Tuesday, April 27, 2010

Pavlova writes in after my last post:

Your point about medicine becoming a business, can it be happening more prevalently in the US because of the state of healthcare? As most of us know, the insurance and privatisation of healthcare is a strong force in the US while other "socialist" countries like UK, which doctors are paid on a fixed wage and when the healthcare is free, one would have a better opportunity to establish a treatment plan that is based on the patient's best interest rather than the dollar signs?
I can't claim to be an expert. After all, I have no basis for comparison; I've never worked as a doctor in Malaysia or the UK, and I certainly can't claim to be an expert in US medical economics. However, I do think this is an area with no clear answers. For one, I don't think the US system neglects the patient's best interest for profit- rather, while it's true that some doctors may put money above a patient's needs, I think this is thankfully the minority.

On the other hand, a free healthcare system may have repercussions. I remember several lectures by prominent UK professors when they came over to present at grand rounds- they shared that the system there is stretched so thin that they have trouble getting routine bone densities for osteoporosis screening (again, this is hearsay- I never got to work in the UK). Rather, if they suspect osteoporosis they feel it is more cost effective to just treat the patient with a bisphosphonate rather than putting that patient through a scan. Likewise, when I was in medical school in Canada (which has a publicly-funded health system like the UK too) I remember Ben, who had to wait 3 months for an MRI of his knee, because it was for a surgery that was deemed 'nonemergent'. So, if you have a public system, the waiting list ends up being very long because of a lack of funding.

Also, when you have a 'free' system, it encourages patients to take advantage of things. I recall the ridiculously good employee health insurance at my alma mater: employees would not take time off to see their doctors at clinic for minor ailments, preferring instead to just pop by the Emergency Department after work for a sore throat or ear infection. Thus, the ED became overwhelmed and the insuror ended up with a bulk of the bill (since ER visits are always more expensive). Eventually, they had to change their coverage to a less generous plan.

Here, while profits may be a driving force, it also does ironically do some good too; most hospitals have the financial resources to be pretty well-equipped. My current hospital has numerous cath labs, 2 medical helicopters, and numerous top-of-the-line MRI scanners and radiosurgical facilities. True, patients pay a premium for medical insurance compared to some parts of the world, but one could argue that the care they receive tends to be superior, too. Also, over here the fear of malpractice lawsuits indirectly force us to give the best possible care, and probably backfires in the process; the so-called defensive medicine. Ie, the practice of getting more tests than clinically (but not legally) warranted just to make sure we don't miss something. It's one of the issues I have with this place, which is real given the sheer numbers of radio and TV ads everyday, promoting a lawyer's service for any injuries you might have suffered. Take my specialty for example- central hypogonadism (low testosterone) is not uncommon, and in most cases is idiopathic (no clear cause). Yet many professional organizations suggest a pituitary MRI to rule out a central lesion. In my 5 years of doing endocrinology, how many cases of this have I seen? 5 or 6. Out of the hundreds and hundreds of MRIs I've ordered. Practising defensive medicine therefore inevitably jacks up the price of healthcare, and doctors do it not to make money but to make sure they don't miss something that gets them sued.

Also, it's a misconception that we get to bill whatever we like and make more money. We provide care, and we code it according to the level of care we provide (usually dependent on risks, complexity, and there is a pretty strict set of criteria for each). The insurance companies have already pre-negotiated with the healthcare systems to pay a certain amount for every level and the doctors have no involvement at this level. This coverage by the insurance companies (and patients may also pay a small co-pay) is the same whether this is to a private clinic, or a not-for-profit organization like the hospital to which I'm attached (at least, that's how I think it works).

So, I don't really know what the best answer is to things. I don't think I'm smart enough to figure out this problem. But I do think the system isn't ideal, neither here nor there. Here, I despise how it costs my patients so much for care, and for medications. There, while it's great that patients who can't pay still get care, what is the quality of it, and how long do they wait? In many ways Malaysia is similar to the UK's (except we have the option of a private-tier): thinking about my hometown, there isn't even a cathlab for emergency PTCA, so public systems aren't ideal as well.

