A lie told often enough becomes the truth - Vladimir Ilyich Lenin
The Mythology of Modern Medicine
A great number of falsehoods have been promoted to physicians and patients as "truths". Like the myths of old, a patina of age hangs around these constructions, implying that we have come to accept them after many centuries of acceptance by wise and experienced physicians. The reality is that most are of modern vintage and have never been subjected to objective study or critical analysis.
They have achieved a myth-like status in our society because of the short memories of physicians and patients and also because medical history is not credibly taught in any of our schools of medicine.
Unfortunately, these myths have none of the interesting symbolism and qualities of ancient mythology, nor do they have the values of fables and fairy-tales to guide behavior and reinforce tribal standards of responsibility and heroism. Lacking in truth, beauty, or insight, they only serve to deceive and degrade.
Pseudo-myths of this sort have been promoted because they serve the agendas of the medical-industrial complex and help to protect their profits and influence.
As with many lies which have been repeated enough that people have started to believe them, these myths are pervasive and are almost always accepted without question by both physicians and patients in the United States. This section will examine a number of these, as well as their implications.
The Storytellers
The creators of medical school curriculums and the faculty of these schools have been the most prominent sources for indoctrination of physicians into these belief systems.
They themselves are responding to pressures from the political and corporate establishment which fund and legitimize our system of medical education. Medical students, limited in their exposure to reality until well into their thirties, continue to be indoctrinated throughout their training. Physicians tend to then pass their belief systems along to their patients.
Some physicians have come to question the value and truthfulness of these myths, as they develop practical experience with the realities of medical practice. However, within the doublethink environment of modern medical schools, the myth of "academic freedom" ensures that faculty can believe and teach without fear of censorship, as long as they teach what serves the needs of the insurance and political system lords. Funding for research is similarly focused.
As with all bureaucracies, compliance is maintained by hiring and rehiring only those who demonstrate politically and economically "correct" viewpoints.
The public perception of these myths are created and maintained primarily by the political and corporate beneficiaries of the present system and are repeated endlessly by their media footpads, the television and print oligopolies. Physicians are exposed to media influence through their own homelives, and the editorial and advertising content of the many medical journals they must review.
As costs are not covered by subscriptions, without advertising on almost every page by the pharmaceutical companies, none of these publishers or their editorial staffs would have a magazine or a job. Little wonder that they support the mythology of the medical industrial complex.
Physicians themselves are considered to be so vunerable to ethical compromise by accepting a pen and pencil set, a free dinner, or some other insignificant offering from the pharmaceutical industry that the AMA has sternly warned against such unethical behavior.
The vast sums spent on drug advertising within the pages of the Journal of the American Medical Association, or the American Medical News, as well as many other medical journals, somehow fails to turn the heads of their stalwart editorial boards and employees. One wonders why we ordinary physicians cannot measure up to this level of moral fiber and good character.
It is also remarkable that the medical establishment is silent when it comes to the corrupting influence of third party payment systems whether governmental, "not for profit", or "for profit". As is widely appreciated in the "business" model of medicine, "he who pays the piper calls the tune", in essence transforming the independent practitioner of medicine into an agent of the State, or a de-facto employee of an insurance conglomerate.
Patients are also increasingly the targets of this television and media propaganda. "Consumer" magazines are increasingly filled with ads for pharmaceuticals and medical procedures, as well as articles which reinforce the viewpoints favorable to powerful economic conglomerates and lobbying organizations.
Myth Number One:
"Medicine is a Business"
One of the most pernicious assumptions daily broadcast throughtout the land is the idea that the practice of medicine is a business like any other. Modern efforts to shoehorn physicians and patients into this ill fitting boot has resulted in tremendous damage to the practice of medicine, with very few, if any, counterbalacing benefits.
For centuries, if not millennia, medicine was understood to be a unique calling in every traditional culture. Although there have always been issues of commerce in medicine, physicians historically were bound by Oaths of Medicine and dedication to the well being of society and tribal unity.
Physicians who upheld these ideals of professionalism were rewarded with a respected place in society. In this character-based system, a patient and a physician developed a long term relationship based on trust and mutual respect, and individualized care resulted as much from the personal basis of the relationship as from the science, art and craft of medicine.
Created by the needs of patients and physicians and their common goal of relief of suffering, this medical system was both logical and efficient.
