Becoming Cheaper by Becoming Healthier

The argument about the economic utility of wellness proceeds apace, with supporters scrambling for data to support their position.

However, I must point out again that the crux of this argument is the contention by many conservatives that the problem with US health care is all of our fat, smoking, alcoholics, not actual flaws in the system. Some people introduce this argument as a way to undercut real reform, and others trail along because the argument appeals to them.

The way to fix what is wrong with American health care is to pay attention to the real issues: universal access, decreased costs, and using proven ways to both improve health care and save money by paying attention to good scientific data about effectiveness and quality standards (see Bush treasury secretary Paul O’Neill’s op ed about quality assurance in today’s NYT opinion section.)

The paucity of good new data about wellness is an example of why we need good systems for collecting accurate data about health care issues. The 400% range cited in the article above is just one case of why we are not getting good answers. We need good ways of collecting accurate data, and a well designed universal electronic medical record is one way. The only good data on wellness, which demonstrates that wellness is not economically effective, is from Dutch studies that are now 20 years old. New studies are poor quality scientifically, but good new studies might support a change in results due to new management standards.

Finally, regardless of cost, wellness is worth pursuing for humane reasons, whatever financial data shows.

The answer is..... NONE OF THE ABOVE!

We need a more efficient system. First get rid of wasteful profit making insurers. Then get more efficient medical practice.

For Pete's sake (who was Pete?) Ezra, you were the guy who found the CEPR calculator (http://www.cepr.net/calculators/iousadeficit/calc_iousa_deficit.html).

This shows (if you believe in CBO projections) that we can turn a huge deficit into a sizable surplus by adopting a better health care system like any of the 23 countries listed on the calculator.

Why don't you write about the calculator?

"At the end of the day, health-care costs are going to have to come down. And that can happen in one of three ways."

Tunnel vision, Ezra? I can think of a lot more than three.

And the civil libertarian in you has no problem with the government assuming authority over all manner of personal behavior b/c of its vested interest in people's health? The same government that absolutely must not listen in on your overseas phone conversations with terrorists is okay to monitor the health impact of your behavior?

"the contention by many conservatives that the problem with US health care is all of our fat, smoking, alcoholics"

Have you got links to "many conservatives" actually thinking like that? Because I'm a conservative, and I'd be happy to go set them straight for you.

This is great:

"We need a more efficient system. First get rid of wasteful profit making insurers. Then get more efficient medical practice."

Are you KIDDING me? When has the government, which never met a dollar it didn't like, been MORE efficient than the free market? Do you REALLY believe that it's only those profits that make the system not work? That the government will somehow magically make things work better? People who have absolutely NO incentive to keep costs down? What fantasy world do you live in? All the government does is give every single program more money every year, and sometimes says they are cutting the budget (EVEN when they cut NO programs and spend MORE on those programs from one year to the next).

Good luck with that, as they say.

Good news on the Obesity front there. I don't know if that translates to other things though - I'll bet smokers are still cheaper than non-smokers.

One thing I'm curious enough about to ask here, but not curious enough about to LMGTFY, is whether the studies of overall healthcare costs take into account the productive working years of the healthy vs. the sick. I have to imagine that healthy people tend to work more years at a higher productivity level, and so their inputs to the system would tend to be higher, which could counteract higher outputs (or make things even more lopsided than they already are in the case of obesity.)

"I'm a conservative, and I'd be happy to go set them straight for you."

The US spends twice as much on health care as most other countries yet gets worse results.

If you don't believe that the problem of poor health habits by Americans is the cause of that, what do you believe?

And don't say that doctors need to charge like vets. Doctors' personal incomes account for only about 7-8% of health care costs, just a little over the cost of one year of health care inflation.

Account for the other 43%. That's about $900 billion a year.

The only other idea I've heard from conservatives is that people should be encouraged to get less health care. Since most of the lower cost countries that show better results actually have more doctor visits and more hospital days, and since study after study shows that the general public does a very poor job of making decisions about what health care they should get, leading to higher costs because of neglected basic care, that argument doesn't hold water either.

1) even with another health care system, how do you force people to take better care of themselves? Hmmm?

2) we spend more because we have more. It is not a valid comparison. Rents cost more, salaries are more, etc. Everything is more expensive in this country (well, many things) - so um, it's not surprising that things like health care ALSO costs more.

