I got some good traction from a recent blog post by Krugman about the dangers of treating medical care as a commodity, sold by doctors to consumer/ patients. The thoughts this inspired just don’t seem to fit in Facebook’s ever shrinking comment window. Here’s the crux:
The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening.
Most of us are able to build the necessary font of knowledge to buy the correct netbook computer or pickup truck. We look at our bank account options and balance risks and rewards. We pick housing based on a rent / own ratio, and we might even be able to decide whether to invest a day in figuring out how to replace a lift gate piston, pay $250 to have it done, or cope with the danger to our head during grocery and mulch time.
The above is crap. Most of us are ill-suited to even these straightforward market choices. I know exactly one couple who did the rent / own financial math before they moved. If we were good at this stuff, the average US citizen would not be swimming in credit card debt, underwater on her mortgage, and terrified of the trivial injury that might bankrupt her. Most of us would have sensible retirement accounts. We would use credit to buy durable goods that accrue value, and we would pay cash for consumer goods that lose value the moment we take them out of the bubble wrap*. The reality of our lives is almost exactly upside down from “sensible.” We are terrible at even the basics of financial life.
Add in the emotional and personal aspect of medical care and we’re 100%, stone cold screwed.
Let’s dig in, just a bit, to that “emotional and personal” aspect. On Wednesday night my “little” sister counseled a family through the decision of when to allow their aged and dying father to die. What I mean is that she explained that until they gave the nod, physicians would default to breaking his ribs and forcing tubes down his throat. The family was unable to nod their heads to allow dad to die in peace. They had planned to have that conversation “tomorrow,” you see. They were unable to get their heads around the idea that dad might die before they had their meeting. Finally, after two ‘codes’ a senior physician made the call to stop what was an eminently pointless and brutal exercise. My spouse advises people who have to balance HIV, pregnancy, poverty, homelessness, sexual violence, and other less straightforward issues like immigration status and sexual identity. My father spent more than 30 years catching and stabilizing whatever disaster walked through the door in whichever emergency room he happened to be working that night.**
Couple all that in your mind – just for a moment. Try to hold in your head – simultaneously – the general financial incompetence of the populace and our general (and reasonable) terror of the great medical unknowns. For bonus credit – try to hold in your mind at the same time the knowledge that someone fucked up your retirement account in 2008. Imagine that your “fixed” income turned out to not be “fixed,” in the sense that you thought. If you succeed in this effort then you understand why medicare is the third rail of American politics.
There are great examples of consumer culture in medicine. Lasik and eyeglasses in the mall are great. Those are commodities. Primary care is where the rubber meets the road – and that will never – should never – be commodified. There is a balance to be struck here – and it is absolutely not the raw commodification of primary care.
Back in the bad old days, there were four “honorable” professions: Law, education, medicine, and (snort) the clergy. These four were supposedly distinguished from the merchant class by a high level of trust and privacy between the practitioner and the client. Instead of a (supposedly) informed consumer wandering between a variety of market stalls and selecting products, the client would establish a trusting relationship with their provider. Within that context, whether it’s law, medicine, education, or spirituality – the practitioner is expected to fill dual roles where they both advise on what should be done, and then perform the service itself. They are expected to balance the needs of the client, society, and their own professional community.
Of course, physicians need to make a living – so they charge for their time. I don’t begrudge that. It’s worth noting that the top physicians in the world make, on average, less than the lower-tier of wall street financiers. Maybe that’s as it should be. After all, physicians rarely impoverish their clients. That has to be stressful.
Hey wait, I haven’t talked about money yet. It’s worth noting that all of the above is invariant with cost. On that topic, I’ll share more Krugman another post on a different topic:
Look, this is an important debate. If you can’t be bothered to look at the numbers, you shouldn’t weigh in.
Go all the way back to economic basics. Instead of “reducing health care costs,” imagine that we’re talking about reducing the economic footprint of an industry***. They’re the same. You want to shrink health care in the US – but you can’t just close Detroit because everyone needs to die someplace. That means that you turn your MBA learning upside down. Just turn your usual methods upside down. Decrease value, increase prices, and wait for the customer to go away.
Hey check it out – that’s what we’re doing. Wahoo!
More loosely, wait for the poor (who don’t deserve it anyway) to die.
That’s not the civilization I want to live in. It doesn’t describe the medical “industry” I hope to have there for me. Sadly, I have no idea how to vote to prevent it.
*: Pop pop, hope no one sees me, gettin’ freaky.
**: At family gatherings, the three of them get going and I go have a soothing cup of tea with whoever else is around.
***: They’re the same thing