In the "business" model of impersonal, standardized medicine, patients are seen as "consumers" and physicians as "providers". The implication is that medicine is a commodity, which can be dispensed simply with no effort on the part of physician and patient except a monetary exchange.
In much the way that a roll of tape sold in one outlet store is exactly the same product in another retail establishment, the implication is that a procedure or diagnosis is a standardized unit of service, and physicians are interchangeable cogs in the vast machinery of "health care".
This pseudomyth defies both everyday experience and common sense. Medicine remains a unique relationship between patient and physician, and cannot be "standardized". It is a relationship as complex and as longstanding as those of marriages, family relationships, and friendships, and the strengths and weaknesses of both patient and physicians contribute to the success or failure of the process of healing.
The priorities of "business" which have been imposed on the physician patient relationship over the past half-century have only served to alienate these former allies.
The Rise of the Medical-Industrial Complex
The modern experiment in disenfranchising patients and physicians began during our second World War, and the ramifications of this experiment have created a monstrous and impersonal medical industrial complex which answers to neither the needs of patients nor physicians. The modern practice of medicine has subsequently decayed to the point where it is hardly recognizable when compared with its ancient forebears.
In an attempt to circumvent wage and price controls and compete for workers in a depleted labor force following the war, employers found a loophole in the tax laws which allowed them to pay for third party medical insurance as a benefit.
This benefit was effectively an increase in wage levels beyond wage controls and so attracted workers to these businesses, and marked the point at which power and decision making shifted from the people to the now all-powerful medical insurance industry.
The tax laws favored businesses paying for insurance, as it was considered a deductible expense. Individuals who bought their own policies or paid the physician directly saw no benefit, as they were unable to deduct these costs from their own taxable income.
It was not until 2003 that self employed individuals could deduct 100% of their health insurance costs from income tax, but there remained an inequality between businesses and individuals: there is no deductibility of health insurance cost for the purposes of self employment tax.
In addition to the inequitable tax situation, the need to submit bills to a third party forces patients and physicians into an irrational system of petitioning insurance bureaucrats for coverage of treatments and medications recommended by medical professionals. And, if you have not met your "deductible", an arbitrary figure which allows the insurance industry to avoid payment for medical services entirely, patients receive nothing for their increasingly unaffordable premiums.
Patients had to wait until 2004 for the creation of Health Savings Accounts so that they could make at least some decisions for themselves regarding the types of medical services they wanted, without the insurance industry telling them what was "medically necessary". This phrase, of course, is another indication of how often the decisions made between physicians and their patients are second-guessed by bureaucrats with no medical training.
Profits For Another Set of Fat Cats
The creation and legitimization of the HSA does not change the fundamental error of creating a business bureaucracy to pay for medical care, but merely shifts the risks around.
As such, it is another accounting and conjuring trick to fool the patient and physician into believing that a new shell game will improve the situation.
Always a credible source when it comes to the mythology of medicine, the American Medical News of February 20, 2006 details how lucrative this will all be for various financial institutions: "There's a gold rush in the financial industry. Banks, mutual funds and other money institutions are the forty niners. Health Savings Accounts are their Sutter's mill."
"Financial institutions are vying for a potential 75 billion in health savings account deposits" (page 19)
However, one can be certain than none of the vast profits that will be squeezed out of this new scheme will flow into actual medical care.
Why Trust Your Employer to Choose Your Physician?
Another malevolent result of these tax code inequities is placing responsibility for choosing the sort of coverage employees receive in the hands of an employer.
Your employer may know a great deal about manufacturing widgets, selling groceries, or whatever, but there is no evidence that employers have the expertise and know-how to choose among the many options of medical benefit levels and coverage decisions, most of which are deliberately obscured by the third party payers.
The result has been to choose whatever has the best effect on the balance sheet and profit margins. The consequences for the employee and their family is significant, but the actual value of medical coverage to the employees are of secondary importance.
Early on, the nascent medical insurance industry saw the potential benefits of making their costs and profits invisible to employees, who knew little about how much profit was built into the payments taken out of their salaries.
In these early days, the greed of physicians also played a role, as "reasonable and customary" fees were almost always paid, and quickly.
Physicians were lulled into believing that dealing with one payer would be easier than maintaining accounts with hundreds of patients. They did not have the foresight to see that at some point, the easy flow of cash would be restricted to pay for the profits of the insurance companies.
