Health Care

stethoscopeA subject which has been a focus of intense debate over the past decades has been health care. Part of the reason for the debate is that there has been a fundamental misunderstanding about what health care really is. Many people feel that health care is a ‘right’, but health care can never be a ‘right’ as we have historically understood rights. Our founding fathers properly described the rights that we have as human beings – the rights to life, liberty, and the pursuit of happiness. These are what may also be termed negative rights, meaning that they demand inaction. We fundamentally have life, liberty, and an opportunity to pursue happiness as long as no one (especially government) impedes upon those rights.

Other purported rights – the ‘right’ to education, the ‘right’ to health care, and the ‘right’ to a job being the most common that are debated – are positive rights, meaning that they require action on the part of other people to be fulfilled. I propose that a different term be used in our discussion of positive rights, in order to prevent confusion between the two. I would say that these are ‘expectations’. I believe that positive rights can never be considered true rights, because in order to honor those expectations, other people must be obligated and forced to work on your behalf. Therefore, while we can discuss whether or not to honor any of these ‘rights’, we can and should recognize that these are only ‘expectations’, and any effort made to honor those expectations should be considered a privilege.

So as long as we can agree that you do not have a fundamental right to health care, we can discuss what obligations a modern society should have towards its citizens. While I strongly believe that your own health care is your personal responsibility, I also recognize that through circumstances often out of your control you may not be able to pay for health care services. This is especially true for people who have been born with congenital diseases which may be very expensive to care for, and which may prevent those individuals from being able to work and provide for themselves.

Taking a pure libertarian position on this entails no government part in providing health care for its citizens, and making people rely on family and charity to provide for them. This, I believe is not only possible in theory, and desirable, but given government mismanagement of this issue for decades, and the amount of ignorance and misinformation that is present among our citizenry, this is not likely obtainable any time in the near future. People will need to weaned off the government teat, a process which will take many years, if it will ever be obtainable honoring our political system. People will always vote their pocketbook, and given the option to require others to provide for them, most people will select that option. Unless we are able to return to a system where everyone is required to pay some taxes, the people who pay few if any taxes will prevent true reform.

ppacaThe recent changes in the health care system, the Patient Protection and Affordable Care Act of 2010 (PPACA, or Obamacare) and Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), are in my opinion, the exact wrong way to go about reforming the healthcare system. These laws make some basic assumptions which are deeply embedded in ‘progressive’ thought, but in my opinion make fundamental mistakes in understanding rights and human nature. These basic assumptions are: 1) that positive rights are true rights that all people ‘deserve’ and are entitled to; 2) that all patients and medical problems are essentially the same and can be treated through treatment algorithms decided on by medical ‘experts’; and 3) that physicians, or ‘treatment providers’ are all the same and are interchangeable, including using nurse practitioners and physician assistants in the place of medical doctors (MDs).

I have already addressed the first of these and will now try to explain why the remaining two assumptions are problematic. As for #2, while it is true that people are very similar in many respects, and often the treatment used for one person or medical condition will work in other cases, people are not widgets. There are hundreds if not thousands of factors that differentiate people from one another, and the best way to determine the treatment for any given person is for a qualified expert to examine and talk with that person. Some of the factors that go into deciding the correct treatment for any given patient include: What are the different options for treatment, and which one best fits the patients’ needs and desires? What other medical conditions do they have, and how will the treatment prescribed interact or interfere with other medications the patient is taking? Is the patient likely to follow the treatment course recommended? What are the patient’s expectations for the treatment? Is the patient able to afford the treatment prescribed? What are the side effects of the treatment and will these prevent the patient from finishing the treatment course?

All of these considerations must be taken into account when deciding on the proper course of treatment for any given patient. Trying to come up with guidelines and treatment algorithms has been the wet dream of progressive health administrators because these would eliminate the requirement for a skilled doctor to figure out how best to treat the patient. One of the biggest battles in medicine now is how to handle treatments which diverge from the guidelines which have been formed by ‘experts’. The dirty little secret of guideline based medicine is that the panels which come up with the treatment algorithms often have fierce debates about what is the proper treatment for any given condition. There are large areas of disagreement, and while the treatment guidelines usually are based on areas where consensus could be found, sometimes they are based on ‘majority rules’ and are deeply divisive.

