One note on this. By all evidience, we get a poor to mediocre system
for all that we are spending. The biggest source of waste could be cut
without cutting care - and that is the insurance companies - not just
their profits and overhead, but the huge red tape medical providers
have to put in place to deal wit them. For example, your average large
provider hires a separate billing staff for each insurer. Smaller
providers (including individual practices) use billing services which
do the same thing.
Thanks to various "medicar advantange" plus standard medigap policies
this is starting to become as true for medical as the rest of the
system as private insurers get more involved with medicar.
Another huge source of waste is preventable medical error or
malpractice. While there is a lot bullshit about how malpractice in
insurance affects the system, actual malpractice has huge costs. What
it amounts to is some additional positive bureaucracy. (Bureaucracy is
a means of getting things done, and it some cases it is the best way
to get things done.) For example, there are a whole lot medical
procedures where there is stuff that should always be done. Have a
checklist that could be gone over for all such procedures, and make
practioners use it, and you save money and lives. (Think of pilots
using a checklist before takeoff.) Another thing is standardizing
certain procedures that can be done lots of ways so that the same
signal means the same way at every hospital. For example there is
every so often a scandal where a hospital performs and amputation on
the wrong patient or on the wrong limb for the right patient. Well
hospitals have instituted new procedures to double check that the
right procedure is being done on the right patient. This is good,
though I'd like to see this required so that podunk medical doesn't
fall behind the curve and fail to improve their procedures. But
secondly, this should be standard. You want to make sure that "do
this" at hospital A is not the same symbol used for "do that" at
hospital B. (There have been cases of tired doctors who have switched
hospitals rmake errors because they momentarily forgot the code
changes, and applied codes in their new environment as though they
were codes at their old enviornment.) So codes, flags, the various
communciation means in a medical environment (which can sometimes
involve actual ribbons or color coded tags) should be standardized,
the same in very practice. Note that this is not impinging on medical
autonomy where medical automy is needed. ("You must do this" does not
prevent exercising jjudgement and doing something else besides. For
that matter you could even allow doctors to skip stuff in the standard
list if , in their medical judgement, it would be medically harmful.
They would simply have to note they were skipping it on the individual
chart, so it was clear that it was being skpped deliberately, and not
simply overlooked. Standardizing codes and means of signalling for
stuff that is always coded or signaled is not an iron heel griding
down doctors. )
Another source of error is the exploitation of medical interns mean
many of them serve patients in a constant state of sleep deprivation.
There have been some rules passed about this in many states, but they
still allow some pretty damn exploitive schedules. Also there are all
sorts of loopholes: for instance of course you let interns stay a
little longer if leaving means someone will die cause there is no-one
to take their place, and if a hospital short-staffs then of course you
can count on such emergencies.
Lastly about elimination of actual unneeded procedures: it could be
done, without eliminating needed ones if it was done by someone really
trustworthy (highly unilkely in our present system). The dirty secret
of modern medicine is that most treatments and medical knowlege are
based on clinical experience and not on scientific testing. Medicine
is a craft skill; most medical knowledge is craft knowledge. So one
way 'evidence based medicine' can be done unfairly is to simply pick
out expensive procedures, and insist they be suspended until there is
scientific evidence they work. It is unfair because it could be used
on most treatments.
Now it would be socially beneficial long term project to
scientifically test all or most medical procedures so we had a better
idea what worked and what did not. It would even be beneficial to
prioritize the testing - testing those procedures with known horrible
side effects, and those that are extremely expensive first. But given
the backlog, it make sense to test procedures before deciding to
reduce or eliminate them. And for a test to be valid it has to
duplicated. You have to do multiple tests, with later tests
tightening methodolgy to address criticisms of earlier tests. So
evidence based medicine makes sense as a way to reduce waste and
improve care quality, but only done right, and only in a context where
we have reason to be confident in the integrity of the decision makers
using the results.
On Mon, Jul 21, 2008 at 5:24 AM, Max B. Sawicky <[EMAIL PROTECTED]> wrote:
> The threat in question re: Medicare and Medicaid is that they grow to absorb
> about ten percent of GDP.
> On top of everything else, that would propel the U.S. from the bottom of
> OECD countries to
> closer to the top, in terms of total taxes as a share of GDP (around 40%).
> Taxes have never
> been higher than about 30%. YOu couldn't finance the expansion with debt
> because debt &
> interest would blow up.
>
> The downside of spending that much is that much of it would be wasted, going
> by current
> evidence. Problem is that cutting waste can entail cutting worthwhile
> spending too.
> The most interesting finding floating around, coming from a few liberal and
> conservative
> econs (Robert Hall and David Cutler), is that for all the waste the extent
> of health
> care spending is worthwhile in terms of health/longevity benefits, and the
> sticky
> point, aside from filtering out unnecessary treatment, is how it gets paid
> for.
>
>
>
>
> Michael Perelman wrote:
>>
>> Tyler Cowen is my favorite conservative. Sometimes I actually agree with
>> -- not very much, but sometimes I do. Today in his New York Times article
>> he advocates means testing for Medicare. He acknowledges the possibility
>> that means testing will make Medicare a welfare program, causing it to lose
>> support -- but he suggests that things are so dire we do not have another
>> choice he does not seem to take seriously Mark Thoma's suggestion that
>> single-payer could create substantial cost savings.
>>
>> I am not sure how big a threat Medicare really is. Any sane political
>> system would find massive savings in the defense budget, but sanity is a
>> scarce commodity. Taxes on the very rich and taxes on purely speculative
>> activities could go a long way to supplement Medicare. Unfortunately, such
>> policies will not be discussed outside of third-party politics.
>>
>>
>> http://www.nytimes.com/2008/07/20/business/economy/20view.html?em&ex=1216699200&en=79692570ab41cad4&ei=5087%0A
>> -- Michael Perelman Economics Department California State University
>> Chico, CA 95929
>>
>> Tel. 530-898-5321
>> E-Mail michael at ecst.csuchico.edu
>> michaelperelman.wordpress.com
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