Sunday, December 07, 2008

Mischaracterizing the Problem (Courtesy of Medscape)

I received a mass email from one of the national physician organizations that sent me into a bit of a cursing fit.

I was asked to participate in a poll that sought to determine whether physicians were 'professionals' or 'businessmen'. Hmmm. I read further, the assumptions behind this question were not hard to determine and this is where I took umbrage.

The question is a distractor, it's moot, it's not relevant, and avoids the real question. The question itself attempts to set us up for huge changes that many feel are long overdue... nationalization of health care being the main one. My point is this, if we can be split into physicians who are arguing about 'professional' versus 'businessman' then we can be conveniently divided into 'caring physicians' and 'mercenary physicians'.

After all, 'professionals' are concerned with their profession right? Therefore 'professionals' really put money on the back burner and should be wiling to accept the hijacking of their profession by other entities. "Businessmen" however, are fine, as long as they are not physicians, because wanting to profit from your profession, if it is medicine, is unseemly, or as close to immoral as one can get in the age of amorality.

Screw you guys! The question is wrong. The question is this... Is the best model for efficient delivery of quality health care a business/capitalist model, or a centralized/bureaucratic model. That's the freaking question morons.

Along with this is the never-asked question; Do patients bear any responsibility for maintaining their health or for paying for services rendered when they are sick? This whole thing is a poorly constructed set up and I encourage my colleagues to call this turd a turd.

The most efficient system for delivery of resources and services is a market system. The only people that can efficiently and routinely make good decisions about their health care are individual patients. When it becomes impossible for a patient or their physician to know what certain procedures, medicines, or treatments will cost prior to choosing them then efficiency in the market is dead and the answer is not to make the whole thing more opaque. Idiots.


  1. Chalk another doc up to


    Look, 911, you should be happy to care for the proletariat, it's for the good of the State.

    And when the State is strong, we're all strong!!!

  2. dear SBJ,

    you are right. and that gives me an idea, i think we should come up with some long term goals for health care and even our country, something that could take place over, say, five years. we could even call it a 'five year plan'. like it!

  3. Hey you can't expect people to pay for Boob Jobs and LASIK outta their own pockets!! Thats why I'm still wearing my 1988 U.S. Navy BCGs instead of breakin down and goin to the LASIKs R US at the Mall...That and I was taught Lasers and Eyes were a bad thing...

  4. How about a "cultural revolution" in medicine!? I like the ring of that.

    very well put...agree 99%:
    I'm a bit vague on the "age of amorality" comment. I thought you liked Sodomy.

    is it really the age of amorality? Can't say I agree with that.

  5. eto,
    i am not saying that the age is 'immoral', rather, that it is unfashionable to call things immoral these days, better to call them, 'maladaptive' or 'contrary'. once you start talking about morality then you need to have a source for the morality and while you and i might make a coherent argument for the sources of our morality others would be put off by the fact that we felt confident that we were right about anything. that's just in bad taste.

    actually argued with a young just-out-of-college girl who called me judgemental and i could not get her to admit to me that Hitler was bad. she really wouldn't take a stand. not kidding. me, out on a limb i know, i think he was bad.

  6. oh, eto, and here's a good one... 'normative'... good ivory-tower mumbu jumbo that one... 'normative'... get used to it or be considered, uh, not-normative or something.

  7. Frank: Nah, you're just a sissy like my husband. Mr.Devo can ride a bike 700 miles in two days with no sleep, but he won't let his doctor take off a skin tag and he's afraid of needles.

  8. Frank: Nah, you're just a sissy like my husband. Mr.Devo can ride a bike 700 miles in two days with no sleep, but he won't let his doctor take off a skin tag and he's afraid of needles.

  9. Well, as a layman in medicine, I vastly prefer the "businessman" physician. I generally find them to be more honest and more competent. I also find that they usually treat their patients like adults and not like children(like "professional" physicians do).

    And as a 21-year-old who's just about to graduate university I have no problem in saying that Hitler is evil and bad. However, I will admit I'm a minority here in academia.

  10. Of course Hitler was Bad, he was a Vegetarian...

  11. Frank: Actually, I'm an involuntary vegetarian. The ex and I were driving to Yosemite with friends when I was 2 mos pregnant. I was hideously nauseated, hormonal and miserable. We drove past a farm, and I started feeling sorry for the cow babies, chicken babies and their grieving mothers etc...---you get the picture. Haven't been able to shake it off in 23 yrs. I actually hate it, as I can't eat gluten either.

