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What US Health Care Needs 584

Posted by kdawson
from the velluvial-matrix dept.
Medical doctor and writer Atul Gawande gave the commencement address recently at Stanford's School of Medicine. In it he lays out very precisely and in a nonpartisan way what is wrong with the institution of medical care in the US — why it is both so expensive and so ineffective at delivering quality care uniformly across the board. "Half a century ago, medicine was neither costly nor effective. Since then, however, science has... enumerated and identified... more than 13,600 diagnoses — 13,600 different ways our bodies can fail. And for each one we've discovered beneficial remedies... But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we're struggling. There is no industry in the world with 13,600 different service lines to deliver. ... And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it's the economic bailout plan. But take both away and you've made almost no difference. Our deficit problem — far and away — is the soaring and seemingly unstoppable cost of health care. ... Like politics, all medicine is local. Medicine requires the successful function of systems — of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively. ... This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do."
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What US Health Care Needs

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  • by adam (1231) * on Monday June 21, 2010 @02:17AM (#32637582)

    If I want to give my patients the best care possible ... This will take science. It will take art. It will take innovation. It will take ambition.

    ...it will also take the AMA not artificially restricting the number of new doctors. More than half of ostensibly qualified applicants every year are turned away. In the 1800s there were 400+ medical schools in the united states. By the early twentieth century there were less than eighty. The fewer doctors we have, the more each doctor is paid. The AMA carefully guards doctor salaries. This practice can be seen over and over (and resistance to influx of doctors willing to work for cheap) in country after country (the film Salud covers this well).

    Furthermore, we need to eliminate the debt load for student doctors. You can't expect doctors to work for lower salaries (as I propose above) when they are graduating with hundred of thousands in debt. Basically we need way more medical schools (or slots in existing schools) and we need to lower their cost in exchange for a willingness to work for less money. This has the benefit of more doctors and lower cost, as well as shifting the pool of applicants to those who want to be DOCTORS and not just those who want to make MONEY or play GOLF all the time (and so on).

    Cuba is a perfect example of this. They have better or equivalent health outcomes to the United States, yet they spend a fraction (read: less than 1/20th) as much per person on healthcare. They achieve these same outcomes using finnicky x-ray machines from the 1980s and out of date textbooks. They do this by having the greatest doctor-to-patient ratio of any nation, and by focusing on preventative medicine. But that's evil socialism. Insert dramatic music here. At any given time more than a third of Cuban doctors are voluntarily serving abroad (often in Africa) doing global health work. More than a third. What percentage of American doctors voluntarily serve in Africa? And they have a 98% retention rate, so any claim that this service is to "escape Cuba" is pretty well dispelled. (and just to go on the offensive for a sec, since I don't generally reply to those who reply to me, unless they actually make good points, since as you know /. has a typical signal-to-noise comment ratio... for those who want to doubt my claims above, calling them propaganda, etc, they are backed up by reputable sources. Paul Farmer, for instance, has written extensively about Cuba [and also happens to be the UN Envoy to Haiti and runs Harvard's School of Social Medicine at their Medical School, so he tends to be considered a reputable source] and almost never has a bad thing to say about their healthcare attitudes or outcomes. The list goes on.)

    • by Anonymous Coward on Monday June 21, 2010 @02:35AM (#32637664)
      An informative first post! Is it the apocalypse already?
    • by kilodelta (843627)
      You make some very good points. One of the prime reasons I didn't go into medicine was the cost. Chose the I.T. field instead.

      The other thing that should be mentioned is that health care in the U.S. excels in one area and by relation another. Medicine excels at trauma medicine. It is at the point where even deaths from gunshot wounds are declining. The relation is in diagnostic technology.
      • by vlm (69642) on Monday June 21, 2010 @08:05AM (#32639176)

        More than half of ostensibly qualified applicants every year are turned away.

        One of the prime reasons I didn't go into medicine was the cost. Chose the I.T. field instead.

        In retrospect, I wish I went into medicine. Instead of competing with a glut of "educated" "certified" "trained" personnel in IT, I'd have a "guaranteed" job as a Dr.

        What fraction of people go into C.S., learn how to design compilers, databases, OS kernels, clusters, large scale BGP networks, etc, and then get stuck on the helpdesk, or if not underemployed, unemployed due to outsourcing?

        On the other hand, it seems that approximately 100% of doctors whom learn how to suture wounds, on the job, believe it or not, actually get to suture wounds?

        The level of underemployment in IT is so extreme, that there is a whole comic industry of making fun of the "peter principle" folks above them in management, the humor being that IT folks are so strongly underemployed that the concept of a "peter principle" line of work is hilarious to them. On the other hand, it seems like doctors actually get to do, what they trained to do, which must be pretty nice.

        • by COMON$ (806135) on Monday June 21, 2010 @10:53AM (#32641092) Journal
          Why do you think my Wife went into Pharmacy? She could have spent tens of thousands of dollars getting a PHD in biology (she already had her Masters and was teaching). Then spend the next 30 years competing for jobs for a crappy salary and moving around the country. Or she could spend the same time, a little more money, and have a guaranteed job. She will probably end up teaching or doing wellness care as she cant stand retail. Even cutting out that sector, her job prospects are WAY better in Pharmacy than they ever would have been in academics.