Even if doctors felt some trepidation of allowing this interference in the physician patient relationship (a violation of the Hippocratic Oath), many of these doctors rightly figured that this would be more of a burden on future generations of physicians, so, many years ago, they sold out the integrity of medical practice, took the money, and retired fat and wealthy.
Myth Number Two
The Exaggerated Efficacy of Pharmaceuticals
All traditional medical systems utilize foods, plants, minerals, and their extracts internally and externally to affect disease. Some of these systems are extremely effective, and their dangers and limitations have been demonstrated over centuries of experience.
It is well known by traditionally trained physicians that all drugs can be poisons, and that in skilled hands, all poisons may be used as drugs. Fairly recent advancements in chemistry and biology have permitted some investigation into the structures and synthesis of many natural products.
As with the tax code's effect on medicine, the quirky legal system which we have has created a commercial bias against developing and improving upon natural medicine and towards creating synthetic and experimental pharmaceuticals. These latter may be patented and thereby confer the benefit of barring all others from creating, marketing, or making money from these patented substances.
Because all reasonable people must accept that the structure of all aspects of medicine are those of businesses, and the purpose of business is to make a profit, it is not surprising that selling pharmaceuticals has become such a large part of the world of commerce, and these enterprises have grown to have enormous strength and influence.
Along with this marketing power has come the implication, implicit and explicit, that pharmaceuticals are far superior to natural medicines. Natural mediciness cannot be "standardized", so therefore the skill of the physician is paramount. This lack of standardization does not prevent those with skill and wisdom from effectively using these substances, as has been done for millennia.
After all, most food items are not "standardized", and yet we accept that a skilled cook can make a nutritious and tasty meal from ingredients which vary from season to season, and from different locales, even substituting ingredients when necessary.
The skills of using natural medicines has become extinct in medical training in the United States, and this trend fits nicely into the goal of standardizing medicine into a service commodity. Once physicians dispense medical care in just the same way as expressos are served, it will be much easier to standardize costs and maximize profits.
Individualized care is a luxury which apparently ordinary citizens cannot afford in the United States, if the profits of the medical industrial complex are to be maximized.
However, even by our own "scientific" standards, pharmaceuticals are not nearly as effective and free of side effects as modern medical mythology would suggest.
Breathless trumpeting of new therapies and "miracle drugs" by the media, and direct to consumer marketing by the pharmaceutical industry (they know you don't have time to read the small print in their ads) never addresses whether these drugs actually work in most people. Those who suggest that benefits and efficacy are exaggerated, even for those well placed within the pharmaceutical industry are generally ignored.
Physicians who actually treat patients know this, but they are often bamboozled by a combination of clever marketing, wishful thinking on their own part, and the fact that many patients rarely return and tell them that the drugs they prescribe haven't helped them or have intolerable side effects. Even if they do, the physician often prescribes another drug and doesn't have time or the interest for reflection.
As a result, it is always a revelation when a pharmaceutical is found to be more dangerous and less effective than all the "experts" "long believed".
It is no surprise to find that the "experts" are always academicians whose grants and salaries are always directly or indirectly dependent on their subservience, or media "favorites" who have learned to parrot the appropriate lies. Practitioners at the front lines, clinicians who see patients in an ongoing relationship, are rarely asked for a sound bite for the media, and are too busy to solicit grant money, present papers and write books.
Industry Calls the Tune
Drug studies are so expensive that only the medical industrial complex can "create" research. This is the only legitimate source of information accepted by the medical establishment. Companies that have the connections and influence to obtain the tax incentives and necessary cash flows to pay for studies essentially determine what drugs will be tested and how their effectiveness will be measured. It is not surprising that studies which show a benefit from the drug are published, and those which find no benefit or hazard are not. It is clear that when results are in line with the interests of the fat cats, the studies are disseminated by medical journals whose advertising and income are dependent on these very companies. No conflict of interest there, of course.
In a review of 56 industry-sponsored trials of non steroidal drugs, every one found the drugs to be effective, a finding that supports the idea that medical journals are de facto marketing systems for pharmaceutical companies. http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020138
Equal support can be found for the inverse: when an industry sponsored study is unimpressive, it somehow never reaches the readers.
