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Outsider

My Career in Medicine

Introduction

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            More Americans are killed by their doctors than by any medical condition except heart disease and cancer. A recent study analyzing prior data conducted by researchers at Johns Hopkins estimated that more than 250,000 of our fellow citizens die each year from medical errors. Compare that to the 600,000 plus deaths from cardiovascular disease and 500,000 plus deaths from cancer. The next most prominent killer is respiratory illness at 147,000 victims each year.[1]  Some 100,000 deaths are attributable to adverse drug reactions, many occurring even when no mistakes are made. Yearly hospitalizations for adverse drug reactions exceed two million.[2]

Despite the amount we spend on healthcare, Americans compare badly in life expectancy and the prevalence of chronic conditions.[3] The US is #31 in life expectancy. We rank #1 in deaths due to heart disease, #2 in Alzheimer’s dementia, and are in the top ten in stroke, lung disease, lung cancer, diabetes, hypertension, kidney disease, and colon cancer.[4]

            Although some 20 million people have acquired insurance coverage since the Affordable Care Act (ACA, sometimes referred to as “Obamacare”) was signed into law in 2010, a large number of Americans – perhaps as many as 29 million, one in ten – remained uninsured as of May 2016.[5]

            In 2015 Americans paid $1,318 out of pocket before health insurance coverage kicked in, up from $584 a decade ago. That's on top of paying an average of $89 a month for health insurance premiums.[6] Last year, annual healthcare spending reached a new peak at $10,345 per person.[7]

            We spend 17.1% of our GDP on healthcare, which is almost 50% more than France, the next highest spender and almost double what the UK spends.[8] In 1960, it was just 5%. US hospital and physician prices for procedures are highest in the world, as well. In 2013, the average price of bypass surgery was $75,345 in the US, more than $30,000 higher than in the second-highest country, Australia, where the procedure cost $42,130 in that same year.[9] 

The exorbitant price Americans pay for pharmaceuticals compared to the prices for the same drugs abroad is common knowledge. US prices for the world’s 20 top-selling medicines are, on average, three times higher than in Britain, according to an analysis carried out for Reuters.[10] And the rise in cost is only accelerating. In 2010, all countries studied had lower prices than the US. In Australia, Canada, and the United Kingdom, prices were about 50 percent lower.[11]

Even though the US is the only major country without a publicly financed universal healthcare system, it still spends more tax dollars on healthcare than all but two other countries. Part of the reason is that prices for healthcare are so much higher in the US. By contrast, the US devotes a relatively small portion of its budget to social services, such as housing assistance, employment programs, disability benefits, and food security.[12]

The sad truth is we deliver the worst quality, least available, and most expensive healthcare in the developed world.

All of this contradicts free market predictions. We are the only country that has entrusted the health of our citizenry to a profit-making industry in the faith that market forces will deliver the best quality product for the lowest price. Instead, we have the opposite. I believe the reason for this can be seen with a closer look at the American healthcare system, which more closely resembles a government-protected monopoly than free enterprise.

By influencing the government with their multimillion dollar lobbies to collude with the industry in maximizing profits while protecting themselves from competition, the healthcare industry obstructs the free market process, standing between the seller and the buyer, i.e. doctor and the patient. Insurance companies, HMOs, pharmaceutical firms, professional organizations, the malpractice industry, and licensure requirements all influence the exchange of services for payment.

They effectively neutralize the supply and demand dynamic.

The question of whether the patient has insurance and what the insurance will cover is a major influencer of what the patient and the doctor will get out of the exchange. High healthcare costs benefit the insurance industry by making insurance increasingly indispensable. When healthcare was affordable, there was less demand for insurance. With the ACA, every American became obligated to involuntarily participate in the insurance industry. Now those who cannot afford insurance have the opportunity to not only be poor and sick, they can be criminals as well.

The ACA does nothing to enhance market forces, further entrenches a predatory insurance system, and (most astounding of all) it was upheld as constitutional by the Supreme Court under the commerce clause. (The government has the right and responsibility to regulate commerce, so they can force citizens to participate in a specific private industry.)

Pharmaceutical firms receive a great deal of money in the form of government grants to do drug research and they spend millions to lobby for legislation that protects their profits even to the detriment of the tax-paying consumer.

Professional organizations spend money to protect their turf to the detriment of the public as well. As a patient, I want the freedom to see any doctor I chose, but legally I can only see those professionals my government licenses – even when they are better and cheaper doctors from countries that deliver better healthcare than we do. By controlling licensure and access to pharmaceuticals, hospitals, labs, and treatment facilities, professional organizations obstruct free market dynamics.