          As a side note, addressing the GP/FP doctors in the US have a bit of a control freak nature. Not only are there not enough of them, they seem to have issue with delegation. Recent pharmacy grads are exceptionally good at prescribing and much better at diagnosis than their predecessors. Yet doctors are still slow to utilize them as specialists. This lack of respect for other disciplines in medicine is causing many issues as well. (There are states that do allow pharmacists to prescribe and are getting closer, but we are a long way from reducing the burden).

    • by rtfa-troll (1340807) on Monday June 21, 2010 @02:39AM (#32637690)

      The thing is, that you don't actually have to go as far, politically, from the USA to see a working health care system. Before Margret Thatcher's management reforms crippled it, there used to be one in the UK and to a large extent there still is one in Scotland. The key element is to understand that money is a terrible motivator in health care.

      There are always many many treatments and tests possible. For any given patient, most of those tests will either do more harm than good or be unjustifiable financially (costs 100,000, has a 1 in a million chance of helping you). The doctor has to be trustworthy to say "no, it's not worth it". That means that you have to believe that a) he has nothing to gain from not giving the treatment and b) he really has to have nothing to gain from giving the treatment c) he has to be competent and well enough trained to make that judgement.

      Unfortunately, as soon as we have insurance companies, financial administrators and ignorant courts involved this breaks down. The insurance means that the doctor is doing the treatment for profit, so the more he gives, the more a non-involved third party pays. The financial administrators (e.g. in UK state care) mean the opposite. Now the patient knows the doctor is under pressure to not deliver treatment and will not leave until they get it (even if they don't need the treatment). The courts mean that the doctor can get away with killing hundreds of people with extra CAT scans, but if he misses one brain tumor by not doing one he goes bankrupt.

      We need to take the direct money out of front line medicine, or at least pay it much more cleverly. For example, if you pay doctors by results (percent patients cured) they will only work on easy cases. Almost any such system I can think of can be gamed.

      • Re: (Score:2, Interesting)

        by Jah-Wren Ryel (80510)

        We need to take the direct money out of front line medicine, or at least pay it much more cleverly. For example, if you pay doctors by results (percent patients cured) they will only work on easy cases. Almost any such system I can think of can be gamed.

        Which is yet another reason to dump the entire concept of prepaid medicine to begin with. Sure, keep true insurance around for catastrophic events, but otherwise let each person decide how to spend their own money on their own regular health care. If you want to subsidize the poor, give them vouchers and let them spend their own vouchers on their own health care the best way they see fit. The idea being that since there is pretty much no optimal 'command-and-control' style solution, you might as well put

        • by Sycraft-fu (314770) on Monday June 21, 2010 @03:36AM (#32637972)

          For just about everything else in life, insurance is just that: Ensuring that in the event something happens, you are covered. It is a risk transfer for certain situations. For example I carry insurance on my house. In the event it burned down, or everything was stolen or the like, I could not afford to replace it all. My cash reserves are insufficient and, indeed, I have to have a mortgage to own the place. So, in an emergency, the insurance company will cover my loss. However, it is only in an emergency. They do not cover regular maintenance and upkeep of the house. Even in terms of qualifying emergencies, like theft, there's a $500 deductible. So if someone breaks in and steals a couple speakers, I'm paying for that myself, but if they steal everything the insurance company will pay.

          It is all about transferring risk. I take care of the high risk, low cost stuff, they assume the low risk, high cost stuff. It is a certainty I'll have to repair things, the risk of something breaking down is as high as it can be, more or less. But the cost is low, I can afford it. The risk of my place burning down is quite low, but the cost is high, too high, so I transfer that risk. Doesn't cost a lot, since it is low risk. Likewise, my insurance company does the same thing. They cover individual incidents. However for large things, like disasters, they have their own reinsurer. That company only deals with extremely rare stuff, the risk of it happening is minimal, but the costs are astronomical.

          But for health insurance, that's all turned around. It covers EVERYTHING. I pay, at most, $10 for anything. Insurance pays the rest. Doctors visits, tests, hospital, etc. I only bear the cost if it is extremely cheap, like a generic drug. Otherwise they pick it up. However they also pick up high cost stuff. If I have a major accident and require intensive care, they pick all that up. They are liable for ALL risks to my health.

          Is it then any wonder that it costs more per month than my home insurance does per year?

          I really thing a medical savings account kind of plan is the right idea. You save money to pay for normal things. In the event of something catastrophic, no problem, your insurance is there to pay any and all costs.

          However finding that is hard. They started offering one at work... And it wasn't worth it. My premiums stayed the same, my employer had to put in just as much money, and my personal financial risk increases. How he hell is that useful? It should cost my employer much less, but it doesn't.

