New Yorker article

The votes are in for gmail. I will tell everyone when they should switch to using a gmail address to contact me (I am going to restrict my new work address to work issues only)

Bill Watkins sent me a link to this interesting article byAtul Gawande http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

What do I think about this? I think the practice of medicine has an uneasy relationship to capitalism. Clearly the entrepeneurial and innovative advances we have seen in medicine in the past seventy years would not have come without capital markets. However - - there are tremendous caveats:

1) Just like technical advances in electronics, etc, much of the early work was funded by government grants (NIH, etc). So a lot of today's innovations by private companies is akin to the 'theft' of public property by the railroad baronies of the 1800s. I think it is an absurdity that companies were allowed to patent genetic sequences, for instance. Would genetic advances occurred without this? I believe so. However, we may not have gotten so far and so fast without private involvement.

2) Many of the advances in medicine would also be impossible without a big burden of safety and efficacy testing. Private companies in general are not going to 'overtest' their products for safety. It took large scandals for the government to take up this essential role.

3) For a variety of complex reasons, there has been a perceived erosion of the higher ethical ideals of medicine - - think to the country doctor making house calls on his horse in the middle of the blizzard, etc. I don't know how real the erosion of values really is. There were plenty of money grubbing doctors in the past, and there are plenty of idealistic doctors today. However, I think a lot of the current problems can be laid to several principles: A) More and New is always better. B) Health is a commodity C) Irrational and fragmented payment schemes/markets.

A) I see this at work all the time. Clinicians are always asking us for new tests, even though these are not always validated. The test maker salesmen usually approach the clinicians instead of the pathologists, because we are the ones who are trained to ask the hard questions!

B) Doctors and patients usually do not know the true cost of the work that they do (see also 'C'). It is very hard to be an 'informed consumer', since it is impossibleto shop around for physician treatment outcomes, and cost of the treatments. Most people go to the doctors and hospitals that are convenient to them.

C) Even in Pathology we order extra tests and do extra work - - it's justified, because we 'want to be sure of our diagnosis', but we also generate revenue by doing so. The way we are paid is absolutely ridiculous. We get about 25-30% of what we bill, and the payment can be longer than nine months after we performed the service. We get different payments depending on whether the patient is in-house or is an out patient. We get different payments depending on the patient's insurance. So we have a whole army of administrators devoted to getting money from insurers (either private or medicare), whose job is to deny the claim. This really forces us to think about the bottom line a lot. And the unintended consequences of setting up payment rules is that there is an incentive to game the system as much as possible.

We have health systems in this country that work very well and at low cost. I am very surprised that Gawande did not mention the Veterans' Administration which provides very high quality health care at low cost. The hospitals might not look so nice, it might take longer to get something done, but the system is very quality 'bang-for-the-buck' driven.

There are no easy answers for us to get out of our current mess - - it's about 60-70 years in the making, so it will take a lot of work and time to correct it - - something that is not easy in our political system that has many voices, and tends to be crises driven. I am a firm believer that we would have better health care with a single payer system, regardless of what people say about the long waits in England etc. Every other Western country has a single payer, and most of them have far better health care for far less money than the US. I see a place for private supplemental insurance. This would give people who have the money to spend, and want a more 'commoditized' product the ability to get 'first class' treatment. Does this mean we would have two (or more) tiers of health care? We already have it, regardless of the political bombast.