During the current health care debate, many policymakers on both sides of the political spectrum have used the word “rationing” as a bogeyman to frighten people. “You don’t want health care rationing”, they say. “Health care rationing is bad”. When most people hear the word “rationing”, what they hear is “I get less”. Since most people have some concern that their health will decline, and want health care to be available to help them if it does, the idea of getting less health care is both unattractive and scary. Since policymakers know this, they use the term “health care rationing” as a way to get people to say “No, thanks!”
There has also been much discussion of “the public option”. The public option, put simply, is a government provided (and to some extent, funded) health insurance plan which would compete with private plans. Now, I am foursquare for a public health plan. Because it is my fondest hope that it will eventually lead to the end of the discussion of “rationing”. Because rationing is not truly what we’re talking about, usually. We’re talking about allocation. Currently, the health care allocation model in the US is widely acknowledged to be broken. Some people get too much, many people do not get enough, and overall we pay more for our health care than people in other nations, without being healthier as a result. A lot of very expensive activity is taking place, without getting the desired result. I cannot imagine anything more un-American.
The most obvious method of allocation is through your doctor. Right now, though, doctors are poor decision makers with respect to what might be called “rational allocation”. Their income depends on you-all of us-using health care. If your doctor keeps you healthy, he makes less money. There are other things at play-your doctor also wants to do a good job, and stay in the good graces of her colleagues-but it’s easy enough to convince yourself that doing more for a patient is in their best interest. That doing more testing, more invasive procedures produces more health. And while this notion is attractive-more is always better in America-it has the disadvantage of being contradicted by some pretty good science. Take heart catheterizations and stenting procedures, for instance. There is good science which shows that many patients would be as well or better served by proper use of medications to control their heart disease, instead of putting stents into them. But stents pay better-so stents are used aggressively, while medication is not. Insurance companies and Medicare don’t pay well for the thinking and discussion with patients needed to properly manage medications.
This is just one example of why your doctor is not necessarily using his best judgment in your best interest. He has to balance his interest in staying in business, and keeping her staff paid and her income at the level he’d like. I work with some excellent physicians, and I’m proud to be one myself, but we’re not superhuman. Those of us who work in private practice have to think about keeping the bills paid. Those of us who are employed have bosses who demand higher “productivity” (a code word for “see more patients and do more procedures”) in order to increase the number on the bottom line at the end of the year. Often our pay is tied to a specific “productivity” target. The pressure to do more will affect how we act as we go about doing our work, without regard to benefit for the patient. Your doctor can’t help it any more than you can help doing the things your boss demands to remain employed, or doing what your business demands to stay afloat.
The problem is that we are paying doctors for the wrong thing. We’re paying them piecework and counting on ourselves as individuals to be the best arbiters of our health. On the surface this sounds great-if everyone takes care of their health, everyone is healthy. In practice, that isn’t how it works. People tend to make tradeoffs in their health care, and most often what they trade is their ability to do something they want now, such as smoke, but postpone payment until later, when they develop the inevitable heart disease, or stroke, or emphysema, and beg their doctors to do something. The time to do something was when you started smoking-the thing to do was to get you to stop. But smoking cessation pays poorly, while heroic measures to save us from the consequences of our collective poor decisions pays well, so again we allocate our resources poorly. The analogy of changing your oil is apt here; if you tell your friends you bought a car and never changed the oil or put air in the tires, few of them will be surprised when your car one day breaks. Yet we are all surprised that our rate of preventable, or at least postponable, disease is so high. Don’t we have the best health care in the world?
Well, we have many smart doctors, and some of the best technology in the world. Neither of which makes the best health care system in the world. What it’s made so far is the most expensive health care system in the world. We spend more per person on health care in the US than any other nation, yet our performance on most major indicators of health is mediocre at best, and downright poor at worst. Why, if we’re spending all this money, aren’t we healthier? In part, we’re spending it on the wrong things-procedures pay well, but thinking pays poorly, so doctors will naturally do as many procedures as possible, while not thinking about the cost; in other fields, certain types of visits (psychopharmacology, for instance), pays well, but talk therapy (arguably as good, and less expensive than a lot of pharmacology) does not. No one is coordinating this marvelous edifice of health care we’ve built. Like any other large system which isn’t managed properly, it has gotten out of our control. We must, collectively, regain that control, or we risk having it collapse upon us.