          • by ashvin213 (1602795) on Monday June 21, 2010 @04:11AM (#32638136)
            1. The reason why healthcare insurance policies are counterintuitive to other insurances is to foster preventive care. If I am covered only for catastrophe, then I will sit and wait for the catastrophe to happen rather than going and getting things fixed early. Because, from my perspectives, my costs are identical in both cases. 2. What constitutes a catastrophe varies wildly with person to person. For someone earning 1,000,000 per year, it could be that a bill of 500,000 is a catastrophe. But for someone who is earning only 10,000 per year, a bill of 5,000 is a catastrophe. The cost of covering a person earning 10,000 per year would be orders of magnitude higher (which he wouldn't be able to afford) than the cost of covering a person earning 1,000,000. For this reason, the insurance HAS to be provided by some agency like a government which can take losses on covering someone who is earning 10,000 and recover some of the insurance costs by charging a premium to the person earning 1,000,000. 3. The model could be as follows. Currently, govt collects 7.5% as Medicare. This 7.5% can be increased to say 10%. But now Medicare will also come cover the person paying the premium in the following manner: The person is covered 100% above a certain threshold which is the function of his/her yearly income (So for example, a person earning $10,000 is covered for all medical expenses higher than $1,000. Someone earning $1,000,000 will have their coverage begin after they spend $500,000). In addition, all are allowed to purchase secondary insurance from the various insurance companies if they so desire (to limit their loss during catastrophe).
            • Re: (Score:3, Interesting)

              by vlm (69642)

              The reason why healthcare insurance policies are counterintuitive to other insurances is to foster preventive care

              Disagree. Very few people avoid preventative care in other insured areas. If I don't replace my sparking electrical wiring, the insurance co will buy me a new house when it burns down. Its a pain in the ass to crawl around on the ground and check my car tire pressure, and if I don't the insurance will buy me a new car when I flip it on the highway. I just don't see this happening.

              Personally, I always thought paying for health care via real estate taxes was the fairest, rather than income. I live six bl

          • Re: (Score:3, Insightful)

            by Qzukk (229616)

            I really thing a medical savings account kind of plan is the right idea.

            If it can be rescued from the companies, it would be great. It should be something that I can go and open at any bank, transfer money into whenever I want, and have no "use it or lose it" rush to waste money in December (or if I get laid off). The banks could use the interest they'd normally pay on the savings accounts to administer them (not that much administration should be necessary beyond reporting how much money was taken out.

          • Re: (Score:3, Interesting)

            by nine-times (778537)

            But for health insurance, that's all turned around. It covers EVERYTHING.

            There's a reason for this: it's socialized healthcare.

            Sorry, you might be thinking I'm stupid right now. It's a bunch of private companies, right? How can that be socialized healthcare?

            Here's the deal: As you've noted, health insurance doesn't work like insurance. Insurance is when you pay into a system, but only receive a payout in the likelihood that something unexpected happens. If the unexpected happens, you get compensation, but most people pay in more than they'll ever get out. It only works if

        • Your suggestions tells poor people who happen to have a handicap or chronic condition to get stuffed.

          You sir fail at humanity. Congrats, you can now enroll in US politics.

        • by toadlife (301863) on Monday June 21, 2010 @03:47AM (#32638012) Journal

          Sure, keep true insurance around for catastrophic events, but otherwise let each person decide how to spend their own money on their own regular health care.

          This leads to people avoiding preventive care, which drives up costs in the long run. There are already dozens of health care models around the world that deliver better outcomes for a fraction of the cost that the U.S. pays. There is no need to reinvent the wheel.

          even though the overhead of dealing with 'insurance' companies can easily equal 50% of the bill.

          And yet you advocate sticking with a system that involves private insurance.

        • by Anonymous Coward on Monday June 21, 2010 @04:10AM (#32638126)

          I'm haemophilic - where am I supposed to get the cash for my treatment?

          The free market is survival-of-the-fittest, healthcare is preservation-of-the-weakest; I don't find it that suprising that they don't get on.

          The best solution is a publically owned industry like here in the UK, with much, much smaller private insurers who can stay light on their feet and plug gaps in the service when they appear.

          This system is way cheaper, higher quality *and* it's fairer.

          If there is a profit motive, doctors will ignore people who are really ill as it won't be worth curing them.

          In the UK we are committed to provide healthcare for everyone until they are healthy, hence it is massively in the doctors and the governments interest to keep people healthy and out of the hospital; so they don't have to pay for their care.

          If everyone suddenly got healthy in the UK, we would save a tonne of money - if they suddenly got healthy in the US your economy would collapse. You need people regularly paying the deductibles.

    • Who is to say where the cut-off line should be?

      You could put that line almost anywhere without being unreasonable. I think we can agree that it's unreasonable to have 99.999% of the applicants on one side of the line or the other, but beyond that? What about taking only the best 10%, or only the best 90%, would one of those be OK with you?

      It seems the AMA decided that the lower 50% are unfit. OK. Well, would you want one of those doctors instead of one in the top 50%? The top 50% is dangerous enough.

      • by martin-boundary (547041) on Monday June 21, 2010 @02:56AM (#32637776)

        It seems the AMA decided that the lower 50% are unfit. OK. Well, would you want one of those doctors instead of one in the top 50%? The top 50% is dangerous enough.

        Doesn't that depend on what your ailment actually is? If you've got the flu, a doctor in the bottom 20% is good enough, while if you've got brain cancer, then you'll want a doctor in the top 10% or better. You could have a system, let's call it "triage", where someone qualified could decide what kind of doctor you need...

