Your Doctor Serves The State, Not You

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As a physician
thoroughly frustrated with our State medical apparatus, I read a
large number of opinion pieces and news articles on its perceived
woes and proposals for its reform. Though I have read some excellent
works on these pages and at the Mises Institute site, the majority
found in the popular media reek of economic ignorance and worship
of the State. Most private physicians knowingly groan when they
encounter such garbage, and simply go about the business of their
day caring for the sick in the often impossible system which they
find themselves. In sharp contrast, many in academic medicine and
professional societies such as the AMA cheer, spread it amongst
their colleagues, and write additional State-supporting propaganda,
the latest of which to come to my attention was the proverbial straw
for this camel, and from which I include a
particularly remarkable quote

“It would
be such a shame if we once again fail to cover the uninsured because
of hang-ups over costs. Physician decisions drive the majority
of expenditures in the US health care system. American health
care costs will never be controlled until most physicians are
no longer paid fees for specific services.”

So begin the
fantasies of yet another healthcare dictator in the making, proceeding
to issue his decree specifying exactly which types of medical services
should and should not be provided in this country. At the stroke
of his mighty pen, many common services demanded by patients are
restricted or (even better) prohibited. Today he limits his list
to seven broad categories, including coronary bypass, angioplasty
and stenting, prostate cancer screening and treatment, mammography,
and CT/MRI (which he interestingly refers to as “art forms”). Tomorrow,
who knows which unthinkable ways he will devise to save money for
his benefactor the State. Forget the decisions of millions of patients
and physicians across the country, they’re wrong, all wrong. After
all, unlike us common grunts providing the care he seeks to limit,
he has the proper credentials! He’s used his medical degree to specialize
in pathology, work as a professor, laboratory director, journal
editor and now “serves” as President and Chair of the Board of The
Lundberg Institute, named for himself, whose mission is to “forge
a patient-physician alliance based on trust, providing leadership,
strategies, and communications that promote evidence-informed, efficient,
and effective health care delivery to benefit the health and well-being
of patients, physicians, and the public.” While possessing a truly
impressive rsum in the academic world, it is woefully devoid of
virtually any experience in that one often messy matter which is
the essence of the profession: actual face-to-face contact with
living, breathing patients. To summarize, perfect for our newest

One would understandably
be excused for choosing not to read his decree in full, but near
its end we are blessed with another treat. “Academic medical centers
should take the lead, rather than continuing to teach new doctors
to ‘take the money and run’.” Yup, yet again, he’s spot on! After
all, that’s the exact take-home message I got during my seven years
of exhausting around-the-clock education and training at academic
medical centers. Ethics? Nope. Squeeze those sick suckers for all
they’re worth, their health be damned! Never mind that during most
of those seven years my colleagues and I could have been pocketing
six-figure salaries in law or six-plus-figure bonuses on Wall Street
rather than accumulating education-related debt. Maybe some physicians
don’t resent his (and
our President’s
) accusations that we base our clinical practice
decisions purely or even primarily on income, but I sure do.

While I agree
that physicians commonly order tests and perform procedures that
are medically unnecessary, this fact is due to two main reasons
the author completely fails to mention: first, the tort system,
which terrorizes doctors in their practices on a daily basis, and
second, that patients have minimal if any financial stake in their
care. As a consequence, they demand everything in excess, and are
often angry when we suggest a desired test or treatment is not indicated,
no matter how much time we spend trying to educate them. When people
don’t pay for something with their own money, they hardly care about
costs. They just milk others for all they’re worth, because after
all, that’s what they perceive everybody else is doing to them,

have two options. We either serve the patient, which increases costs
primarily to the State (for many physicians, it is the largest payor),
or serve the State (and insurance companies) by limiting care and
in so doing expose ourselves to increased customer ire and legal
risk. For most, the choice is easy. Others, often rather conveniently
insulated from such issues as customer preferences, anger, reimbursement,
and legal risk, resort to utopian fantasy and contorted illogic
to justify their servitude to the State, all while concealing their
wolf-like aggression in the sheep’s clothing of nonsensical platitudes
such as the mission statement of the institute quoted earlier.