Not only do the medical professions make it difficult for well-trained and qualified doctors and nurses to come to the US and ply their services, they guard their own turf from each other. As a doctor, I can work as a physician but not as a physician’s assistant. I can supervise nurses but cannot work as one. Even with all of the equivalent education of a naturopathic physician, medical doctors cannot get a license to work as a naturopath unless they can present a diploma from one of the recognized, albeit inferior, naturopathic colleges. We can’t even sit for the exam.

All of this compels the public to accept only the narrow choice of professionals offered to them by a government-sanctioned and guarded industry. Licensing in the US – far from protecting the public from poorly trained practitioners – forces the public to accept lesser trained (and more expensive) doctors and paramedic personnel by keeping out the competition. Indeed, incompetent and even dangerous doctors are often protected by their professional organizations, aided by a government reluctant to investigate and prosecute malpractice.

The issue of monopolistic medicine is illustrated in my home state of Washington in yet another way. The University of Washington hosts the only medical school in a five-state area including Washington, Alaska, Idaho, Montana, and Wyoming. They control all graduate and post graduate medical education and certification in five states. No governmental or regulation body dares threaten them with closure or removal of accreditation because the UW is all there is. It would paralyze medical education in five states.

They’re too big to be held accountable.

I am personally aware of two attempts to create additional medical schools in Washington state. They were unsuccessful not because they lacked the financial backing or credentialed expertise. They were simply obstructed by bureaucratic roadblocks, strongly influenced by the University of Washington, whose sole interest is to protect its privileged position. Backers of both attempts moved on to create medical schools elsewhere in more welcoming states.

There is a lot of talk today about making access to healthcare a right. While I am sympathetic with the idea of providing basic healthcare to everyone, healthcare isn’t and cannot be a “right” any more than transportation, communication and entertainment are. We can declare them a fundamental service, like we do with education, but no one is born with the right to healthcare. But we do have the right to pursue our own health and wellbeing and inasmuch as the government or elements of industry obstruct them, they are obstructing our inalienable human rights to life, liberty and pursuit of happiness.

Having lived and worked under both American and state-sponsored systems, I believe that universal, single-payer, national healthcare is a good idea. It would certainly be an improvement over the predatory system we are subject to today. More people would get basic healthcare for less money than they currently do. But national healthcare brings with it a new set of problems, some of them serious.

For one thing, when healthcare is free or nearly so, the system rapidly becomes clogged with people who don’t need the care and thus drain the resources from people who do. Put this together with the fact that healthcare is the third largest cause of death in America. More access to healthcare exposes more people to the risks that come with it.

We have to limit access to healthcare both to conserve resources and minimize the harm that inevitably comes with medical treatment. Copays and caps on services discourage people from going to the doctor for minor problems.

From the provider side, patients should be screened and turned away if they do not need care, but in today’s legal climate, doing anything but the maximum for a patient opens the doctor and hospital to lawsuits. It’s one of the reasons healthcare is so expensive. “Give the patient all the care the patient deserves” is the oft-repeated phrase. It should be “Give the patient the minimum care necessary to adequately treat the condition.”

This raises the issue of legal reform. Suing doctors is big business both for lawyers and insurance companies. This would be less profitable if malpractice cases were settled mostly by arbitration, outside the courts and independent of the legal industry. New Zealand approaches malpractice in this way and it appears to work well.[13]

If the medical profession adequately policed itself, very few cases would even reach arbitration. In Hungary, where I practiced for decades, the Department of Forensic Medicine functioned as an independent watchdog of the medical profession. The Hungarian Chamber of Medicine along with the local ethics committees – which are made up of members from outside the profession as well as doctors – effectively safeguard the public. In America – or at least in Washington state where I lived and practiced – the medical profession polices itself with the full protection of the government and little input from the public.

 The medical profession in America feels embattled and under siege, but an independent watchdog organization serves to protect the physicians as well as the patients from unreasonable punishment. Doctors are people too who make mistakes, even though our mistakes can have the most serious of consequences. When doctors are confident that their shortcomings will be addressed fairly, and that one mistake would not end their careers, flushing away a twelve-year investment in education, they can better focus on patient care and less on their own protection.

            People sometimes worry that socialized medicine would eliminate private healthcare. This is nonsense and didn’t happen even in the Communist countries. I practiced in Hungary before it threw off Communism. I and many of my colleagues worked in the state-run system and maintained private practices for cash at the same time. You just have to be good enough for patients to be willing to pay for your services out of pocket rather than settle for whatever is available from the government. In the US, even terrible healthcare providers get paid well through insurance which doesn’t distinguish between good doctors and bad ones. Cash-only medicine, as we practiced it under the Communist governments, is pure free enterprise with market forces governing supply and demand.