        • by gd2shoe (747932)

          That's an appealing theory. The problem is that there are serious conditions which masquerade as common ailments, and require a great doctor to catch (such as Cushing's). The more mediocre doctors we have, the more misdiagnosis we will have. You seem to suggest better doctors closely oversee lesser doctors, but that will either become an exercise in rubber stamping or a horrible bureaucracy (the former tends to fail and become regulated into the latter). How do you suggest dealing with misdiagnosis?

          I ag

      • Let's ask the AMA (Score:5, Informative)

        by adam (1231) * on Monday June 21, 2010 @03:00AM (#32637798)
        Don't listen to me, just listen to the AMA instead; they're happy to admit their mistake (although they won't overtly admit the motivation behind it). Basically in the 1980s they wrongly predicted in 10-20yrs we'd have a surplus of hundreds of thousands of doctors and the market would crash (yeah, wouldn't that be horrible, to have too many doctors? I mean, horrible if you want to drive a Lexus and you're a doctor, I suppose...). Of course they got it wrong ("accidentally," I am sure) and overshot in the other direction and now we have a huge shortage. "Whoops." Unfortunate byproduct: ridiculous salaries (mostly for specialists). Not so unfortunate if you're a dermatologist, though.

        Some quotes from the AMA themselves [ama-assn.org]:

        "Not a single allopathic medical school opened its doors during the 1980s and 1990s ... The surge in new medical schools is taking place as the Assn. of American Medical Colleges predicts a shortage of at least 125,000 physicians by 2025 ... But some experts on work-force issues say new schools are not enough. They say that without more federal funding for residency slots or changes in the doctor payment system, the schools are unlikely to avert an overall work-force shortage or address the undersupply of primary care physicians and general surgeons ... 1 in 3 active physicians is 55 or older."

        I think we can agree that it's unreasonable to have 99.999% of the applicants on one side of the line or the other, but beyond that? What about taking only the best 10%, or only the best 90%, would one of those be OK with you?

        How about 98% rejection rate? From the AMA article above: "Many private medical schools have 5,000 or more applicants for a class of 100 students."

        Again, I hope it comes across, I know something about this issue. I said "ostensibly qualified" and "more than half" in my OP because I didn't want to get into a big debate about the exact percentage of people who apply and are grossly underqualified and rejected versus the legit applicants who are rejected, but basically the former is not happening, since you need to take the MCATs (not easy) and complete the equivalent of a degree in Molecular Biology simply to even apply to med-school (and currently to be competitive you need hundreds of hours of volunteer work, professional medical experience such as EMT work, and even then it is often a crapshoot, I know many qualified applicants who have been rejected more than one year in a row).

      • by fishexe (168879)

        It seems the AMA decided that the lower 50% are unfit. OK. Well, would you want one of those doctors instead of one in the top 50%? The top 50% is dangerous enough.

        That's largely a false dilemma. At this point, for millions of Americans, the choice is between the lower 50% and no doctor at all.

    • Insurance companies, hospitals, and even individual doctors are profit driven.

      While it is certainly no crime to make a dollar, that dollar shouldn't be THE_MOTIVATING_FACTOR in health care.

      If/when every doctor, every hospital, and every insurance agent actively seeks to provide the best REASONABLE care possible, at the lowest REASONABLE cost possible, then we will have gone a long way toward solving our health care problems. Ambulance chasing lawyers need to be reigned in as well. An accident in which a p

    • Re: (Score:3, Insightful)

      by JackDW (904211)

      Cuban healthcare costs 1/20th of American healthcare for similar outcomes? That's... not really suprising.

      Most of the cost of health care is the cost of labour. Health care is very labour intensive, as I am sure you know. In the West, labour is expensive. In the third world, it is cheap. The cost of living is lower, the average salary is lower, and therefore the cost of labour needed to provide healthcare is also lower. But the healthcare itself can be just as good. There are excellent hospitals throughout

    • Re: (Score:3, Informative)

      >>>Cuba is a perfect example of this. They have better or equivalent health outcomes to the United States, yet they spend a fraction

      False. The second part is true but the first is false, because Cuba's government hospitals often don't treat people at all. Since those persons are left to die, they never become part of the system and don't appear in the statistic. Plus given the type of government (totalitarian) it wouldn't surprise me to learn unfavorable stats are removed by the government. (Se

  • Interesting... (Score:5, Insightful)

    by nametaken (610866) * on Monday June 21, 2010 @02:24AM (#32637604)

    One side says war spending is the problem, the other says it's the economic bailout plan. But take both away and you've made almost no difference. Our deficit problem -- far and away -- is the soaring and seemingly unstoppable cost of health care.

    I'll admit that my concept of our spending is probably skewed by intentionally misleading infographics and such, but this doesn't seem to jive with anything I've ever seen. Can someone explain how this is true, or point to something that does?

    • Re: (Score:3, Informative)

      by xcut (1533357)
      It is true. Here's an article in the economist, which has good coverage of this: article [economist.com].

      Note: The proportion of GDP devoted to health care has grown from 5% in 1962 to 16% today. Rising health-care costs appear to have suppressed wages, as firms seek to make up for the expense. America spends 53% more per head than the next most profligate country and almost two-and-a-half times the rich-country average..