It is not our
responsibility as physicians to deny access or limit desires, other
than by informing patients of risks and benefits, sticking to our
oath to do no harm, and by charging a fair price. If someone wants
to spend many thousands of dollars of their own money on larger
breasts, that’s their business. Only they can judge if the money
and the risk of surgical complications including anesthesia-related
death is worth the benefit of a new bra size. However you might
disagree, you have no right to decide for them. Incidentally, such
cosmetic procedures are one of the few areas in medicine where costs
have been driven ever lower as quality only improves. The reason?
Plastic surgeons generally only accept patients who actually pay
the price they mutually agree upon, compared to the majority of
physicians who must accept State-mandated rates (and frequently
no payment whatsoever) in exchange for the “benefit” of additional
paperwork, regulation, and clipboard-carrying overseers. Essentially,
free market vs. State market.

Referring back
to the initial quote, if physicians aren’t paid fees for services,
then what exactly should we be paid for instead, and by whom? A
flat salary for providing “healthcare” from the State, or from some
State authorized co-op or State-regulated “insurance” company? For
checking the right boxes on a form, for adhering to scientifically
absurd “best practice” guidelines, for incentives to keep a patient
healthy and out of the hospital no matter how many packs per day
he smokes or motorcycles he chooses to crash while riding drunk
and unhelmeted? Yeah, that’ll work. Well, it might, if we just outlaw
alcohol, and cigarettes, and motorcycles, and stupidity.

Here are some
parallels that expose the utter ridiculousness and complete ignorance
of economics revealed by his claim:

  1. American
    plumbing costs will never be controlled until most plumbers are
    no longer paid fees for specific services.
  2. American
    grocery costs will never be controlled until most stores are no
    longer paid fees for specific foods.
  3. American
    computing costs will never be controlled until most technology
    companies are no longer paid fees for specific products.

Oh, imagine
how much better it would be if plumbers, groceries, and tech companies
were instead paid by the State to provide equal access for all Americans
to their products and services!

Would expenses
skyrocket, because plumbing, groceries, and computers would be “free,”
and people would demand all the toilet-unclogging, truffle-eating,
and number-crunching that other peoples’ money can buy? No! Instead,
by Dr. Lundberg’s reasoning, demand would skyrocket because plumbers,
grocers, and electronics stores “drive the majority of expenditures!”
The customers (citizens, serfs, proles) are clueless! They care
nothing about price, they care nothing about quality, they care
nothing about risks or opportunity costs, they are too stupid to
know anything at all! They just do whatever the greedy grocer tells
them, such as “BUY MORE SPINACH!!! HA, HA, HA, HA!!!” So, of course,
we must take care of them.

So how could
costs be controlled? How could the State achieve its aims? Just
how exactly would it work? Simple, a bureaucrat or even better a
“blue-ribbon” panel of bureaucrats would get to declare that no
one needs more than 2 GB of memory on his computer, or more than
3 apples per week, or a toilet with more than 1 gallon per flush
(OH WAIT! They ALREADY dictate that to us!). Of course, any APPROVED
graphic designers, or bakers, or influential friends in high places
could obtain special State permission for an exception, even through
lobbying and “donations” if necessary. And going further, that such
important items as these must pass rigorous State standards and
regulations, and therefore can only be purchased from licensed entities
such as Halliburton Computer Company, or Goldman Sachs Apple Orchards,
or General Motors Plumbing! See how the web of power and control
works! Of course, prices could not be allowed to rise, so the plumber
would be paid no more than $50 for unclogging a toilet, the grocer
no more than $0.25 per apple, the tech company no more than $200
per desktop computer.

