Thursday Ramble: Money

Last week I rambled on about religion and politics, this week I will touch the third taboo, money. More specifically money and health care.  (I will spare you the unsorid details of my sex life.) 

Exploring the correlation between health care and age, I have had the pleasure of getting to know a bunch of medical doctors, not in a doctor patient role, but as professionals collaborating on research and policy. 

There is a reoccurring conversation, usually held off the record, often an after the second martini conversation about money and health care. Many have a genuine fear of losing jobs, if they speak up on the job, or in print, or if their name is somehow associated with what they know to be true. 

There are two concerns.  Sometimes they can't get approval for payment to practice the best medicine for their patient, and at other times they are compelled to order tests and treatments, because insurance will pay for it, even if they believe it is not the best medicine. Simply put, the insurance companies and other payers, control the medicine they can practice.  

This deeply bothers a lot of docs. I read an article recently about mental health among health care providers and a primary driver of poor mental health is fighting with insurance companies and corporate practice managers about what treatment they can provide, and what treatment they are compelled to provide.  How bad is it, doctors in the United States have a high risk of suicide. 

A couple of years ago, my sweet bear laughed so hard, that he passed out.  A call to his doctors office, recommended a visit to the nearest Emergency Department.  The evaluation there found nothing wrong, it is simply something that happens sometimes when people are over stimulated - and instructions to follow up with his doctor.  The doc was honest, in saying I am going to refer you for all of the standard follow up tests, several thousand dollars worth, but odds are the tests will simply confirm what we know, there is nothing wrong, you just laughed too hard at a YouTube video.  And that is exactly what the tests revealed, nothing.  But the insurance paid, and paid, and every test that would be paid for was ordered, done and paid for.  

The doc has two factors driving this, if he didn't order the tests, and they missed something, he could be sued for malpractice because the standards of care justify all of those tests, and a practice manager who is urging every test that insurance will pay for, because well that is what pays the salaries.  What happens to docs that don't order all covered tests and treatments, they are rated poorly, don't get raises, and are likely to be assigned the duties that no one wants to do (The midnight to 8AM shift every Saturday night.) 

At other times docs are told they can't try that treatment, or order that test, because insurance won't pay.  Medicine is both a science, and also an art.  Often the docs are not sure what is happening, they are offering scientific guesses.  And at times they would like a little more information to base that guess on, but if it is not in the standard treatment protocol, they are limited in the data they can have to base their best guess on.  

It is a backwards system, where panels of experts and insurance executives determine what your doctor can do or not do. 

How bad is it? The two best doctors we have had the past 8 years, have both left the active practice of medicine for research and teaching.  Jobs that are not controlled by insurance companies and practice managers.  

If we want better medicine, we need to put the doctors in charge of what they recommend.  The docs need to be able to confer with their patient and decide what is enough and what is too much. 

We have a shortage of doctors.  Accrediting medical schools is left to a professional associations.  Want to lower the cost of medicine, get the insurance companies and practice managers out of the picture and open more medical schools, oversupply the marketplace with doctors.  

The flip side of this is abysmal salaries for young doctors.  In the USA, these are the overworked and underpaid interns that provide the majority of hospital care, in the UK it is the "junior doctors"  who are the backbone of the NHS, who make less money than a manager at Starbucks.