      There is a systemic problem in the US that is well document: that of wrong incentives in the system

    • Re:Interesting... (Score:4, Informative)

      by evilviper (135110) on Monday June 21, 2010 @02:45AM (#32637726) Journal

      It's called Medicare. It's a large percentage of federal spending right now, and it's projected to exceed 100% of all federal spending by about 2020, baring any changes.

      If you don't know this, it's simply because you aren't informed at all. Experts have been sounding the alarm bells for at least a decade, loudly and repeatedly. It seemed to be the top topic just a handful of years ago, when ballooning medical costs were the largest problem facing the general public, just a while before the economy started to fail completely, and more immediate concerns became paramount.

      Obama, Clinton, and McCain talked about it all through their presidential primaries and campaigns, in no uncertain terms. It was a major issues discussed endlessly in the house and senate for about a year as Obama tried to push health care reform through. I have no idea how you could be ignorant of this fact, if you pay attention to national/world events at all.

      http://blogs.abcnews.com/theworldnewser/2009/12/president-obama-federal-government-will-go-bankrupt-if-health-care-costs-are-not-reigned-in.html [abcnews.com]

      • Re:Interesting... (Score:5, Informative)

        by nametaken (610866) * on Monday June 21, 2010 @02:58AM (#32637788)

        Of course I've heard all the clamor over Medicare. Medicare represents $491 billion. DOD's annual budget alone is something like $1 trillion. I believe we've spent over a $1 trillion on the wars in Afghanistan and Iraq. Iirc the bailout ran into many trillions of $'s (certainly correct me if I'm wrong, some more inflammatory sources seem to put it at $24 trillion). Not to say that Medicare isn't a serious problem, but this doesn't seem to answer this question of our war and bailout costs being a fraction of what medicare costs us. No?

        Sounds like the earlier posters overall estimation of all healthcare costs as a percentage of GDP was more likely what he was talking about.

      • Re: (Score:2, Interesting)

        by MsGeek (162936)

        Here's how you fix it:
        1.) You re-tool Medicare to widen its coverage, in preparation for what will actually save it:
        2.) You open Medicare to everyone. Until 65, Medicare is a buy-in system. You will actually have to pay for it. Just like you pay for an insurance policy. Actuarially-sound price scales are created, with sliding scales derived from them for income sensitive pricing. Basically Medicare becomes an option on the "Exchanges" that will be up and running beginning in 2014.

        And how will this fix Medic

        • Re:Interesting... (Score:4, Interesting)

          by Gavin Rogers (301715) <grogers@vk6hgr.echidna.id.au> on Monday June 21, 2010 @05:36AM (#32638506) Homepage

          This is pretty much what happens right now in Australia.

          All income taxpayers pay the Medicare levy. A large payment base means there's enough in the nation-wide pool to cover pensioners, unemployed, etc who can't afford to pay-in.

          Private health insurers then come in and make a killing on gap insurance and covering things Australian Medicare doesn't - like dental.

      • Yes, unfortunately we DO need to put a price on life. This attitude of "Do whatever you can, whatever it takes, no matter how little good it does," doesn't work. We have some extremely expensive procedures these days, and can dump a lot of money in to the last few months of a person's life and make little difference. Unless we want to become a nation where healthcare is more or less what we do, we need to start thinking about economics.

        Now this doesn't mean saying "A person is worth $300,000, once that much

    • by AHuxley (892839)
      In most of the world you have
      Public health for all, private if you want it, gov health bureaucracy.
      Take your chances with either system, free or some $ gap, good dr, bad dr.
      But nobody has to stress, working, not working, young ,old, rich, poor as a citizen you have a safety net to see a local Dr, go to the ER, get expert services ect.
      Or you can go private and pay for them.
      The US seems to have stuck in an extra layer of private health bureaucracy.
      The gov to pay for a safety net, public health ect and th
    • Re: (Score:3, Insightful)

      by phantomfive (622387)
      Look here [wikipedia.org] and especially pay attention to this graph [wikipedia.org]. Here's a good one [wikipedia.org] to show what has happened with military spending: basically over the last 50 years military spending has dropped (until recently when it remained constant) and the money went to welfare/medicare/medicaid.

      The Iraq/Afghanistan war has only cost a little over a trillion dollars over the last decade, and that amount presumably will drop in the future. The stimulus also cost around a trillion dollars, but it was mostly a one time expense.
      • Re: (Score:3, Insightful)

        by fishexe (168879)

        The Iraq/Afghanistan war has only cost a little over a trillion dollars over the last decade, and that amount presumably will drop in the future.

        Which is why we'll have to go find a couple more wars to start. Don't you just love the military-industrial complex?

  • by RightSaidFred99 (874576) on Monday June 21, 2010 @02:30AM (#32637634)

    Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.

    I'm not saying this is the entire problem, but it's a huge part of it. If you don't see the costs of your health care, you won't wisely use it. It's the same problem plaguing college tuition costs. "Oh, it's free money - either I'm getting a loan (free money!) or someone else is paying for it!". Yeah, until schools notice this and start charging $25k a year to attend because nobody cares - it's "free money".

    My solution is a high deductible plan. If you can't afford it, the government picks it up for you. You pay the first $5k of your health costs out of pocket, the HDHP kicks in afterwords. If you're too poor for that, then they have government clinics for you.