  12. OK...I get it. you are talking about relativism. Have you been reading French philosophers or something?

    I bet the Hitler chick WOULD claim Obama is pure good however.

    Free OJ!

  13. Considering that the customer/patient doesn't actually pay for their services directly, nor can anyone with reasonable speed and accuracy tell the customer/patient was the costs for half this shit are at point of service, it's hard to say the physician is a businessperson.

    Hospitals were dragged kicking and screaming into this "post your prices on the internet" deal and they obliged, in the most half ass fucked in the ass sense possible.

    "Acute Coronary Syndrome Treatment"
    Average length of inpatient stay:3-6 days. Cost:$14,893-33,765.

    What the fuck good is that?

    I would have no problem to have a price list, adjusted for my insurance coverage, that showed what the prices were. Only when I, as a patient, can make a decision as to if I can actually afford this shit, would I decide to get it.

    The fact that patients don't pay for shit is due, in part, to the fact that you have no idea as to the cost. I'm all for people paying for services. It pisses me off when these degenerate fucks stiff the hospital and the hospital then fucks me in the ass by jacking up my prices because some poor fuck won't pay his bills.

    If I went to the hospital with a cough, fever, chest pain, and chills and some doc says, "Hey, you need an X-ray. We think it might be pneumonia. We also need to do a 12 lead, and some labs. This will cost $295 for the chest X-ray, about $600 for the 12-lead, and an additional $500 for the labs." I might be like, "Whoa baby. Papa isn't made of money. How about I grow some nuts, tough it out after you throw me a scrip for some antibiotics? I'll sign whatever refusal paperwork you want."

    It's like ordering at the bar. Until you get the tab, you never know what that fancy fucking glass of imported beer costs. And by then, the damage is done when you see the tab.

    I don't see why this is so hard. If some ER doc says, "Hey, I don't have a 100% certain idea what's going on. I'm going to get a specialist here to evaluate you. He does have a fee of $900 for a consult, and will probably order tests." I'd be like, "Listen, just give it your best shot. It's not worth another $900. You graduated medical school, correct? Then make an educated guess."

  14. And an enterprising lawyer will be happy to sue the doctor and the hospital for not giving you all the tests that you could of had. Liability paperwork would not save the doctor from a system played by lawyers and made by lawyers. Physicians would be in a better boat if they ran for office more often, however, unlike in law, becoming a politician is detrimental to a physician's skills.

  15. Is it a good thing to have patients put cost before diagnostics? I'm just saying, if they refuse the studies and then come back a week later much worse, who wins?

  16. Anonymous1 -- most hospitals with on-site labs will give you a price list. Just have to ask for it. Those who've gone through periods w/o insurance benefit greatly from this. Hospital A, it turns out, is 40% less expensive than the company that picks up the blood from my Dr.'s office. Apparently it's too damn hard for the government to issue any kind of control over these kinds of discrepencies. Oh, wait. that's right. Then we'd be communists. Heaven forbid hospital a and hospital b charged the same fucking fee for the same fucking test. That would just be tooooo sensible and soooo communist.

    Let's classify doctors as doctors, assume their worth saving hundreds of lives a year & pay them accordingly. Then kick the administrators out of the hospitals, turn the hospitals into ummm, i dunno...hospitals, cap the CEO's salaries, then grab the fucking insurance companies by the throats and make them do what's right.

    It'd be really nice if doctors quit playing resident experts on every fucking subject under the sun and just stuck to doctoring. Wow. Wonder what that would be like.

    Oh, and by the way...your answer is neither. You all are hospital employees. You don't count.

  17. Yeah, I'm gonna make a bet here that the Docs (ER Docs, Pathologist excluded) on this site are not hospital employees at all.

    They are either 1099'd by a group or an employee of a group that staffs the Department.

    So in a lot of ways, ED Docs are especially like business people, I've seen Docs move for a few bucks an hour more and to States with no income tax (For that reason alone). I personally know ED Docs that create complex tax shelters to filter their 1099 income through to keep just a little more a little longer.

    Furthermore, I know of a Department that put everyone on a fee-for-service split with open books (Any Doc could review), Docs who work there work hard, cause they keep a lot more of what they produce.