How would the
plumber, the grocer, and the tech company respond? Would they bask
in the glow of the State’s beneficence? Perhaps, shielded from competition
with their executives ensconced in Aspen or St. Martin, but they’d
still plumb fewer toilets, grow fewer apples, and make the crappiest
computers you’ve ever had the pain of trying to use, while customers
remained on waiting lists for months just for the chance to redeem
their quota. In disgust, their best employees might even decide
to take up carpentry instead. In fact, about
half of physicians in a frequently cited though controversial poll

have admitted considering similar measures if another thousand or
so pages of preposterous power-grabbing healthcare law is passed
in the near future. Admittedly, I don’t think half will quit, but
in my circles the number making such considerations, particularly
to cut back their practices significantly while exploring other
career options far exceeds half.

Forget freedom,
forget choice, forget customers actually informing themselves about
what they do or do not wish to purchase with money they have actually
earned themselves, all because many in this country have been brainwashed
into believing that our so-called “free market” doesn’t work, is
broke, kaput, out of service, and that the classic conception of
individual rights is helplessly pass, replaced instead with their
newfangled “progressive” misconception of rights such as a right
to healthcare, a right to affordable housing, a right to food, and
a right to whatever anybody wants anytime (except when it costs
too much, whereby your rights will be modulated by your rulers to
fit their budget!).

Some other
essential points to round out the picture while I’m at it:

  1. State “insurance”
    is not insurance. It is money taken by force from some to pay
    for the medical care of others. In the case of Medicare, it is
    also money taken by force from some to pay for their own care,
    though they may very well prefer to use said money for other purposes.
    This is wrong. Period. Arguing for expansion of such programs
    is therefore also wrong. If Medicare were an insurance company,
    it would be out of business, or its executives in prison, or both.
  2. Most private
    insurance is not insurance (health savings accounts coupled with
    high-deductible plans excepted). It is prepaid care, or care paid
    for by a third party, usually an employer. Insurance does not
    usually cover routine expenses (e.g. homeowner’s doesn’t cover
    window washing, auto doesn’t cover tire changes). Insurance is
    a voluntary agreement whereby an individual pays a portion of
    current resources in order to protect against a potential future
    large loss. The reason private medical payment is structured in
    such an unnatural way is a direct result of the employer tax-deductibility
    of health insurance, which has been in effect since the World
    War II era as a direct consequence of State price and wage controls.
    True insurance, such as HSAs, tends to reduce costs compared with
    State programs, as Whole
    Foods CEO John Mackey has explained recently
    to much liberal
  3. We are
    not operating in a medical free market, or anything that comes
    anywhere close to approximating one. When the State already
    spends approximately half of all healthcare dollars
    , we are
    operating in a half-socialized market. When the State endlessly
    regulates providers and payors, and engineers a system where employers
    rather than patients pay for “private” care, we have even less
    of a free market.

State interference
in the free market is the number one reason for the cost problem
in healthcare. It has increased demand through programs such as
Medicare and Medicaid, and by making even those with private insurance
relatively unconcerned about prices. It has also limited supply
through professional licensing laws, patents, certificate of need
requirements, and other innumerable regulations. The State, not
physicians, is “driving the majority of expenditures in the US health
care system.”

In the absence
of State intervention, charity care would be provided, and in abundance.
The uninsured and the indigent would have a place to go, to be cared
for, even more so than they do today. Imagine, if the State stole
less of your income, if it deprived you of less of your life, if
it regulated and ruled you less, if you were faced with gratitude
rather than entitlement, would you be more or less likely to contribute
to charity, and to provide charitable care?

Medicine is
not fundamentally different from any other product or service. Medical
services have a monetary value. Consumers can be educated on the
value of medical services. If they can learn about such esoteric
concepts as computer memory, processor speed, hard disk size, monitor
resolution, internet bandwidth, etc., then they sure can learn about
the risks and benefits of prostate surgery. Physicians are just
one of the many sources of education for them. The internet is the
great equalizer and educator.

The only reform
that isn’t some scheme to increasingly violate individual rights
in a vain and misguided attempt to defy the laws of economics, which
is to say our essential human nature, is to free (repeal State programs
and regulations) rather than to even further socialize medicine.

21, 2009

Scott [send him mail] is
an emergency physician practicing in the Southeast. He likes tinkering
with electronic gadgets, getting in over his head with home improvement,
and dogs.

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