Between 1987 and 2004, drug firms registered over 70 clinical trials of antidepressants with the FDA. Erick Turner of Oregon Health and Science University in Portland found that 23 of these studies never made it into a journal. One reason might be that all but one of these studies found no benefit or increased hazard from the drug treatment. (New England Journal of Medicine vol. 358, p. 252) This "publication bias" makes drugs seem more effective, so doctors dutifully prescribe.
Myth Number ThreeTechnology Will Make It All Better
Vast advances in medicine have been possible as a result of technologic developments in imaging, anesthesia, surgery, cellular biology, and biochemistry. When physicians fail to apply these tools with wisdom, and develop unquestioning and dogmatic attitudes with regard to these developments, they may lose touch with clinical reality. Increasingly, I see patients discomfited or injured by physicians who seem to have lost the ability to apply centuries-old patient centered evaluation processes.
Late last year a patient appeared in the office who told me of her symptoms of chest pain waking her at 3 a.m. two nights before. The story she told suggested a blood clot in the lungs, a pulmonary embolus. She had gone to the emergency room of one of our more famous local hospitals and evaluation for a heart attack was negative.
Despite having fairly classical symptoms for an embolus and an exam that was consistent, these doctors seemed to only be able to think in terms of the technology which was available to them. The patient was sent off with only the reassurance that "it was not a heart attack".
Even when alerted to look for a blood clot, technological tests could not locate the clot, as it was probably too small. The physicians in this case could not accept the evidence of their history and exam, and instead galloped off in search of rarer conditions, applying expensive tests with abandon.
Fortunately, these tests did not place the patient at much risk, though they resulted in no useful information. She was again sent home with no treatment for this rather dangerous condition.
Trusting in my own exam, which confirmed my suspicion that she most likely had suffered from an embolus, I told the patient that her doctors likely found a "false negative" result for their exam, and applied the techniques of natural medicine to the problem, which resolved the symptoms and signs of the disorder at each treatment.
Although not a perfect resolution, when a specific treatment for a condition improves the condition, it helps to confirm the diagnosis. It took about 4 treatments over two weeks to completely eliminate all symptoms and signs.
These doctors could not accept the diagnosis which was most likely because they have been trained to be uncomfortable and uncertain if a machine does not confirm their suspicion. Increasingly in the area where I practice, machines and their results determine what doctors accept as truth.
In addition to preventing treatment of conditions which require it, this attitude results in many tests being ordered which are not indicated. I usually advise a patient that a test is not indicated if the results have no effect on treatment or supply useful information for the physician's management of the disorder.
There is another side to this problem of unquestioning reliance on technology. The finding of any abnormality may prompt an invasive or overaggressive treatment where a more considered approach based on traditional Oriental medicine may produce good results at lower risk. One reason that techniques such as acupuncture are not acceptable to many physicians is that neither the procedure nor the symptom response can be measured by a machine.
For symptoms such as pain, fatigue, disorders of the menstrual cycle, daily function and so on, there is no machine that can measure improvement. When a patient tells me that her headache is gone, no technology can "confirm" the truth of this and, as a result, there are some physicians who deny the benefit has occurred. These are often the same physicians who have no problem accepting an improvement if the pain has been treated by surgery or drugs (see Myth Number Two, above).
Clinical measures of improvement are losing credibility in a society where technology is worshipped, despite their central importance in all traditional medical systems.
Electronic Medical Records
Another example of uncritical acceptance of a technologic solution for our dysfunctional health care system is the belief that transferring the information from a medical chart into a database will improve results.
Both Congress and Mr. Bush have gone on record supporting this expensive and unfunded mandate for physicians already burdened with a variety of financial challenges. In April of 2003, President Bush set a goal of creating an EMR for every citizen within 10 years, and he visited Cleveland in January 2005 to promote this part of his agenda to local physicians.
Where is the evidence that such an expensive and trouble prone program will improve the skills of physicians or the results of treatment? Citizens who are familiar with calling computerized banking, credit card, and utility companies and being told that "our computers are down" might be less likely to believe that these ponderous and unproven systems will be reliable and secure. Remember that a vast number of technicians and bureaucrats will be required to have access to these records to keep the system running.
Better Reliability Than Pencil and Paper?
Viruses, hackers, grid failures and more have shut down airlines, utilities, and even parts of the internet. During the Christmas holiday of 2004, a computer failure grounded 1,100 flights for the carrier Comair on just one day. Imagine what will happen when the operating room schedule, the EMR, or the computerized pharmacy system goes down.