3) we are subsidizing the rest of the world, for all sorts of things. Things like research, is the biggest. But also that people come here from the rest of the world for certain types of treatments. Also pharm companies give away drugs to much of the world - that's one reason our drugs cost more.

We can stop doing what we are doing - but in reality the rest of the world doesn't really seem to pay 'their fair share' in costs - because we are subsidizing (I know many of you won't believe me, but seriously - it's our obligation to do so, considering, well, WE CAN). When that gravy train stops, what happens? Hmmm...?
Or do I have everything wrong? I'm sure y'all will tell me...

Housekeeping:

First, altmom, there is no question that in health care Medicare can deliver insurance with much less overhead than private insurers, both by decreasing costs for operating the program itself and also by decreasing the costs providers have for dealing with insurance. The amount of the difference is subject to argument, but overhead associated with private insurance adds an extra $100 billion (the number cited by defenders of private insurance) to $400 billion (the new favorite number of single payer fans) a year to health care costs. On the side of the private enterprise advocates, almost all processing of Medicare claims is done by private companies, some of whom are also insurance companies. They just can do it a lot cheaper in Medicare than in their own business.

Second, Drew etc., the issue of productivity is not a significant factor in the question of good health habits and expenses for two reasons: the first is that the overwhelming amount of costs are incurred after retirement, the second is the availability of a huge surplus labor pool to pick up any lost productivity by people lost to the system. "Atlas Shrugged" to the contrary, in the US almost everyone can be replaced. Easily.

altmom:

1.) As I have said, that is not a major issue as policy, since good habits actually cost more. People should have good habits for their own sake, but we will not save money because of that.

2.) We spend almost twice as much on health care as a percentage GDP, spending a much larger share of our wealth than other countries for our poor results.

3.) We actually spend less on research as a fraction of GDP and per capita than most other developed countries. A large amount of innovation actually comes from other countries, in medicine especially. Pharm companies do not give away drugs, they sell them for closer to their costs in other countries. In the US, pharm companies spend more on TV advertising (interfering with the doctor/patient relationship) than on research, and, as has been pointed out many times, most critical pharm research is done by and paid for by public entities.

Many doctors only take a certain number of medicare patients because the payments from medicare are too low for them to be able to operate properly. So what's the answer? Squeeze the doctor?
My kids' pediatrician works from 6 AM to probably 8 PM most days of the week, then it on call several days a week. Doctors work hard, and that's after 10+ years of training. And constant retraining yearly.
The reality is that we have been squeezing the doctors - the very people who actually administer the health care - for years, and each and every 'extra' $5 I send to my doctor, well, that's because they're not getting it from somewhere else (i.e., the insurance companies, public or private, keep giving them less).

Far from being squeezed, the reality is that doctors' incomes are rising continuously, with primary care doctors making an average of nearly $180,000 a year and many specialists over $400,000. Granted, there should probably be more money for primary care (and less for specialists,) but no one is hurting.

As a doctor, I am not very worried about seeing doctors on corners with signs saying "will give vaccinations for food." However, as I said in an earlier response, doctors' incomes are not the target of opportunity for health care reform or savings, since there just is not enough there.

What is an appropriate target is doctors' practice patterns, where management approaches unique to the US raise costs by about $800 billion a year and yield worse, not better, results.

But what if the cheapest means of cure is not conventional wisdom? Take diabetes -- many have been relieved of their symptoms and can dramatically cut back or even remove their insulin, by cutting their carbohydrate intake to an absolute minimum. Dr. Bernstein's New Diabetes Solution explains this well. However, the ADA is influenced by the government which is influenced by the wheat and sugar lobbies, and the last thing they want is folks cutting their wheat and sugar, so his methods don't make their platform. But they work. The ADA is are also influenced by the drug lobby, who has a vested interest in keeping diabetics on insulin. But it certainly would be much, much cheaper to drop the drugs and the wheat. Here is where comparative effectiveness scares me. If the government sponsors CER, will they be unduly influenced by big sugar/wheat/pharma?

Interview with Dr. Bernstein

The following is an interview with Dr. Bernstein.

http://livinlavidalowcarb.com/blog/?p=5184

We rent an oxygen unit for our home. It is doctor prescribed. The oxygen company bills my insurance $500 a month for this service. For the first couple of months, my insurance paid about $150, and then I got a bill for the rest. I complained, and my bill magically changed to a $38 a month co pay, the rest of it having been "negotiated" by the oxygen co.
This for a unit that costs $749 brand new, and is currently three years old.
Medicare pays about $140 a month for this unit, period.
The CEO of the oxygen company was paid 7 million dollars last year, up %40 from the previous year.

