Wednesday, August 12, 2009

Melting to the Money

Dr. Rob left this comment a few days ago, and this was the most thought-provoking part to me: "[I] hope the congress will avoid melting to the money and actually push primary care." I agree with him -- I hope that primary care is a priority in the new system (and since the legislation is still being debated, it's not certain that the final draft of the reform bill will prioritize primary care), but it took me a while to figure out why ignoring primary care would be "melting to the money."

Here's what I figured out: since we have, excepting Medicare and Medicaid, a largely for-profit health care and insurance system, the most profitable parts of the health economy become larger, and the less profitable parts shrink in size -- the system flows towards the money. Examples:

1) Notice how you never see television advertisements for prescription drugs that cure disease or fix a problem? The drugs worth advertising -- the most profitable ones -- are new treatments for chronic disease like irritable bowel syndrome, fibromyalgia, erectile dysfunction, etc. These are treatments one has to take over and over again, and the reason only new drugs are advertised is because the profit margin is highest on drugs that are still under patent. This book puts it particularly well:
Jurgen Drews, a physician who has been the research director of a major global pharmaceutical company...argues that in recent years an obsessive, and ultimately self-defeating, focus on the bottom line, and the increasing costs of launching a new product, have led pharmaceutical companies to devote their research efforts increasingly to so called "me too" remedies for conditions such as high cholesterol and hypertension for which useful therapies already exist.
Because it's quicker, and more profitable, to seize control of a market that already exists than it is to undertake the long process of truly improving public health.

2) Why is it that a trip to the dermatologist, even a very simple one, is likely to cost three times as much as a trip to a general practitioner? Supply and demand -- there are fewer dermatologists, and they can demand a higher price, even though their specialty is no more complicated than general practice medicine, and they don't have more training, just different training. It is weird that we have plastic surgeons driving around in Benzes while some rural counties with obvious need have a crisis-level doctor shortage. I'm not arguing that people should be stopped from paying for health care, I'm just pointing out that under the current system, the most profitable branch of medicine is cardiology, followed by radiology, orthopedic surgery, ophthalmology, anesthesiology, and dermatology. Those are all great, and deeply necessary for good health care, but they're not the medical care that we need most. They're the kind of care that is most specialized -- when you need a specific surgery on your eye, there's a very limited number of people who can do it, and they can charge whatever they like. Meanwhile, your primary care physician is deeply involved in saving your life in a number of ways (monitoring your blood pressure, providing early cancer diagnoses, catching diabetes before serious symptoms set in) but they're not paid a premium for it -- because there's lots of general practitioners.

3) Public health initiatives -- education and availability of the most simple, most effective health interventions -- make zero profit (because they address a need before the point of crisis) for private industry and provide measureless profit to the community. So we leave it to non-profit, often non-medical groups to do things like encourage HIV prevention, provide flu shots (which are organized in my neighborhood by the LA County government), educate expecting mothers (a service of the March of Dimes), etc. etc. Resources -- money -- literally melts away from these needs, because they don't fit into our current profit-based model. This is not cost-effective -- if we had an organized, national health care system that could ensure that folic acid was provided for every pregnant mother, we would pay less in emergency room visits, government-sponsored care for premature newborns, lost work and wages, etc. etc. etc. The problem is that it's not profitable to tell women to take a multivitamin in the first weeks of pregnancy -- at least not profitable in the narrow, free-market sense.

I probably come off sounding a little bit critical of the free market in the examples above, and I'm really not -- private companies can be, under certain conditions, terrifically helpful. Unfortunately, too much money has melted to the shape of that free market, and we're missing all the benefits that can be had from a not-for-profit, community option for health care. That's the public option -- and to get it, we're going to have to overcome the entrenched interests (and the money they've accumulated) that profit from the current system -- namely, insurance companies and the politicians they support.


  1. We don't have a free-market with the current insurance system. It's not even close.

    The point of my cynical statement was that my existence as a PCP has the purpose to reduce hospitalizations, reduce use of medications, reduce number of specialist visits. In short, I exist to keep my patients as healthy as possible. My success would be lousy for the hospital, pharmaceutical, and device manufacturing industries, as well as hurting my specialist colleagues.

    There are some who benefit greatly from a lack of PCP's.

  2. Point taken -- we're not exactly in a free market system now, considering the pressures from both sides like tax breaks for employer-based insurance, Medicare/Medicaid, etc., and on the other side the decidedly unfree tendency towards monopoly. I changed the most directly offending line in the last paragraph.

    Your other point makes me rethink my medical care, though -- the only people who have ever checked me out and then told me to go home because I wasn't sick were general practitioners. I've personally never had a specialist tell me to wait and see or just go get some rest. I mean, I'm sure specialists do that sometimes, but cost-saving usually falls to the PCP, which would be why they're not the ones with gold-plated stethoscopes.

  3. Because of a society obsessed with procedures and quick-fixes. Care was hospital-based for a long time, so it tended to favor those physicians who supported the hospital more. Procedurists were paid a lot at first, and so they gained power and influence. I don't think this is about evil people; it's about power and money.

    Old story; new actors.