The theft of computerized records of every active and retired member of the United States Armed Forces in May of 2006, and then again a month later should be a reminder of the shortcomings of electronic medical records. Many smaller intrusions into medical databases have already occurred and are ongoing, but for obvious reasons are not widely publicised.
These systems will be hacked or stolen and you and your children's private medical information will be made available to international and local criminals, busybodies, as well as your bosses, co-workers, and neighbors.
Electronic records will not improve the accuracy or value of the data entered or we would have seen a vast improvement in the quality of literature when writers moved from pencils to typewriters, or typewriters to word processors. Is there any reason to believe that merely moving information into a new medium will improve its value?
At an initial cost of $20,000 to $50,000 per physician in practice, along with the usual ongoing maintenance and "upgrade" costs, I think it would be useful to see some evidence before this plunge into the unknown is prescribed for America's physicians and patients.
"Garbage In" Equals "Garbage Out"
One issue that seems never to be a concern is how data will get into the "electronic data base" in the first place. Will physicians be typing their history, exam, and treatment into a keyboard while they are seeing a patient? Don't expect a very complex or realistic record if it it has to be done while the patient is in the room. Will we just be checking off squares on some standardized list? Are physicians going to be typing into the night to add detail to their charts?
One unintended consequence of using 'templates' and 'macros' to create detailed records optimized to enhance insurance code submission will be to create paragraphs of medical boilerplate in people's charts, whether or not they reflect the actual exam or findings.
A recent report by the U.S. Pharmacopeia suggests that electronic interfaces for prescribing are also not likely to improve patient care. In this study, "computer entry" was the fourth leading cause of errors, and "performance deficit" was the first.
What is "performance deficit", you may wonder? It seems it means that the user of the computer had the required knowledge to use the program, but still failed to apply that knowledge. The solution? You guessed it. More training and better design. Of course, better "training" and we would not have a need for a technologic solution at all. American Medical News January 24, 2005 page 11
Another Danger to Your Health: "Multitasking"
Doctors who are "plugged in" and typing into an electronic medical record, are also likely to find that their analytical and problem solving skills diminish below acceptable levels. Perhaps there are some people out there who are great at multitasking, but almost all scientific evidence and everyone's common experience suggests otherwise.
If a doctor is typing while interviewing a patient, even if they are perfect typists and the software is not distracting or crashing, I guarantee you that doctor's mental abilities and problem solving skills are less than a physician who is not "multitasking" and is just communicating with the patient.
Most doctors are poor enough listeners as it is, without another mandatory source of distraction. And, remember that when the doctor is looking at the screen, there can be none of the non verbal communications that are often essential to perceive.
The level of impairment for multitasking doctors may be comparable to being legally intoxicated, if a study at the University of Utah is applicable.
Myth Number Four
Health "Insurance"
Mislabeling this financing technique has created a vast burden for physicians and patients, and brought the "health care" industry into existence. Consuming an ever increasing proportion of worker and tax revenues, this bloated monstrosity will eventually consume and destroy the tradition of medical practice in the United States.
But, it is not "insurance". A quick review: People and businesses buy insurance to compensate for unlikely or unpredictable disasters and events, which, if they occur, will wipe out a large proportion of your assets and earning power. Should your house burn down, or be hit by an airplane, the insurance will not restore your losses completely, but will, after considerable time and effort (which is not insured), allow you to painfully rebuild your life and assets.
"Actuaries" attempt to estimate how likely events are, and insurance companies set their premiums accordingly to maximize profits and minimize payouts. Estimating such probability levels of various events is not exact, so premiums are always adjusted to ensure suitable levels of profits for insurance companies. In addition, insurance companies can use "deductibles" and non renewal of policies to protect their cash flow.
In contrast, the services of medical personnel are not unlikely or unpredictable events. Preventative and regular medical care is not only a good idea, it is mandated legally for children to receive certain vaccinations as well as prenatal and childhood visits to the physician or nurse practitioner. A certain number of surgical procedures will be required during most people's lifetime to treat injury, screen for disease, and for treatment. Close to forty percent of all Americans are taking pharmaceutical drugs chronically, which requires ongoing supervision, laboratory testing, and evaluation of results and side effects.
