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Questions & Thoughts regarding Justice in Health Care.

I do not want my blog to be simply a health and nutrition blog that occasionally features topics on plastic & hand surgery.  I like a lot of different things and I like to think about a lot of different things, which is one of the reasons that I started this blog in the first place.  My interests are varied and include things like music, art, and philosophical questions as they relate to human psychology, morality, and justice. And in the case of this blog, healthcare justice.

I think of the many great challenges of our healthcare system, there are two that take precedence. They are not necessarily mutually exclusive, but in fact, tightly related.   The first challenge, from my perspective, is that the delivery of health care must be radically restructured to create a disease prevention system rather than what we have now, a rescue care sickness system that waits for disease to manifest itself and treats it with expensive medications, that often only mask the symptoms and underlying causes.  We spend 2 trillion on health care in this country, and the more I am practice, the more I see we could do a lot better. The first step is prevention through re-establishment of a more cohesive and trusting doctor-patient relationship, and I have written about this extensively in my blog. And in fact, it is one of the reasons I write a health and nutrition blog in the first place!

But the second issue which is very pressing in our current healthcare system is finding a way to provide every one of the members of society a basic and decent level of healthcare access and quality.  There is no doubt about this.  This is basically an unassailable point. And it is one of the talking points in the whole debate that invokes very deep levels of emotion and very intense debate. Rightly so.

As a doctor, I have seen how the ‘sausage is made’ and frankly, it is frustrating to see what medicine has become, even since I started practice only about 6 years ago. Though, we have wonderful rescue care system and excellent technology, there are many other things that are bogging down the system.  Economic incentives are misaligned and core values have deteriorated in a way that has resulted in a system that is controlled and influenced by just about every other player in healthcare, except the doctor and the patient. That is why I feel that re-establishing the accountability and trust within that relationship is a central tenet, and in fact a sine qua non, of any plan or attempt to make the healthcare system better.

But what about justice, specifically? Here is what I think and you can add your comments, if you want, at the end of the blog.

As I see it, the main question when dealing with the issue of  justice comes down to the question of whether free markets or a single payer system in healthcare is better. In other words, the pressing question is: does the government allocate resources with greater justice than a free market?  That is the critical question in regards to healthcare.

Some economists, like Kenneth Arrow, have chosen to answer that question by saying that health-care does not lend itself to a free-market model at all and must be treated differently. People do not know in advance that they will need or how much they will need to spend on health care. In some ways, I certainly agree with Arrow’s point. When you have a business, you want to spend, make profit, and re-invest, and with healthcare, you want to spend as little as possible.  But it seems to me there is a bigger issue regarding free-markets in health care, and that has to do with having real choice and real economic power to achieve those goals, whether they be more and in the case of health care, less.

When talk about a free market system versus a single payer system (which would in all likelihood be controlled by the government), my answer is that the free market model works better; however, (and this is a big however), the model that we have now is NOT a free market model, and doesn’t capture the essence of a free-market exchange, because neither  of the players in the transaction, the doctor and the patient, have true authority over their decisions regarding what is best.

In essence, we have a part of our health care system system that is labeled as a free market, but this is only nominal title, because we rely on a third party payer system which has too much control and exerts too much influence in the healthcare transaction between the doctor and the patient.  As a result, there are different interests being served rather than the exchange of information and services in an accountable and transparent fashion between the doctor and the patient.

This is a critical point in my view, perhaps the most critical.  If you are really going to have more of a free market system, then you have to radically reduce the influence of third party payers.  Otherwise, they will ultimately seek to serve their own interests as they already have as anybody who pays insurance premiums knows. Why did your premiums go up 30%? Why is the CEO of the company making million dollars bonus? Where does my money go? Does anybody know?

So what is my solution to this problem?  Ultimately, there has to be complete accountability, transparency, and exchange of information between the doctor and the patient. One of the practical ways this can be achieved is that the doctor has to set prices fairly and explain why those prices have been set in such a fashion.  That is, doctors themselves need to be responsible for the quality and the value of their work.

Likewise, the patient should be able to access the procedures/interventions that are available, what are all the options including the nonsurgical options.  Obviously, many people in an emergency situation obviously cannot do that and that is where a traditional form of insurance is very important, but unfortunately this type of rescue care is not always what is contributing the skyrocketing cost of healthcare. Things like diabetes, heart disease, cancer, end of life issues, and arthritis, etc. are.

So, as I see it, the ultimate way to shift the game and take the power out of the third party payers (and this would include the government as well, should it move in that direction) is to allow patients to have direct access to the resources in healthcare, not unlike a spending account. In this way, patients would be able to pay for things like education, preventive medicine, and they themselves be able to pay their doctors’ for their work and even pay them bonuses based on keeping them out of the hospital and serving as good doctors. As a result, you develop a relationship that is based only on the individuals involved, not what someone else will pay for, or what someone else recommends who may have no medical knowledge or a conflict of interest.