    And, Anon, how in the blue hell is capping a CEO salary gonna change one thing? Why do you hate others success? I want everyone to make as much money as they possibly can.

  18. anonymous,
    agreeed. stick to what you are an expert at, posting anonymously on blogs.

    as for the government fixing prices between hospitals why not just let the market do it by competition. it works better anyway and wouldn't require hiring folks like you to do a bunch of paperwork.


  19. 911,

    I have oft wondered what would happen if we completely outlawed insurance and forcing hospitals, doc, ect. to make prices known before they do anything. I would imagine I'd drive down prices quite a bit. I'd definitely become a more market-like environment(because the consumer...erm, patient is paying directly as well as increased information about the market) but I do wonder if there might be some unintended consequences to such a move as well. Might float the idea by my father(an economist) to see what he thinks about it. Anyways, I need to get back to my term papers. Have a good and safe day docs.

  20. I think this board has been happy to discuss the failures of the centralized model. What arguments can you come up with regarding the possible or current failures of the market model? Honestly curious.

  21. the market model has never failed though individual pracitioners have failed.

  22. I want centralized 5 year plans. I have no motivation for individual gain. I only want the state to succeed. All hail Obama, master and lord of the U.S.S.A. I will gladly give up my individual property and business for the greater good of the state.

    (tongue now taken out of cheek and placed in Nancy Pelosi's old nasty worn out love box)

  23. Anon,

    There isn't a free market and there never was the information or responsibility in order for a free market to really exist. What we have is a form of pseudo-socialized healthcare. And to be honest, only with sparse elements of the free market, American Healthcare is still better than any socialist system.

  24. You know whats great, I was talking to someone yesterday and I suggested he visit a Doctor.

    He goes, "I don't have insurance"

    I say, "Well, you can pay cash"

    He goes, "Doctors take cash?!"

    He has money, that's not the issue, he just didn't think about that Doc's might take cash as payment for services. He is a very smart guy, it's not that he's an idiot. And I can see how one can think that.

  25. I went to the Dr. the other day. After it was all over with, I went to the desk and they said the fee would be $78.00. So I reached in my purse to grab the cash, and the Nurse and a receptionist and someone else (don't know who it was) looked at me like I was an alien. Their jaws all dropped. Receptionist: "Ohh, you're paying cash? REALLY?" Me: "Yes." Receptionist: "..." Me: "..." Receptionist: "Oh, well then, it will be $55.00"

    As I was walking out the door I heard all 3 of them exclaim "WOW!"

    I had a good chuckle over that.

  26. just a side comment...our patients are wearing green arm bands if they've paid their copay...bizarre but true.

  27. What would a realistic price list of services look like to the average consumer of health care? Would doctors, like car dealers, be involved with the financing of procedures (I think this is done with cosmetic surgery, right?)What about emergency procedures-- would people need to get the financing for them approved before receiving emergency interventions?

    How would you run an ER on the market system?

    --- poster who asked about this earlier

  28. dear lubert,

    i have no idea. the fact is that we have created so many layers of mystery between the patient and the bill that i do not have a good answer for your question.

    my first reaction is to say "fund EMTALA" but that's just equivalent to a tax increase and is too honest so no one will do it.

    capping liability for care given for free would go a long way to averting disaster as would allowing physicians who are mandated to give away their services by federal law to deduct the cost of these services, but the services cost is such a guess that this might be unworkable (and certainly unpopular with those who buy the 'greedy doctor' mantra).

    frankly i have no hope of any of this actually happening as it is too easy to demonize my side of this debate as being uncaring and heartless.

    the fact is, that if people are not made to feel the consequences of their poor decisions then why bother? the political likelihood of a 'personal responsibility' solution is about zero.

    it would not be unworkable at all, however, to have a federally funded basic/catastophic insurance for all, and a private sector side for those who choose, but this would be vulnerable to the kind of class politics that passed ETMALA in the first place.

  29. The formal name for the logical fallacy on which the question ("professional vs businessperson") is, "the fallacy of the false dichotomy." This common error assumes, without evidence or logical defense, that to be one precludes being the other, which is nonsense. This error is the result of either sloppy, biased thinking, or, intentional rhetorical manipulation intended to convince the reader of the truth of the assumption (professionals cannot be business people) while avoiding the task of supporting that belief with facts and logic.