The history of third party intrusion into the physician patient relationship was outlined previously in Myth Number One, and now the inefficiency of this system has grown to the point that most citizens will be paying more for "health insurance" than they would if they paid for medical care directly. Unable to influence the decisions of the powerful mega corporations who control medical cash flow, patients are forced to pay for care they will never receive, as well as to support an increasing bureaucracy of middlemen and women. And, many of these middlemen are paid much higher compensation than doctors or nurses.
Maximum Inefficiency
Having a complex and mostly unfathomable third party payment system requires that patients and taxpayers support the costs of delivering payment in addition to the actual costs of medical care. This does not improve the value that patients receive, does not improve outcomes of treatment, and actually drives efficient and effective practitioners out of business, in contradiction to the propaganda from the political and medical industrial complex.
Hiding behind the falsehood that citizens and businesses cannot afford the "increasing costs of health care" instead of "increasing costs of the middlemen and compliance with an increasing regulatory burden", the solution is always a new and expensive "program" that diverts cash flow from actual medical care to the regulators and bureaucrats.
If a car owner had to wait for approval from his or her automobile insurance company to buy gas, install wiper blades, or perform regular maintenance, would this be an efficient system? Imagine that only a few approved gas stations would be covered by your insurance, forcing you to travel farther to fill up. Which stations are "approved" would change every few months or years, so you would never know when you pulled into a gas station whether your insurance was still accepted.
Occasionally, you would not have enough gas to drive to an "approved" station and the extra cost of being towed would have to be considered and added to your insurance premium.
Imagine that your automobile insurance company then requires submission of paperwork so complex that every family with a car would have to hire a specialist to submit bills for everyday expenses that would require at least a few more hours of work and a few months' delay before payment was received by the gas station. What do you think the cost of gasoline would be? Do you believe that that gasoline would be of any better quality than what you obtained when you just handed over your money at the pump?
Suppose that you had to have your insurance company's approval to fix a squeak in a hinge, or repair a light bulb? After all, you can get used to the noise. A clerk will wonder why you have to drive at night, anyway? Every decision and expense will be second guessed and will require you to produce more paperwork and spend more time on the phone to "appeal" these dictates. Having the "benefit" of not paying directly for everyday expenses would also soon require new regulatory agencies to "maintain standards", and all of these costs would have to be figured into your premiums.
In short order, your expenditure for this type of "insurance" would exceed the cost of your car.
So, of course, is the reality of health "insurance"; directly paying for medical care would be less expensive and result in better accountability and higher standards.
Fraudulent Financing
Mislabeled as "insurance", the present system represents a financing scheme where the actual costs are hidden from patients to such a degree that the result is equivalent to consumer fraud. One egregious example is the yearly "deductible", which allows your health "insurance" entity the pleasure of not paying anything until some arbitrary outlay of cash is made by the patient every time January rolls around.
Perhaps appropriate when it was created to discourage small claims on real insurance policies, this feature is nonsensical when applied to health care. Your house isn't destroyed by fire every year, but you will need medical visits every year. Multiply this deductible amount by the number of "insured" and you will see why the resulting millions bring smiles to the multimillionare CEOs of this overpaid sector and their stock and bond holders.
Every medical practice now needs at least one full paid employee (with benefits and all the attendant expenses) to comply with arcane and constantly changing billing rules. Increasing communications between physicians and third party payers to "justify" medical billing has required more phone lines and considerable inefficiency as medical staff wait for hundreds of hours a year on hold or in navigation of multiple automated menus.
The increase in paperwork or electronic transfer of records and creates another layer of costs. Entire city blocks full of buildings are filled with people doing nothing but this.
Not a wise use of your "health care" dollars.
Another result of this growing "insurance" industry is that medical information is disseminated so widely that another ponderous regulatory scheme to maintain the privacy of this information has been created. New software, new regulations, new middlemen have to be paid for. And, of course, we need a staff of enforcement officers to ensure compliance with the new regulations, and a system of fines and fees for infractions.
A seminar industry has sprung up to help physicians, hospitals, and medical staff understand how to comply with these new intrusions on the physician patient relationship, and the ongoing patchwork "fixes" by legislators when the unintended or unexpected results of their complex regulations are found. (Think of the Tax Code) The cost for new software and training has to also be added to the final expense, and this takes time away from actual medical care for patients.
None of the privacy regulations work, of course, as there are so many places to hack into the system or create problems from human error that compromises of patient privacy are commonplace, daily occurrences.
