 

Again if your main points are true you make a powerful case.

[Winstonm]

If true you make a powerful case.

 

 

The concern is that govt healthcare inhibits innovation and creativity. That central govt control of health care inhibits competition which leads to stagnation. The concern is govt health care does not allow for failure and competition to replace failure.

 

Again if your main points are true you make a powerful case.

 

Mike,

 

I think you are misguided in thinking that innovation and creativity is stifled by government because of lack of competition. Innovation and creativity are not products of a desire for profit and riches but of the interest and imagination of innovators. Production of an innovation, on the other hand, is a choice of profit/loss and can be aided or hampered by lack of competition.

[barmar]

I think you are misguided in thinking that innovation and creativity is stifled by government because of lack of competition. Innovation and creativity are not products of a desire for profit and riches but of the interest and imagination of innovators. Production of an innovation, on the other hand, is a choice of profit/loss and can be aided or hampered by lack of competition.

 

What's your point? If a guy living in a cave has an idea that can cure cancer, it does no one any good. For all practical purposes, innovation and creativity must be considered to include the ability to turn it into a product.

 

Furthermore, creativity doesn't generally happen in a vacuum, especially in medicine. You have to do experiments, or run simulations, etc. to work your way towards solutions. This is expensive, so you can't even begin to innovate without substantial financial backing.

 

All you seem to be saying is that he chose poor words, not that what he clearly meant was wrong.

[Winstonm]

What's your point? If a guy living in a cave has an idea that can cure cancer, it does no one any good. For all practical purposes, innovation and creativity must be considered to include the ability to turn it into a product.

 

Furthermore, creativity doesn't generally happen in a vacuum, especially in medicine. You have to do experiments, or run simulations, etc. to work your way towards solutions. This is expensive, so you can't even begin to innovate without substantial financial backing.

 

All you seem to be saying is that he chose poor words, not that what he clearly meant was wrong.

 

Profit and competition are not the only driving forces of human activities. Money is needed for R&D, but whether that is venture capital or collected taxes is of less importance than basic human curiosity.

[barmar]

Profit and competition are not the only driving forces of human activities. Money is needed for R&D, but whether that is venture capital or collected taxes is of less importance than basic human curiosity.

 

We're talking about medicine. You can be as curious and creative as you want, you're not going to create any useful drugs or medical procedures without boatloads of money supporting you. It has nothing to do with the profit motive or competition, you simply can't do it because it's too expensive to turn an idea into a reality.

 

In the modern world, there's no medical equivalent of Facebook, Google, or Apple -- where a couple of guys with a clever idea create a solution in their garage or dorm room. This kind of thing happened occasionally a century or more ago, but now it's a practical impossibility.

[Winstonm]

We're talking about medicine. You can be as curious and creative as you want, you're not going to create any useful drugs or medical procedures without boatloads of money supporting you. It has nothing to do with the profit motive or competition, you simply can't do it because it's too expensive to turn an idea into a reality.

 

In the modern world, there's no medical equivalent of Facebook, Google, or Apple -- where a couple of guys with a clever idea create a solution in their garage or dorm room. This kind of thing happened occasionally a century or more ago, but now it's a practical impossibility.

 

Take two of the welathiest entrepreneurs in the world who know nothing about medicine or science, lock them in a laboratory for 20 years and you will come up with no new medicines.

 

Of course it takes money - but competition and profit are not the driving forces of invention and investigation.

[mike777]

Mike,

 

I think you are misguided in thinking that innovation and creativity is stifled by government because of lack of competition. Innovation and creativity are not products of a desire for profit and riches but of the interest and imagination of innovators. Production of an innovation, on the other hand, is a choice of profit/loss and can be aided or hampered by lack of competition.

 

 

Ok, clearly we strongly disagree. I prefer the word inhibit but stifle is a cute word that Archie Bunker often used.

 

Lack of competition and I prefer the word incentives but profit is a fair word.

 

In any event I put forth this issue is crucial and colors both of our worldviews.

 

I hope at least we both can agree that humans can and are motivated and have incentives other than money, but money is a really huge thing. Ego/fame/praise and competition is a really huge thing. Then there are true saints.

 

---

 

"Of course it takes money - but competition and profit are not the driving forces of invention and investigation."

 

I strongly disagree but that is ok.. May we define profit as more much more than simply cash. For example lots of, ego, fame, praise...etc.

 

With that said sure creativity in some may simply be the only way to a pleasure in life. Not that they may still appreciate a Nobel Prize.

 

My point remains that central control inhibits innovation in favor of protecting the status quo, in protecting stability and that leads to stagnation.

