The radio show This American Life is running a two-part series on health care reform; the first one, More is Less, aired today. I heard some parts of it two or three times while traveling home from Texas: it’s good.
Rather than another argument about the merits or problems of various current proposals, they looked at situations that run up the cost and provision of care. Physicians, patients, insurers, regulators of health care all talk about their jobs – and the various incentives and motives that act on them as they go about their work. It reveals the complexity of the problem.
One physician who followed a set of guidelines so that a young woman did not have a CAT scan that she probably didn’t need comes across as the hero of avoiding the unnecessary radiation to the patient and cost to the system. Not long later, we hear of a physician who followed a set of guidelines indicating that a man in his 50s didn’t need the PSA test for prostate cancer; within a year he was diagnosed with an aggressive and terminal prostate cancer, and sued. Both sets of empirical guidelines are correct: more damage is done, overall, by the excess treatments than damage avoided by always having the test. But – as the doctor resisting the unneeded CAT scan said – the damage from excess radiation would show up 20 years later and no one would come to criticize him for it, while the danger of missing the very unlikely fracture would be found and blamed on him now. He named the motivation for making the choice for more testing – but resisted. The doctor who made that choice and was sued, subtly urges patients to ask for the probably unnecessary test.
Unforgettable moment. One part of the show really struck me: the cash flow through the medical care system. While insurers and care providers recognize that the system is broken, that we pay more and get less for our health dollar, there is a reality we do not acknowledge:
If the amount spent on health care is cut in half, then the amount spent on insurance is likely to be cut about in half, and the amount paid to physicians and medical centers will be reduced by about half. For those industries, this will be a big re-adjustment.
Those numbers are an over-simplification, to be sure. Nonetheless, the reduction in the size of the health care industry will affect jobs as well as profits. One of our local clinics operates its MRI machine into the night – I once had a 9 p.m. scheduled appointment. If fewer MRIs were ordered, fewer regularly scheduled hours would be needed – along with fewer technicians, fewer receptionists, fewer laundry and housekeeping staff for the changing rooms.
It is clear to all concerned that our economy cannot pay the sky-rocketing costs we have been experiencing. Most agree that it is immoral for some of us to have ready access to excellent care while others can’t get care unless they pay for all of it out-of-pocket. But we also need to see that this industry is also a major provider of well-paid jobs; any reform that truly saves money must do so, in part, by reducing employment or pay levels. That, too, will be a difficult adjustment.
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