Saturday, April 17, 2010

Obamacare, Medical Economics, Gov't Guidelines

This blog is an attempt by a family physician to evaluate "Obamacare" from the perspective of a patient, since the bill will affect them the most. To begin with, the same arguments made today against "Obamacare" were made 35 years ago against Medicare, and by the same groups. Almost all of my MCR patients today are more than satisfied with the system, and their children are even more so, since they can spend their money on their children's college education instead of on their parents' medical bills.

The first modern government to start government medical insurance as well as social security and workmen's compensation was that of Prussia under Otto von Bismarck in 1887 (cf. "Blood and Iron"), because he felt that a socially secure worker was a better worker. The first state government to mandate health care was Massachusetts. I don't yet know how it is working out, except that there is always a dearth of primary care physicians, since diagnosis and thinking through are not well-compensated. I think that it is wonderful that the parents' coverage of their children will be extended to age 26, since fewer newly-minted college graduates are getting immediate jobs.

Initially, the plan will cost more than is predicted, because fewer people will die. This was discovered when MCR covered dialysis in all ESRD patients. Without dialysis, many patients died of their renal disease. With dialysis, many lived longer lives, and therefore cost the system more.

I also envision that with state-controlled insurance, you won't have to go scurrying to find a new internist, gynecologist and pediatrician just because your employer changed medical insurance companies.

The one economic calculation that is never done, however, is how much living people contribute to government finances. If you dropped dead from a heart atack now, then that is the end. If they call 911, do CRP, rush you to the hospital and do emergency CABG surgery, the economists say that you cost the system $30,00 in medical expenses. No one adds that now you will work and pay taxes for another 20 years, and yourtaxes will amount to much more than $30,000.

Medical economics is also unpredictable: I bought a lot of Pfizer and Merck stock years ago, because they had the largest and most aggressive sales force. I reasoned that the more drugs people bought, the longer they lived, and the longer they lived, the more drugs they bought, so drug stocks should rise forever. When the drug stocks flattened out for 2 years, I realized that the market made no sense to me, and got totally out.

We will also spend less on acute medical care if everyone has his/her own doctor, because workups of medical problems in the emergency room is enormously expensive, while your family doctor who knows you can diagnose your problem with much fewer tests (e.g. he will not order a CT scan of yuor brain for ordinary dizziness).

BTW, the best way to diminish medical malpractice suits is to eliminate contingency fees. This law could be passed by any state legislature. At the same time, perhaps we should eliminate medical class action suits as well. Dow went bankrupt because a Texas jury was convinced of the "fact" that leaking silicone breast implants caused chemical lupus in susceptible females. Of course the fact that an article in NEJM demonstrated 2 years later that the association was not one of cause-and-effect did nothing to reverse Dow's financial position.

We should be very cautious about following any government guidelines for medical treatment. As I have stated before, it is very unlikely that a panel of 20 physicians agree 100% on anything, but unlike the arguments about global warming, we never get to see a minority report. The "normal" value of glucose and of cholesterol keep on being lowered, although statins seem to benefit everyone regardless of their cholesterol level, and intense control of diabetes seems to benefit few, if any (but if you are over the limit it does raise your life insurance premium). The suggestion that mammograms do not benefit women in their 40's was met with a storm of protest. A Nobel prize in medicine was given to the doctor who "proved" that pre-frontal lobotomies cured schizophrenia.The drug Singulair came out 2 months after the guidelines for asthma treatment were published. The only pro/con discussion about benefits or lack thereof of lowering salt in the diet was published in Lancet more than 10 years ago. The government knows that moderate use of alcohol reduces heart attack risk, but they still don't recommend starting. No patient is "average", and every patient is "special", best known by his family doctor, and we are spending too much time excplaining to insurance companies and Medicare Part D that in this particular patient the generic drug does not work as well as the brand name does.

The overall economic picture is that medical care saves lives, technology works but gets increasingly more expensive, and we wil end up rationing by time, availability, or money

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