The costs of this ill conceived system, and all the other costs of our inefficient and bloated third party payment financing system are always entirely passed on to the consumer. Prices for physician services and surgery have been inflated by a factor of at least 2 to 5 times to account for this extraordinary level of waste and inefficiency. The resulting effect that the cost of "health care" seems so large that no one could afford to pay for it directly. This is what you are supposed to believe, and it is repeated endlessly by the media and, of course, our "representatives" in the government.
Can Citizens Really Afford Health Care?
Absolutely. Both patients and physicians will have to retake responsibility for our past mistakes, and rich and powerful interests will stand in the way, so this would not be an easy transition. These interests now maintain a cozy relationship with our legislative branch of government, which is dominated by millionaire lawyers who will not give up their power to control these vast cash flows to their cronies and "contributors". The opposition to a return to a sane system of health care should not be underestimated.
The alternative, however, is to suffer the continuing death spiral of damaged relationships, increasing "errors" and poor quality care. The exodus from healthcare by experienced physicians who can no longer afford their overhead, or the constant unfunded mandates of third parties, will continue.
A significant first step might be to unwind the vast wealth amassed by third party "insurance" companies and their executives, as unlikely as that would be given their political influence. This money could be restored to the defrauded victims of this scheme or to establish a fund for the indigent.
Patients who are now able to afford their health care "premiums" are actually spending a great deal of money which could more efficiently be self-directed into actual medical care. The Agency for Healthcare Research and Quality reports that in 2002, the average cost for two person "insurance" coverage was $6043.00 a year, and this number has risen faster than inflation since. For patients in Ohio, a two person high deductible ($5150.00) HSA in 2006, the yearly premium is very close to $10,000! Given average primary physician reimbursement, a family could afford two visits every week for a year and still save money.
Tax advantaged health savings accounts might allow people to establish funds to pay for medical care in just the same way they establish savings for taxes, utilities, vacations, and retirement. As presently configured, however, they still allow "insurance" companies another vehicle for exorbitant profit.
If we could relieve the cost of supporting the present burden of the third party sector, there will be pressure on physicians and hospitals to reduce their prices to reflect the market value of their services, more in line with what they now eventually receive from third parties. We see this already happening to a small degree with the development of "Health Savings Accounts" since these patients realize they are paying with their own dollars.
Government Payment Schemes: More Bureaucracy than Private Systems
If a more inefficient and bloated system than that of the private sector could be devised, they would resemble what our elected representatives have created in the Medicare, Medicaid and Worker's Compensation systems. At least the private systems have to generate profits.
Government regulated programs are vastly more bureaucratic and irrational, and have the same need for an "enforcement" bureaucracy to ensure compliance with a Byzantine system which changes on a monthly basis. Fueled by tax revenues, accountability is even less than in the private sector. And, government based schemes are subject to political manipulation to a greater degree than the private sector.
As with other aspects of our society, dependence on a regulation based system of laws and enforcement will always create an inferior service than a character based system of ethics and shared tribal obligation.
When is a Benefit Not a Benefit?
When it comes from Medicare, of course. I cannot resist sharing this gem from "Family Practice Management", page 15, February 2005. Thanks to the "Medicare Modernization Act", new beneficiaries will receive coverage for a "Welcome to Medicare" exam.
In the article, after physicians are told how to code for the visit's initial exam, electrocardiogram and blood screening, the author points out; "...because the initial preventive physical exam is subject to Medicare's deductible and coinsurance provision, beneficiaries will typically end up paying most of the Medicare allowed charges...". The author goes on to warn physicians that they "might want to alert patients to this fact so it does not come as a surprise when you attempt to collect from them." No kidding.
Without any sense of irony at all, the author ends his article with the statement, "The new benefits provide an opportunity for physicians to get paid for prevention and screening not previously covered by Medicare." Well, only if the patient pays for it, so it is "covered" in a sense that only the Red Queen in Alice in Wonderland can appreciate.
As far as the new Medicare Part D "benefit", the complexity of this program and the troubles it has already created for patients and the bureaucratic hassles it has created for physicians are too numerous to list.
Modest Reforms of the Tax Code Would Benefit Patients
Several adjustments to the tax codes would be helpful in supporting a transition from a program which rewards inefficiency to one which rewards results. Individuals should enjoy all of the advantages presently available to corporations and the self employed. Patients should be able to deduct from income all out of pocket payments for any medical care, whether from physicians, nurse practitioners, massotherapists, homeopaths, midwives, herbalists or whoever. The same should apply for costs for drugs, supplements, and herbal treatments.
