From: sbharris@ix.netcom.com(Steven B. Harris) Subject: Re: doctors of the nation - unite? Date: 02 May 1997 Newsgroups: sci.med In <dgs4.835.0E85D6CA@psu.edu> dgs4@psu.edu (Dennis Shea) writes: >No, not a non sequitor. You claim that managed care endangers patients because managers have a financial incentive to undertreat. I claim that unmanaged care endangers patients because physicians have a financial incentive to overtreat. There is a total lack of evidence that either leads to greater potential or actual harm to patients.< At last, the voice of reason! Geez, why is it so rare? We need some bigtime randomized studies, and lots of outcomes research to find out the truth. That's not such a hard idea, now is it? One of the greatest harms that democracy in general does (and Federalization in particular) is that it stiffles what are otherwise very useful social experiments. Government "policy" is almost always premature, because almost never does government *TEST* its proposed social policies before universally implementing them (at the point of a gun, needless to say). States don't either, but at least if the Feds butt out, you can compare state to state. >As for me, I'd go teach economists. Don't worry about me. You DO create adverserial relationships with administrators when you claim they have no interest in patients, when your holier than thou attitude impairs your ability to understand the that doing EVERYTHING for some patient sometimes not only endangers the welfare of other patients, but also endangers the welfare of that same patient.< Sometimes. Unfortunately not all the time. In a world of limited resources (which will always decribe the real world) it's useful to have some super-organization to put a crimp on expensive treatments which provide SMALL benefit. What the best nature of that organization is, remains to be determined. One simple method of feedback involves little organization at all: it's merely a rule requiring that there be no such thing as a medical treatment with no deductable. Deductables enlist the patient (and family's) brains in the very complex question of risk/benefit/cost in medical treatment. And the more brains you have working on a problem, the better you can solve it (parallel processing). That's the big lesson of a market economy vs command economy, but one that we persist in trying to keep from applying in many situations. Steve Harris, M.D. From: sbharris@ix.netcom.com(Steven B. Harris) Subject: Re: doctors of the nation - unite? Date: 02 May 1997 Newsgroups: sci.med In <dgs4.848.10D4C9FA@psu.edu> dgs4@psu.edu (Dennis Shea) writes: >Third, let me suggest that the threat to patients in the past from >unmanaged physicians may well have been as great as that of managed care. >Yet, did we see physicians rise up in outrage over fellow physicians >over-use of care which endangered patients? Did we see physicians call >for stricter tort laws and tougher licensure standards to protect >patients? Did we see daily letters to the editor warning patients about >the threat to their health from other physicians? > >No. The outrage, the hue and cry came ONLY when physician income and >autonomy was threatened by managed care. > >So, excuse me, if I am a bit cynical when collectively or individually >physicians claim they are only interested in patients. Yep. On the other hand, where is the *institution* more interested in patients than doctors are? It surely isn't the government-- if you want to see how the governments runs a medical system, take a look at the V.A.s. If you want to choke on cynicism, take a look at all the stuff on advanced directives now being pushed by MediCare. These are probably in the best interests of the patient, but it's rather strange that they somehow didn't appear until MediCare needed a way to save bigtime money. Same with all the studies these days about how withdrawal of food and water from dying and semi- or unconscious patients isn't necessily always inhumane. This is probably true, but how come it took so long to figure out, if so? When the government was willing to pay for any medical treatment private hospitals want to dish out, the issue of "compassionate dying" somehow never arose. Hmmm. We doctors certainly didn't push it. >Year, after year, after year, physicians, individually and collectively >opposed any government efforts to contain the costs of health care. As >they sowed, so they reap. They forced the private sector to develop its >own solution. I don't shed tears for them. Me, either. Except that the doctors who generated the problem are not the only ones being punished by the attempted cures. I'm a bit pissed that an earlier generation of doctors generated the problems and retired, leaving yours truely and the younger physicians having to deal with the government "solutions." Steve Harris, M.D. From: sbharris@ix.netcom.com(Steven B. Harris) Subject: Re: doctors of the nation - unite? Date: 04 May 1997 Newsgroups: sci.med In <dgs4.858.002BA7F3@psu.edu> dgs4@psu.edu (Dennis Shea) writes: >In article <5kdpl3$hol@sjx-ixn4.ix.netcom.com> >sbharris@ix.netcom.com(Steven B. Harris) writes: > >> At last, the voice of reason! Geez, why is it so rare? >> >> We need some bigtime randomized studies, and lots of outcomes >>research to find out the truth. That's not such a hard idea, now is >>it? >> >> One of the greatest harms that democracy in general does (and >>Federalization in particular) is that it stiffles what are otherwise >>very useful social experiments. Government "policy" is almost always >>premature, because almost never does government *TEST* its proposed >>social policies before universally implementing them (at the point of a >>gun, needless to say). States don't either, but at least if the Feds >>butt out, you can compare state to state. > >I don't know if I'd lay this at democracy's door. Bigtime randomized social >experiments are enormously expensive and complicated. You might check out >Joseph Newhouse's book "Free for All" on the RAND Health Insurance Experiment. Well, look--- such experiments can't be that much more expensive than simply deciding on social policy and implementing it. Social policy is, after all, just an experiment with one treatment group. If you have to do the experiment anyway, and have to monitor the results anyway, adding one more group is not that big a deal. >While deductibles are useful, there is not much evidence that they (or >other cost-sharing devices) are any better at eliminating wasteful, >rather than helpful treatments. There's lots of evidence in the case of ER visits. I cannot imagine why the same forces would not apply to every other medical condition. I know my own patients give me Hell about stuff they have to pay for deductibles on. If nothing else, deductables eliminate the patient who wants another test just to fix their anxieties. Generally, the doctor in that case has to order the MRI and be the foolish guy, or else refuse and be the bad guy. If the patient has foot some of the bill, he's going to be asking how badly he needs this MRI. And if the answer is: "not that badly," he's going to HELP me do what needs to be done anyway. Which is to wait that back pain out for awhile to see if it goes away all by itself.... Deductables seem to save money on drugs, too. My no-copay dyspepsia love Prilosec, for instance, and demand it with the most horrible of wailings that nothing else works. My cash-pay patients buy Zantac at the grocery store, and get by.* Steve Harris, M.D. * Yes, they've all been treated for H. pylori. |
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