    • Based on the cost of private health care here in Australia I reckon I would be better off investing the money and paying for health care in cash.

      (in 99.9% of cases anyway).

      • Most HDHP plans negotiate highly discounted rates. You'd be paying what the insurance companies pay, not what you as a private cash customer might pay in most cases.
    • by beelsebob (529313) on Monday June 21, 2010 @02:53AM (#32637754)

      Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.

      Which is why in the UK, where everyone can use the health service for free and is insured automatically by the government provides better health care cheaper?

      Doesn't sound like you've sorted that out right.

      • Re: (Score:2, Insightful)

        by roman_mir (125474)

        If you thought that Greece has problems, just wait until you find out how much debt UK has to other nations and what their trade imbalance is.

        It seems nobody is paying attention to HOW things are funded anymore, bankers give out loans to companies and to governments without understanding the first thing about the ability of the debtors to pay this money back.

        Imagine what will happen to all of the entitlements once nobody wants to bankroll it any longer.

        UK government, like all other governments consists of p

    • Re: (Score:3, Insightful)

      by interkin3tic (1469267)

      Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.

      While that would -sound- like a convincing idea, I see no evidence of that being the case. From personal experience, I don't decide to schedule myself, fill out the forms, disrupt my schedule, and then take the MRI for my sore throat, and I wouldn't even if it were absolutely free, no questions asked. A buffet of food, yeah, I'll take extra because I like eating food. Extra medical procedures? Who wants more of those? Are you telling me that people pointlessly waste other's money and their own time, an

    • Buffet style insurance is a huge part of the problem. People don't see the costs of their health care, and they're accustomed to getting as much as they want (not need) for a set amount of money, much of which is paid "magically", "somehow" by their employer.

      So what is the cost of a human life?

  • by mjwx (966435) on Monday June 21, 2010 @02:39AM (#32637692)
    1. Put old system into barrels marked "nuclear waste".
    2. Throw barrels off cliff.
    3. Pick working system like that from Australia or Canada.
    4. Copy it.
    5. Don't let the rebulocrats change anything.
    6. Profit.

    I'm serious, even if you choose to keep private health your premiums will go down as they now have to compete with the lowest cost alternative (public health), which is net profit for you. Another boon will be increased service from private health funds as public health sets the minimum standard for care.
    • Re: (Score:3, Insightful)

      by AHuxley (892839)
      The public/private Australian system would be great for the US.
      All the private practice you want with a free system for all "citizens" if/when needed.
      This would expose the union free, interchangeable, disposable workforce and not be allowed to pass.
    • Re: (Score:3, Informative)

      by Mashiki (184564)

      Too bad the Dem's in the US want this brilliant idea to micromanage every single freaking point of the healthcare system. Sorry but systems like socialized insurance in Canada, are wholly incompatible with the Dem view of how it should be done. Only the feds know the right way to do it. To point out the obvious, in Canada, the feds do nothing to the healthcare system unless it's run federally aka reservations and government(RCMP/Mil/etc). It's all in the hands of the provinces.

      The republicans have the r

  • Half a century ago, medicine was neither costly nor effective. [...] Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive.

    This is the problem in a nutshell. The notion that leads people to call for universal health care is intuitively moral: that every human being deserves the best medical care possible, even if they can't pay for it. It seems cruel to deny that. But medical care is some of the most expensive labor in the world. And justly so: pharmaceutical patent abuse aside, doctors and nurses deserve to be paid a bundle for how long they have to study to get certified and for what a general pain in the ass their job is. So

    • You're right that the money isn't there, but we can still promise the care. We don't have the stomach for death committees or official rationing. We will refuse to accept the problem.

      Of course, the waiting lists will grow as required to ration out the supply. Everybody gets healthcare, except the people who die while waiting for treatment.

      Maybe you can bribe your way to the front of the list, make friends with a senator, or claim to be part of some disadvantaged group that needs special treatment. The black

    • Your post has quite a bit right and I hate to pick nits, but you conflate two different things and they are very very different.

      [..] every human being deserves the best medical care possible [...] every human being should be provided with ample attention from doctors

      We can certainly afford to provide pain relief and basic medical care for every member of humanity. "the best medical care possible" is a completely different thing. There is always one "the best heart surgeon in the world" and he will never be able to see everyone. Hopefully he gives access to people with difficult and interesting cases, but in the end money or pot luck may n

  • by Anonymous Coward on Monday June 21, 2010 @02:56AM (#32637778)

    1. Uniform billing codes and realtime price-lists so that we know we're not getting ripped off. California's chargemaster publication requirement is a step in the right direction, but it needs to be updated more quickly, and rural hospital exemptions are BS. If you can run a hospital, you can update your billing DB no matter where you are.

    2. No anti-trust exemptions. This is so fundamental it's mindblowing.

    3. Nationwide competition.

    4. No more buyer's clubs. If the doctor and/or hospital is *licensed* then the insurance must pay out. You get to keep your doctor no matter what. Any company that wants to keep having a buyer's club can do that; but you can't be compelled to purchase into a club, only real insurance.