"1.) As I have said, that is not a major issue as policy, since good habits actually cost more. People should have good habits for their own sake, but we will not save money because of that."

But if a goal is for people to be healthier, then, again, how do we actually do that? How do we force people to have better habits? Go to the doctor more? Catch cancer earlier rather than later?
I certainly agree that something needs to be done (1: get rid of 'insurance tied to employment - or modify it somehow and 2: we don't need more INSURANCE, we need more HEALTH CARE), but I don't see anyone discussing the issues in a way that will actually make it better.

If you further obscure the payment for healthcare services behind an even larger Government blanket do you really think that is going to induce Americans to demand less healthcare? If they demand more healthcare what will that do to the cost of healthcare?

If the Government is directly or indirectly responsible for the cost of healthcare via a public option or honest nationalization and it is determined that increased wellness brings down costs are we all going to end up with telescreens in our bedrooms ordering us to workout to marching music every morning?

"How do we force people to have better habits?"

There are some things beyond the reach of policy.

What we can do is improve access so that the uninsured and underinsured do not avoid health care they should get, and change the way management works to favor effectiveness over high tech.

mb129's example of management of type 2 diabetes is a good one. Management patterns that are cheaper are often better. SMDC, a large health care system in Northeastern Minnesota, recently published an article about a very effective program for congestive heart failure, the most expensive health problem in the US, that reduced costs greatly by use of intensive outpatient and telephone contact by nurse practitioners.

PatS2:
"The US spends twice as much on health care as most other countries yet gets worse results."

You really should read this -- you sorely need it:
http://online.wsj.com/article/SB124640626749276595.html#mod=djemEditorialPage

Our standards of care are at least as high as other countries, and our discretionary income is generally higher. We *should* spend more, with only marginal gains to show for it due to diminishing returns. "Worse results" is highly debatable. Are you relying on things like Cuba's infant mortality to make that claim?

"Account for the other 43%. That's about $900 billion a year."

Defensive medicine in a system where doctors are uniquely vulnerable malpractice lawsuits, particularly compared to government-run systems. Or, as you libs like to call it, "unnecessary procedures." Technically unnecessary, but there is a reason those tests and procedures are ordered. Care costs more because it's illegal to shed liability for overlooking diagnoses on the basis of economics and statistical improbability. Exceptionally expensive drug approval processes. All kinds of things we could fix to actually make the system more affordable instead of just trying to make it appear to cost nothing.

"The only other idea I've heard from conservatives is that people should be encouraged to get less health care."

In other words, that pretty much takes care of the whole fat smoking alcoholics strawman, huh?

I overheard a conversation a while back that had me floored.
Mom was complaining because one of her kids was sick. She told other mom: it would cost at least $100 to have a doctor see her. That's crazy. She indicated her husband was currently out of work so they didn't have insurance.
What is wrong with this picture? Basically, her words and attitude indicated that the health care she wanted for her child *should be free*. Free, as in, she shouldn't have to pay for it.
I'm sure if someone asked her: well, who should pay for it if not YOU? Your child is sick, you should take her/him to a doctor.
People are under the mistaken impression that health care should be free - since typically someone else picks up the tab anyway. But someone has to pay for it (and we've been paying in exchange for wages for years, people just don't realize that.
We've been highly conned. And it's only going to get worse once we have only the government to go to for our healthcare.

Do you really think that all of the current discussions *won't* lead to a completely government run health care system at some point? Companies are more than willing to get out of the health care business.

There so much nonsense floating around today I hardly know where to start. How about defensive medicine. There have been many studies (one by the CBO) that show that there are no more "unnecessary procedures" in states with no limitations on malpractice suits as in states with draconian limitations.

I had a conversation with one of my physicians yesteday. He told me he is willing to take less money from Medicare because the administrative mess of collecting from private companies is a nightmare. His office of 5 doctors has 3 full time people just to deal with private insurance companies.

Our drugs cost more because we have no controls on prices. Drug companies spend twice as much on profit and three times as much on "marketing" as they spend on R & D (google Alan Sager). The purpose of marketing is to get patients to rquest drugs they do not need or physicians to prescribe new expensive drugs in cases when older chesper drugs are as good if not better. Marketing includes, not only the odius ads on TV, etc., but also the thousands of "pushers" that haunt doctor's office. They also pay Billions to physicians both over and under the table. Here's an example http://www.nytimes.com/2007/11/25/magazine/25memoir-t.html

atimon - You ought to get out more. Live a year in France.