In some ways, I do catch myself thinking, if you want to have the perfect healthcare system, get rid of 1) the doctors, 2) the lawyers, and 3) McDonald's! That way, you cut down on risk factors, and you get rid of the people who mess up the system (McD: I'm being facetious, obviously. Don't sue me!)


Blogger pavlova said...

Thanks Doc for your lengthy post.
I am not expert either, have not worked in the US healthcare system but I am in the NZ healthcare system, which has a free component but also have a private option.

Yes in most Commonwealth countries you do have a system that is free hence creating a long waiting list, but the waiting list is for elective surgeries.
If heart patients over here need their surgeries, they are flown to Australia to have it done (after strict selection criteria).
Yeah a waste of taxpayers money you would say, but for me personally, I take comfort that if I (or my loved ones) need help, the system is there.

For me, some healthcare is better than none. I don't understand the US system where so many people are against universal healthcare, saying the government is "regulating" the industry, but to me, the insurance companies are regulating the system as well. Those who can't afford insurance and are not eligible for Medicare and Medicaid are getting no treatment.
While I applaud that US has one of the best and more innovative medicine industry in the world, I'm not sure if I totally comprehend the vast gap between the have's and have-not's.

Thanks for the post again, Doc. :)

2:39 PM  
Anonymous Anonymous said...

Checkout "What's ailing our healthcare system in Malaysia" here:


10:01 AM  
Blogger Hannah Tan said...

Dr.V... thanks for your post... I have a friend from SF and she was telling me how her bill for going into the ER for a hypo came up to USD 6K for just a few hours of monitoring to make sure her sugar levels are stable (she's a T1). But because she has good insurance, her insurance company pretty much disallowed 90% of the bill and paid the negotiated rate with the hospital and my friend only had to pay the minimal co-pay and nothing more.

I have another friend who has no insurance and ran into some medical problems with episodes of hypo and DKA which landed her in the hospital for 3 months in Arkansas. Her bill was USD 500K and now she owes that bill pretty much her whole life although she was treated.

Just from the above 2 examples its pretty evident that in US if you don't have any form of insurance you're "screwed"... i've also heard of many folks getting bankrupt just because they can't pay the medical bill and we have many folks coming into the diabetes forum seeking help saying I have no insurance but I can't afford to see a doctor

I've heard as well that some places they would provide free healthcare if you can't afford it... but you really have to look out for them in the US... (of course i'm no expert in the US healthcare system as everything i know is from what i hear from my friends from there)

In a way i'm glad that the healthcare bill passed through as many of my friends that are diabetics will then be covered... which is why i don't understand why some folks are so against the healthcare plan

For that... I'll say... while malaysian healthcare is definitely not bad at all... we have the choice to choose between government or private... at least i know that if i run into financial problems and can't afford healthcare... at least i can still get some care at the gov hospitals / clinics

4:18 AM  
Blogger Hockeyclimber said...

Just a couple of comments:
1) If we get rid of the docs, you're in trouble V!

2) Question of the day: do we compromise the quality of care for everyone to provide healthcare coverage for a fraction more of the population?

3) Most people in America do not realise what taxes are in the countries with universal healthcare. There are only 2 ways to fund or expand funding of government programmes -- print more money (very bad) or double/triple current tax rates (also not good). Which would you prefer?

I agree with parts of the healthcare bill, but not enough to support it in its current state. So I guess that means I'm not a fan of it.

6:10 PM  
Blogger Hockeyclimber said...

Sorry, forgot one more thing: the bill does not provide ANY protection for the unborn -- it does not prevent the use of taxpayers' monies to cover abortions at all. The politicians have given some smokescreen comments about not routing the money directly to cover abortions but have left the back doors wide open to do so in some (rather illogical and insensible) indirect way.

6:15 PM  
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8:43 PM  

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