    5. Real insurance means you can't lose your life savings due to a percentage payment or a cutoff. After all, you can't actually insure health. Only genes and behavior can do that. When we talk about health insurance, we're really talking about medical bankruptcy insurance, and the current system fails to do that. In order to be considered a real insurance plan, you have to prevent medical bankruptcy. That means, for example, you can lose no more than 10% of your net worth or income in any calendar year. That way, you could be severly ill for 5 years, on chemo, and emerge with roughly 60% of your life savings intact instead of nothing.

    6. Stop torturing doctors. No, really. Many people won't even consider med school because it's torture. Maybe we need to put some doctors through boot camp. Maybe it's important for brain surgeons; but I can't imagine this system is really doing much to increase the number of competent family doctors.

    7. Malpractice/tort reform. Duh! If a doctor is so incompetent that we're better off taking him out of the profession then let's do that. Requiring all the other doctors to pay out as if they're that bad is insane. Multimillion $ payouts won't bring back your relative. License revokation, however, will prevent it from happening to somebody else. Note, this is tricky since it's possible for competent people to make mistakes. You actually need to make sure that the number of mistakes is statisticly significant. Otherwise, nobody will want to risk becoming a doctor (see point 6). Statistics is a bizarre thing. There's actually an expected number of botched operations; but the odds of a single doctor botching 10 operations in a row are probably low enough so you can safely conclude that doc needs to lose his license.

    8. Everybody self-pays and submits claims. That's right. You run healthcare like a normal business. I know it's hard to believe, but it really is just like buying a loaf of bread. Fire the beurocrats. No biggy. They'll get free health care while they look for a real job.

    9. No paper work until the patient is well. No signing anything under diress.

    10. You can put a pharmacy in the hospital. Quit making sick people drive to get meds.

    • by fishexe (168879)

      After all, you can't actually insure health. Only genes and behavior can do that.

      I think you're confusing insure with ensure. The way you seem to define insure, fire insurance would be a payment you make to prevent fires from happening, and flood insurance would somehow prevent floods.

  • by Anonymous Coward

    science has... enumerated and identified... more than 13,600 diagnoses — 13,600 different ways our bodies can fail. And for each one we've discovered beneficial remedies... But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures.

    It's too bad that Western medicine doesn't have a comprehensive guiding philosophy. Imagine if they taught principles like these in M.D. schools:

    • The body must be properly nourished, and must be able to assimilate nutrients from food and the environment.
    • The body must be able to evacuate waste products from the system. The organs of elimination are the skin, the lungs, the kidneys/bladder, and the large intestine/colon. If any of these systems are compromised, problems will result.
    • The body's structure must s
  • /.tivism? Slashtivism? This is the first time I've seen the editors directly come out on the side of a political issue in the form an article on the main page.
    • Re: (Score:3, Insightful)

      by fishexe (168879)

      /.tivism? Slashtivism? This is the first time I've seen the editors directly come out on the side of a political issue in the form an article on the main page.

      If this is the first time you've seen it on /., why would you name it after /.?
      Also, I suggest you look up meme [wikipedia.org].

  • by bezenek (958723) on Monday June 21, 2010 @04:04AM (#32638096) Journal

    Dr. Gawande suggests the "13,600 different service lines [doctors] deliver" is an issue in health care costs. I put forth these comments:

    * How many services are listed in the manual which guides the number of hours an auto mechanic is allowed to charge for a repair, e.g., replace spark plugs: 0.75 hours. How many items are in this book?

    * How many different services does a software engineer deliver over a year's time?

    I suggest the problem is related to control over charges. Car mechanics have a job with similar complexity to what doctors face. Software engineers often face a problem much more complex. (How many "surgeries" require several weeks to solve a single-line bug?)

    The control of health care "service" in the US is in the hands of the AMA and the bureaucracies created around hospitals and other facilities. If they were willing to reduce their profit margins (assuming we can eliminate the defaults they see because of uninsured/under-insured patients), we could see significant reductions in general health-care costs.

    This is just a thought...

    -Todd

  • by DrJimbo (594231) on Monday June 21, 2010 @04:12AM (#32638140)
    Pick any two:
    1. 1) Affordable health care
      2) Effective heath care
      3) Obscene corporate profits from health care

    As long as corporations control our government, number 3 is not optional.

  • The real solution (Score:3, Interesting)

    by bradbury (33372) <(Robert.Bradbury) (at) (gmail.com)> on Monday June 21, 2010 @08:47AM (#32639486) Homepage

    The article is interesting in stressing the need for a more systematic approach to medicine in the hope of providing both better care and lower costs. That will improve things but it does not solve the fundamental problem.

    The fundamental problem is the inherent improper design of biological systems which results in aging. As organisms age components fail and need treatment, repair or replacement. As the fraction of the population which requires these therapies increases costs will increase. Period. There are only two ways to solve this. Agree that because the biological systems are failing and will eventually lead to death we should reduce the level of care provided to these failing systems. Or redesign the systems so that they are more resistant to aging -- i.e. eliminate aging. If one eliminates aging one eliminates a significant fraction of the anticipated increases in the costs of health care.