Large expenses, such as a surgical procedures, can be financed by banks at a low interest rate loan with an affordable maturity in just the same way that homeowners can now take advantage of low interest loans guaranteed by Freddie Mac or Fannie Mae. Interest on medical loans would be as deductible from income as home loans. Practitioners should also receive some of the largess extended to the medical industrial complex: Many hospitals already are tax advantaged and the same freedom from property taxes should be extended to all practitioner owned medical facilities.
Once they have regained the power to understand the real costs of treatment and compare prices, coupled with these tax advantages, patients would be able to afford uncommon expenses, such as unusually expensive drug therapies like chemotherapy or immunotherapy, or high technology and rarely needed expensive surgical procedures in just the same manner as they now can afford other expenditures like a $15,000 to $40,000 car every three to five years, or a $200,000 to $500,000 house every five to twelve years.
Tax credits for entities who provide uncompensated care for lower income patients would be an option, as would vouchers, or we might see a return to charity care, such as was common in this country before the rise of third party payments and the transformation of charitable hospitals into profit centers. Some of the high end real estate now occupied by third party payers would make fine clinics.
Before the impossible burdens of the past 40 years of social engineering were placed on them, physicians were able and willing to provide charity care. Transforming medical care from a "business" back into a tribal relationship valued by society would restore the respect given to the medical professional, and professionalism would slowly return to medical care.
Myth Number FivePay For Performance
As with other trendy catchphrases, such as "health maintenance", "disease management", and "wellness promotion", the meaning of "pay for performance" requires some investigation. Everybody wants more "pay". Everybody wants better "performance", although this is a pretty vague concept when considering medical care. So who could find fault with this burgeoning trend?
The reality behind this seemingly attractive phrase is a new methodology for improving the profits of the medical industrial complex. Hiding behind well worn euphemisms such as "improving quality" and "patient satisfaction", these programs focus primarily on cost containment.
In short, as with the capitation and health maintenance movements, physicians are rewarded for spending fewer of our "scarce" health care dollars on patient care. Since physicians are responsible for prescribing most drugs and procedures, controlling their choices and utilization is the focus for all of these modern-era experiments in paying for medical costs.
A serious student of the history of modern medicine will notice that every few years, groups of influential experts reveal to the rest of us (those who pay for, utilize and provide medical services) that they have discovered answers for any number of the problems of expense, error creation, and increased suffering that our present medical system creates.
It is remarkable that the solution is always a new payment bureaucracy or layer of regulation.
There is also always a need for "more research", funded by and for the benefit of the medical industrial complex. The end result of all of these schemes have in common the creation of new levels of interference to the physician patient relationship. The creation of another level of middlemen or a policing agency also serves to shift money out of actual patient care and into the nebulous black hole of "health care costs".
Medicare Tests "Pay for Performance"
In a new experiment on the country's most chronically ill and vulnerable, but expensive population, The Centers for Medicare and Medicaid have revealed in February 2005 that they will launch a project to "...lower Medicare costs and improve health care quality by offering to return to physicians a portion of the money that they save the government program".
This very statement raises important questions, most centrally whether we have any evidence to suggest that money saved will "improve health care quality" and why taxpayers and medicare recipients, not to mention physicians, should primarily be concerned with saving the government money.
This statement also establishes right up front that the experts who designed and mandated this program are assured that the link between "..money..save(d).." and "...improve..quality.." is not to be questioned, so we can expect that in the three years planned for this project, it will accomplish both, according to how carefully the definition of "quality" is managed.
It is also obvious that cash flow, and where it goes, is the most important issue in this "test". Once again, the "business" model for medical care has created a monster.
In a refreshing burst of candor, Michel Hillman, M.D., one of the doctors who will direct this program, states, "Under the current system... there's absolutely no incentive to limit care." He goes on to predict that under this program, the clinic that he directs is "confident" that they can "save the program enough money" for the practice to be rewarded with "dollars". American Medical News Headline February 21, 2005
As with prior "managed care" schemes, the source of profits for the third parties is always to shift payment for actual services to administrators. In the case of "pay for performance", a bone will be tossed to the doctors for being the agents responsible for limiting care.
To be continued....