[mike777]

In rereading my above post I should add a crucial feature and that is failure.

 

Free markets must allow for failure. This is a big issue since companies wont eat their children and then they fail. Central governments in general don't allow for failure. They won't allow the VA to fail.

 

Of course hopefully we keep failures as something that is often but cheap and fast.

If we don't fail often, we are not trying hard enough.

[mike777]

We're talking about medicine. You can be as curious and creative as you want, you're not going to create any useful drugs or medical procedures without boatloads of money supporting you. It has nothing to do with the profit motive or competition, you simply can't do it because it's too expensive to turn an idea into a reality.

 

In the modern world, there's no medical equivalent of Facebook, Google, or Apple -- where a couple of guys with a clever idea create a solution in their garage or dorm room. This kind of thing happened occasionally a century or more ago, but now it's a practical impossibility.

 

"It has nothing to do with the profit motive or competition"

 

 

You guys don't really say what are the drivers of innovation or creativity.

 

 

wE DISAGREE STRONGLY

 

ok clearly we disagree I choose the word competition. fwiw I think profit motive and competition and a culture that thrives on failure are 3 keys...the important keys.

Edited June 2, 2014 by mike777

[Winstonm]

You guys are smart but have your heads buried within the confines of a free market ideologically based belief system. It causes you to conflate money with motivation. But making money and spending money are side effects of human activities, not the driving force behind those activities.

 

But when a family of four buys tickets to Disneyland, their goal is not to spend money. Likewise, the creation of Disneyland was not driven by Walt Disney's desire to earn money - the money was a side effect of his dream to entertain children and adults alike.

 

Profit may be the motivation of the corporations who create new drugs, but that money-flow does not trickle down to the actual scientists, doctors, and technicians involved in the research, so profit is not their motivation.

 

The world cannot be resolved to winners/losers. The world is not black/white. There are millions who do not want to win at all costs, but simply want to lead a reasonable life with an interesting and meaningful occupation. For them, life is not about profit but about people.

[hrothgar]

ok clearly we disagree I choose the word competition. fwiw I think profit motive and competition and a culture that thrives on failure are 3 keys...the important keys.

 

Here's the rub: You seem to be assuming that the outcome you want (improving the health of US citizens) is aligned with (increasing the profits of the health care industry).

 

Sadly, rational profit driven private industries have determined that the most effective way to improve their profits is by denying service to individuals who try to use their services. (It's ever so much more efficient to take money from young healthy people and then terminate their coverage when the look as if they might get sick). In a similar vein, R+D on new drugs is incredible expensive. It's much more efficient to devote those same resources on ad campaigns trying to convince people that they suffer from "Low T". When those companies do engage in research, the bulk of this seems to go for the latest viagra follow-on rather than antibiotics.

 

FWIW, I have many of the same issues with school voucher programs.

 

Folks who are constantly promoting systems based on school choice always seem to assume that parents want to select schools based on the quality of their children's education when, in fact, their primary concern is making sure that their kids don't need to interact with "darkies"...

[Winstonm]

"It has nothing to do with the profit motive or competition"

 

 

You guys don't really say what are the drivers of innovation or creativity.

 

 

wE DISAGREE STRONGLY

 

ok clearly we disagree I choose the word competition. fwiw I think profit motive and competition and a culture that thrives on failure are 3 keys...the important keys.

 

There are many motivations other than money: curiosity, interest, intellect, a desire to improve others' lives, etc.

 

I find it interesting that the free market ideology seems to rely on the same modal logic flaw as Plantiga's ontological argument for god - a contigency converted into a necessity. I see this in the reasoning that individual motivations can and are the same as corporate motivations and thus, the conclusion is that profit, failure, and competition are the driving forces of individual actions.

 

But for this conclusion to be true, the internal consistency must hold that individual and corporate motivations are the same.

[barmar]

Take two of the welathiest entrepreneurs in the world who know nothing about medicine or science, lock them in a laboratory for 20 years and you will come up with no new medicines.

Conversely, put 10 of the smartest scientists there, and you won't come up with anything, either.

Of course it takes money - but competition and profit are not the driving forces of invention and investigation.

 

But it's a prerequisite to get anything done.

[barmar]

But when a family of four buys tickets to Disneyland, their goal is not to spend money. Likewise, the creation of Disneyland was not driven by Walt Disney's desire to earn money - the money was a side effect of his dream to entertain children and adults alike.

 

But if he couldn't make money while entertaining us, the park would go out of business, and no one would be entertained. So unless your creativity extends to bookkeeping, creativity by itself isn't enough to get anything done.