    Now as is usually the case the devil is in the details. What causes aging? Largely the inherently poor design of the system, e.g. energy production methods (the electron transport chain in the mitochondria) which produces free radicals which in turn damage the DNA producing point mutations and/or DNA double strand breaks the repair of which cumulatively corrupts the genetic program of each and every cell in the body until one ends up with either cancer or "aging" [1]. From a programmer's perspective each and every program in the trillions of cells in an adult human's body is becoming corrupted and will eventually fail. We have replacement capacity for some of those programs through our stem cells but those programs become corrupted as well. Until we have the ability to replace or repair the declining genetic programs we will not solve the increasing costs of health care.

    Note that one can replace the programs in bulk (organ transplants) and there is an X prize pending for growing replacement organs from ones own stem cells. There are also a number of companies, e.g. Regenexx, BioHeart, etc. working on legitimate autologous stem cell therapies. There are also companies like 23andMe, Navigenics, etc. making personalized medicine available to the masses (so one can known what ones own genetic weaknesses are). And eventually if molecular nanotechnology develops quickly enough and we get real nanorobots like "chromallocytes" the repair of the cumulative DNA damage in each and every cell may become feasible (at low cost without the need for an operating room and a team of surgeons to perform a large organ replacement proceedure).

    But until one starts seeing more people point out that the lack of clothes on the emperor (that the real problem is gradual genome corruption and "aging") and the need for a real "industry" to deal with it *and* the political problem that if you solve aging (so people live indefinitely [2]) then one is also going to have to touch the "third rail" of politics (social security entitlements) if one is going to avoid bankrupting nations [3] then speeches such as the one cited will miss the critical issues.

    1. This isn't the only way the system is mis-designed. One could argue that the use of free radicals and inflammation by the immune system is questionable. On the one hand it may help to fight bacteria or viruses when one is wounded or otherwise exposed to them but at the same time the same processes probably contribute to heart disease. But heart disease can largely be dealt with through proper diet and exercise, and if necessary relatively inexpensive drugs, the same cannot be said for cancer and aging.
    2. Indefinite lifespans are not "immortal" lifespans. Fatal accidents still have a non-zero probability.
    3. All of the news debates about medical care costs, national debt, etc. (largely promoted by right wing politicians, new "Tea parties", etc. IMO) *all* ignore the probability that these perspectives largely disappear in light of molecular nanotechnology. People largely don't need Medicare if their genomes were better engineered to last indefinit

  • A Possible Solution (Score:3, Interesting)

    by ThosLives (686517) on Monday June 21, 2010 @09:26AM (#32639870) Journal

    After thinking about things for a bit, here's a simple statement of the health care "problem" - from a bias of being familiar only with the US system. I've also got a proposal that could address many of the issues while meeting most of the goals of a health care system.

    As introduction, the marks of a "good" system might be: treatment at any given level is available to all independent of individual wealth (equality of care), there is enough care at a given quality to support the needs at that level (availability of service), there is an emphasis on preventive care, and cost to individuals is proportional to amount of service utilized (fairness of cost). These are pretty much the main arguments of the day - people want to get (good) care for everyone but it is not economically or socially responsible to have everyone pay the same amount personally to get massively different benefit.

    My solution would be along the lines of requiring everyone to pay some baseline amount for insurance. This would be a small amount so everyone could afford it. Note that I would not exempt anyone from this small payment. But: If individuals go in for at least the basic regular checkups and basic preventive care, they would receive rebates that would offset this minimal fee. However, if you need more service than that, you must pay increasing amounts depending on the level of service needed.

    So this is something like the Taguchi loss function - if society as a whole has zero health care that's a big loss so should have a cost (the "minimum fee"). But if people have basic care to prevent communicable disease, basic checkups, etc. the total cost to society is lower - this is why rebates are offered. But then there are major illnesses and the like, which increase cost to society - so those should carry larger costs.

    Admittedly there are details that are probably important, but the major idea is sound - it encourages both minimal levels of treatment and preventive care but also (fairly) puts higher costs on those who need greater amount of care. This "greater cost" should probably be on some kind of relative scale; chronic illnesses with treatments should have not have debilitating payments (think of future value of work). Probably something like cost is inversely proportional to amount of time remaining to the average lifespan or something. Or so that "chronic" treatments are just a small amount per month, but a major illness at age 68 would cost more than the same illness at age 28 or 38. The costs should really be structured to reflect the cost/benefit to society rather than simply spreading high costs for a few to a small amount of people (in other words, avoid the "car payment" situation where yes, the monthly payments are lower but the total cost is higher. This is the sad economic effect of the current health care system; individual payments may be lower but the total cost to society is higher.)

    To summarize:

    1. Minimum fee required by all.
    2. Rebates for routine checkups and basic preventive care that would fully offset the minimum fee.
    3. Additional fees for any additional treatment beyond preventive/basic care ("basic" here things like non-STD communicable diseases or non-lifestyle-related injuries) to discourage unnecessary treatment and overly-risky behavior (e.g., X-games participants would pay for injuries or take out additional "occupational/hobby injury" insurance) but structured in a way to not financially crush people who need it.
    4. Provide some mechanism to reduce facility costs - property tax breaks or something. After all, we provide public libraries but not public clinics?
    5. Reduction in certification requirements for basic health services to increase the available health care providers to help with supply side. Things like nurse practitioners are a step in the right direction.

    I'm sure there are other minutiae, but this framework should address many of the personal-cost-side issues related to health care.

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