Is this is a perfect system?  Is this an ideal system?  Is this the utopian system that can never exist?  I understand the criticism that will be brought up. I have heard them many times before, but the fact is with an internet age and complex society, doctors and medicine in general must move from the closed paternalistic, rescue care model, to a new system that really focuses on openness, information, and accountability in the pursuit of health and wellness, above all.

I think it is worth trying to move in that direction where it is patients that ultimately have the power and doctor who are ultimately responsible to one person only in the system, their patients, and their patient only.  Not hospitals, not protecting themselves from lawyers and litigation, not government, Big Pharma, or insurance agency or any other industry.  One patient at a time.

Otherwise, we will just continue this vicious circle over and over again.

So, I have given you some fodder for thought. It’s your time to go for it.

Please note: I know healthcare discussion usually brings up very passionate and intense emotions and I respect that. I have two kids with type I diabetes. I am not your enemy, and neither is anyone else.  All I ask is that do not be mean and call each other names. Be accountable for your ideas as well…

Ultimately, we are all on the same side and we want the same ultimate eventual outcome. Better health and a chance to fully pursue happiness for Americans.

2 Responses to Questions & Thoughts regarding Justice in Health Care.

  1. This is a great topic that needs to be discussed but seems taboo for some reason. I will give you my thoughts as a person who has stage IV cancer and lots of money has been spent on my behalf so far. The doctors tell me there is no cure for my condition and the cancer will return at some point. I figure they are saying eventually it will kill me. I’m glad I had insurance so far as medical treatment prolonged my life and right now I feel good! However, going through chemotherapy etc. to treat my cancer showed me how awful it feels to be sick. My greatest fear is not dying – it is suffering! It’s been stated that the last 6 months of one’s life is where most of the money gets spent. I imagine during my last 6 months will be plenty of suffering (as there was for my brother,and for my mother and for my father) as the medical profession/politicians don’t give me the option of opting out of this stage of my disease. WHY NOT??? Why can’t I, at my option, say when life gets too miserable to live, give me something to end it? This would save resources for someone else and I wouldn’t have to suffer. I’m not saying everyone needs to go this way. Some people may want to suffer to the bitter end no matter what. But some of us don’t, we should have a medically supervised better option and this would be much less expensive for society – a win win.

    On a brighter note, I do think things may be changing. My oncologist told me that she believes cancer is being approached wrong, the emphasis should be on prevention. I think she watched “Forks Over Knives” (I know, it involves vegan propaganda) and it made her think. Hopefully this attitude spreads throughout medicine.

    • Johannah, thanks for sharing your story. I wish you the best in your cancer fight, and I can tell that you are both brave and honest. In regards to healthcare, and my thoughts for its future improvement, I think it really hinges on taking the heavy 3rd party payer influence out of it, whether it be the government or the private sector. The key is putting the power of choice in the hands of patients. This comes with certain responsibilities, which have to be fulfilled by both the patient and the doctor to work. A patient in your situation can be very desperate to try just about anything, and as a result, healthcare is not similar to other goods in a free market, because a person with stage IV cancer will spend and try just about anything because there is no penalty or harm fiscally to do so. I think to offset this condition, there have to be several things involved: (1) an agreed endpoint, which you say is to provide comfort and reduce suffering, not necessarily prolonging life. Unfortunately, most oncologists/cancer doctors measure the effect of drugs they use by how they prolong life, not by how they make you feel. After all, they use poisons, in essence, which make you feel terrible and sick. (2) Clear understanding of the what the drug or treatment does/how effective it really is. This is where doctors can exert the type of influence that actually helps people if they have the proper incentive to serve the patient’s interest only, and not any outside influence, eg hospitals or protect themselves from litigation, etc. If you are getting paid directly by the patient for the quality of the service that you provide, and not the quantity or the nature of that service, then you as doctor, will view expensive technology or medications in the same light as doing nothing, or providing comfort care, or placing someone on a lifestyle program to help them lose weight and gain metabolic health. We currently do not have that in the system, and rely heavily on technology, which people think is often more useful than lifestyle management, and is certainly more remunerative. It has created an overspecialization in my view, which has made a lot of doctor mere providers of technology. This is not only sad, but I think it’s harmful to health. The only was to really restore and revitalize medicine, in my view, is to give patients the power of choice (through economics and information) and give patient’s access to opinions while making doctors accountable and transparent in terms of both price and value of their treatments. That is, restore the central power of the doctor-patient relationship in health care. To me, that is the only way to make things work. I wish you the best for your health, Johannah, and once again thanks so much for sharing.

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