 

You could say that this isn't stifling creativity -- the creativity is still there, it just doesn't turn into a product. That's a "tree falling in a forest" argument, so who cares? I suppose it's a little better, since maybe someone with money could eventually run with the idea, so at least we got it out there. But in biotechnology, just figuring out if an idea is useful is usually prohibitively expensive. All you have prior to spending lots of money is some educated guesswork.

[Trinidad]

Conversely, put 10 of the smartest scientists there, and you won't come up with anything, either.

 

 

But it's a prerequisite to get anything done.

I think you are grossly underestimating scientists. Look at the scientists in most countries. Look at their accomplishments, their efforts (starting with sacrificing the first 10 years of their adult life in relative poverty, compared to their fellow countrymen with a regular job), and their salaries when they are recognized scientists (compared to the salaries of recognized entrepreneurs).

 

These people are not driven by money. They are driven primarily by fascination, and secondarily by a desire to improve the world.

 

If you put 100 scientists together for 10 years under one roof and give them a bed and 3 meals a day, they will get out after 10 years with innovative ideas, of which some can be used to improve the world.

 

If you put the 100 wealthiest entrepreneurs with their money together for 10 years under one roof and give them a bed and and 3 meals a day, they will come out after a month. 1 will be filthy rich, 49 of them will be poor and 50 will have died of starvation.

 

;)

 

Of course, to make scientists function well, they need to be facilitated with - simply said - money. (Or, if you want to see it differently: entrepreneurs need to be facilitated with scientists.) But, in principle, it is irrelevant where that money comes from: a private company or a government.

 

There are, however, good reasons to put medical research more into the hands of governments (or government organisations): It takes a very long time (10-30 years) to develop new medication or new medical treatments. This time scale fits much better with the time scale of governments (e.g. the EU with a budget period of 7 years) than with a private company that needs to show the results of the last quarter to its shareholders. Many companies don't even last 20 years, let alone that they can afford to put large amounts of money into an R&D project for 20 years before they might (i.e. not "will") see a return. Compare that to the development of a new car model, which takes a few years. That fits private enterprise quite well.

 

Rik

[StevenG]

These people are not driven by money. They are driven primarily by fascination, and secondarily by a desire to improve the world.

You're talking about scientists. The rest of the contributors to this thread are talking about American scientists. There is a difference.

[Trinidad]

I wasn't talking about a scientist of a specific nationality. But I think that my post above is even more valid for American scientists than e.g. European scientists. I got an MSc from the Netherlands and a PhD from a US university, so I think I can compare.

 

US grad students live in poverty. It is hard to get on a tenure track in the US... and the track is long (with many a winding turn). You need to love science a lot to go that road. It is better for corporate scientists, but their salaries are small, no tiny, compared to the managers.

 

In Europe scientists are better off. PhD students get a small, but decent pay and the difference in salary between scientists and managers is smaller.

 

Rik

[mike777]

edit

[helene_t]

US grad students live in poverty.

I thought Barmar's point was that pharmaceutical research needs money for all the other costs (lab equipment, reembursement of healthy volunteers in phase I trials, etc) rather than that the scientists themselves necesarily need big carrots. But maybe I misunderstood.

 

From my experience, working with largely govenment-funded medical research (but sometimes in colaboration with pharma or charities) in UK, NL and DK, I would say that the resource waste is enormous, and that it stands in sheer contrast to the very efficient patient care which paradoxaly often takes place in the same institutions. Read "The truth in small doses" to see why. While a small for-profit company has a clear objective (to make money) and the care departments at a hospital have a clear objective (to make the patients healthy), it is really hard to identify the raison-d'etre of a goverment-run medical research facility. Something like obtaining grants for doing more research, and to publish papers so that we can get more grants, and to breed PhDs so that they can apply for grants as well when they grow up? It sounds a bit circular. It is rare that I get involved in a project that, even with some imagination, has the potential to advance science and/or patient care. And even when it does happen, the slow pace of the apply-for-grants-get-rejected-reapply-do-research-submit-paper-get-rejected-resubmit-apply-for-new-funding cycle means that we always run out of momentum before we deliver anything: the technology we work with gets out of date, key workers get children, key workers move abroad to advance their carrere, key workers reach retirement age.

 

I am not sure what the solution is. The pharmaceutical industry isn't necesarilly better at serving society than we are - while they occasionally invent drugs that actually help patients, their business model is largely parasitic: to invent new diseases that require costly treatments (ADHD, post-menopausal complaints), and to make (at best) marginal improvements of old drugs when the patents expire so that new patents can be obtained.

 

Anyway, patient care seems to work most effectively in countries that have socialised medicine. So I think that one is easy.