Just as patients are not interchangeable, fundamental mistake #3 above is that medical providers can be treated as widgets in the system. The payment system in medicine already makes this assumption, which is deeply flawed and not reflective of reality. In truth, some physicians are very skilled and able to diagnose and treat patients very efficiently while others order a large number of laboratory tests and imaging studies in order to make a diagnosis. Some physicians are also better at making an emotional connection with their patients, a skill which I believe makes diagnosis and treatment much easier, while other physicians have trouble relating to their patients. Unfortunately, the current medical system we have in this country rewards the wrong things. Doctors are not paid to think, but are paid on the basis of the tests that they order and the procedures that they perform. Therefore, the unskilled doctor who requires a large number of tests in order to make a diagnosis actually gets paid more than the physician who does a complete examination and is able to make a diagnosis based on their very in-depth history and physical. The system forces doctors who know what they are doing to order unneeded tests in order to get a reasonable reimbursement for their time.

“So why do we not go to a capitated system, where doctors are paid a flat fee for each patient?”, the astute reader may ask. This type of system may in fact work, but there will always be bad players who see a lot of patients and order no tests in order to make a lot of money. This type of system also would encourage doctors to only see well patients who do not require much testing. The sickest patients who require a lot of care may be left out.

I do not pretend to have all the answers as to the best payment system which will reward the best doctors and help the sickest patients, but I do believe that doctors should be able to charge different amounts based on their skill. Just about every other profession in this country allows experts to charge more than novices. The time of the best, highly trained and experienced doctor in this country is certainly worth more than the time of the unskilled and unexperienced new graduate. But the current system pays the same for everyone. Therefore, the skilled and experienced doctor, in order to make up for the inability to charge more, must see more patients and spend less time with each individual patient than desirable. While the highly skilled and experienced doctor should be able to do this because they have become more efficient, the combination of less time with patients and increasing paperwork requirements means that mistakes will be made.

And this leads us to another area of discussion in the health care realm: medical mistakes. There has been a trend in recent decades of organizations such as the Institute of Medicine (now the National Academy of Medicine) to come out with studies showing a large number of ‘mistakes’ being made in medicine. If you dig down into the definitions of mistakes in these studies they often include such things as the patient being out of the room when morning medications were given, so the patient got the medicine at lunchtime. Other ‘mistakes’ include known interactions between medications that potentially could be avoidable, but the physician felt that the benefit of the medication outweighed the potential risk.

“So why are all these things labelled as mistakes?” you may ask. That is a very good question and goes to the agenda of the people doing the studies. The more that doctors can be marked and viewed as unreliable, the more oversight they theoretically need. This goes to the heart of the argument of people who want government intervention and control in health care. They believe that if they can label doctors as prone to making mistakes, then they can swoop in as ‘government experts’ to protect the citizenry from the ‘harm’ that doctors are inflicting on them. In truth, the only harm here is to the integrity of the medical system and the overall trust of people in their doctors, and this harm is being inflicted on us by the ‘government experts’.

We have a system in place for suing doctors for malpractice. We do not need another level of government oversight in medicine. However, the malpractice system desperately needs reform. Turn on the television at any given time and you will likely be inundated with commercials from lawyers who want to help people sue their doctors or the drug companies. Sometimes these suits are laughable, but unfortunately they will cause great expense, trouble, and damage to reputations in the meantime. For example, we have been blessed in medicine with a number of new replacements for warfarin for thinning blood. These new blood thinners can prevent potentially lethal blood clots from forming after surgery and can also prevent many strokes. How do they perform this magic? By slowing the coagulation system preventing the formation of clots. So if we prevent the formation of clots, what would be an expected side effect? Bleeding, naturally. The use of these anticoagulants has to be weighed on a scale of risk and benefit – clot prevention versus bleeding – and this calculation has been the basis for hundreds if not thousands of medical studies trying to find the right doses, delivery systems, and potential reversal mechanisms for these medications. This is what doctors do – this is our area of expertise.

Yet the trial lawyers want to sue the drug companies because some of the people who take these medications have suffered bleeding side effects. The lawyers know that they can play on emotion and drum up sympathy for the unfortunate patient who may have had a devastating side effect. The lawyers also know that they can often bully doctors, hospitals, and drug companies into settlements. Who benefits from these lawsuits? The lawyers clearly benefit, the patients less so. There needs to be a system in place for malpractice to be prevented and compensation for malpractice litigated, and we can even argue that there should be some sort of compensation system for the people who suffer known potential side effects of medications, but the current ambulance-chasing and hit-the-jackpot system is not it.

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