In countries with state-run healthcare, there is a tangible difference in quality between private care and government-sponsored care. Government programs tend to be overused, underfunded, and poorly administered. But much of that can be remedied by relegating as much of the decision-making to the lowest level possible and including lay participation on the boards of hospitals and health administrations. Transparency goes a long way in keeping standards of care up and preventing waste, fraud, and abuse.

Each community faces its own unique spectrum of problems. Miami is not rural Wyoming. New York city isn’t Boise. Some communities have a large elderly population with chronic diseases. Others face more trauma and surgical cases. The local administrators need authority to create or at least influence the budget to make sure the resources are allocated where they will do the most good. The best management of resources demands including the people who know the most and care the most about the results in the decision-making process. These are the local doctors and patients.

Healthcare should be centrally funded but locally administered.

National healthcare can bring down the cost of drugs. It solves the problem of getting everybody into the system. It opens the avenue of policing the profession by an independent body, possibly as part of the Department of Justice. It can limit the expense of our current malpractice industry, delivering for us all (except the lawyers and insurance companies) a huge savings. It should eventually facilitate reciprocity and standardize procedures across states and even other countries. Medicine, just like everything else, is becoming global and borders need to do less to hinder the seamless delivery of medical care worldwide.

It's time we caught up with the rest of the world in healthcare.

            Medicine in America is at its core a for-profit industry. The money that changes hands between you as a patient and your doctor is miniscule compared to that between your insurance company and the organizations that control the doctor’s practice. Insurance is the prime source of their income. The insurance you bring determines the extent and quality of care you will receive.

I neither understood nor appreciated any of this when I embarked upon a career in medicine. I shared the naïve vision of the healthcare professional as a human being first and above all dedicated to the wellbeing of the patient. Salus aegroti suprema lex est. I knew doctors made a good living but did not realize that the big money was in medical management – managing clinics and HMOs, marketing pharmaceutical and medical devices, and selling medical insurance.

Doctors are under pressure to conform to the policies of the institutions for which they work, the contracts that pay the bills, and the approved treatment protocols. A doctor truly cannot act primarily in the best interest of the patient and survive for long.

This dynamic – the major healthcare industries and insurance companies doing business with each other, protected by the government, with doctors and patients functioning as mere cogs in the machine – explains why medical care in America is so expensive and does so little good – at least for the patient.

It does not explain why we who live in a representative democracy where We the People have some say in our government, allow this to continue. I believe the “insider vs. outsider” dynamic lends a valuable perspective in this regard. We are social animals. We join together in packs, gangs and clubs. Insiders get the benefits of the “in group;” outsiders don’t. The healthcare community is no different. It has its “in” groups and “out” groups. To sit at the cool kids’ table, you have to show respect for the dominant culture – walk the walk, talk the talk, and dress the dress of the “in crowd.”

This book is the story of my career in medicine and the struggles between outsiders and insiders I’ve experienced, including my own. I hope within these pages to offer a little insight into why things are the way they are and perhaps on how to make them better.

 

[1] https://www.cdc.gov/nchs/fastats/heart-disease.htm, https://www.cdc.gov/nchs/fastats/cancer.htm, http://www.npr.org/sections/health-shots/2016/05/03/476636183/death-certificates-undercount-toll-of-medical-errors

[2] http://www.worstpills.org/public/page.cfm?op_id=4

[3]  M. Avendano and I. Kawachi, “Why Do Americans Have Shorter Life Expectancy and Worse Health Than Do People in Other High-Income Countries?” Annual Review of Public Health, March 2014 35:307–25; and Bradley and Taylor, American Health Care Paradox, 2013.

[4] http://www.worldlifeexpectancy.com/world-rankings-total-deaths

[5] http://www.thefiscaltimes.com/2016/05/10/Even-Obamacare-29-Million-People-Are-Uninsured-Here-s-Why

[6] http://time.com/money/4044394/average-health-deductible-premium/

[7] http://www.pbs.org/newshour/rundown/new-peak-us-health-care-spending-10345-per-person/

[8] http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

[9]  International Federation of Health Plans, 2013 Comparative Price Report.

[10] http://www.huffingtonpost.com/entry/americans-pay-more-for-drugs-than-anyone-in-the-world_us_561bda8fe4b0e66ad4c89449

[11]  P. Kanavos, A. Ferrario, S. Vandoros et al., “Higher USBranded Drug Prices and Spending Compared to Other Countries May Stem Partly from Quick Uptake of New Drugs,” Health Affairs, April 2013 32(4):753–61.

[12]  E. H. Bradley and L. A. Taylor, The American Health Care Paradox: Why Spending More Is Getting Us Less (New York: Public Affairs, 2013).

[13] http://www.slate.com/articles/health_and_science/medical_examiner/2017/07/adopting_new_zealand_s_method_for_medical_malpractice_would_lower_health.html

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