John Galt - Don't worry, I don't expect you to follow this discussion.

One simple solution...change agriculture subsidies.

Ezra talks about changing things outside of the health care system to help bring down health care costs. I completely agree, and I think the starting point is changing our agriculture policy.

Our current agriculture subsidies create perverse incentives for growing nothing but soybeans and corn. As a result, food producers will turn to using corn for EVERYTHING, since it's so cheap on the open market. The resulting monoculture and infusion of corn syrup into every aspect of the average American diet is leading to horrible health consequences starting with childhood diabetes.

Some of the commenters have complained (directly and indirectly) about the implicit proposol of Ezra's post that Government should somehow be involved in regulating healthy behavior. In this case, I think the easy thing (which I assume at least the commenter known as whoisjohngaltcom would agree with) is for the government to STOP engaging in practices which encourage bad health.

Now, it's quite likely that if we want to ensure a robust and affordable agriculture system that it will have to be subsidized (with, yes, the more wealthy and well off, paying a greater share to ensure that people don't starve). However, these subsidies should encourage farmers to grow a greater diversity of crops in a more sustainable fashion. Ezra had a post a couple of days ago talking about urban farming and criticisms of economic viability. It's likely that most agriculture is not economically viable if we want to maintain a food supply that is not cost prohibitive to a segment of the population, but as Ezra suggests in his article, these subsidies can be more broadly targeted so that they empower farmers and not the giant agro-industrial companies (e.g. ADM and Cargill).

Unfortunately, addressing this problem is probably not politically viable since the Senate disproportionately represents rural, farm states where the ADMs and Cargills of the world reign supreme.

I did live in France, actually, in college. So thanks. I liked what they have. The govt sets rates but does not have doctors that are govt employees - they are allowed to do whatever they want...Not like England or Canada (which is apparently what everyone wants) where the government tells you when and where you can do anything.
Meaning, well, in the UK and Canadan people wait for whatever procedures they may need...which typically have bad health consequences...the government decides who gets what procedures and you have waits...

lensch:
"There have been many studies (one by the CBO) that show that there are no more "unnecessary procedures" in states with no limitations on malpractice suits as in states with draconian limitations."

Maybe you should tell that to Obama:

"[Obama] also cited unnecessary tests and procedures as part of a "defensive" medicine culture created in part by the risk of medical malpractice lawsuits. To loud applause, he said ending unnecessary procedures could require restrictions on malpractice liability to protect doctors."

(http://www.cnn.com/2009/POLITICS/06/15/obama.ama/)

I don't know why they were applauding. Maybe somebody should tell all those doctors that their malpractice liability has nothing to do with the procedures they order.

"The purpose of marketing is to get patients to rquest drugs they do not need"

Insurers should be able to legitimately deny claims to these drugs if they are "not needed." Since they also have the necessary incentives to deny claims, I can only guess that their hands are somehow tied by government. Maybe you could explain the actual problem better than just explaining why marketing exists?

atimon - Thank you for the polite reply. If you like what they had had in France how can you doubt that the government can efficiently run health care? Why don't you support Medicare for All (HR676) which would be very similar to the French system?

BTW I also lived in England for a year and it's not at all the way you descibe it. Furthermore I have friends in Canada and they love their system. An 08/2008 Globe - Mail and Canadian Broadcasting Poll asked Candians which health care system they prefer, theirs or ours. 91% preferred the Canadian system.

You should look up the data on wait time. Try http://canadaonline.about.com/od/healthcarewaittimes/Wait_Times_for_Health_Care_in_Canada.htm

but remember, everyone in Canada who needs treatment gets it while many in the US do not; their wait times are infinite.

Finally, even though the government does not "tell you when and where you can do anything", I would prefer to have a government employee tell me what procedures are covered than an employee of a rapacious for profit insurance company.

If you think profits are so evil, why do you live in a capitalist country? Why do you think profits are evil? Should the company you work for not make profits? Are there some companies that are allowed to make profits and some that are not?
What industries are allowed to make profits? The problem in my opinion, is that with our government, and they have definitely showed this to us recently, is they have no idea what anything cost, how anything within capitalism works, or what they are doing with our money. They spend and spend and it your money and my money. They do not feel a fiduciary responsibility to anyone.
This is one reason that I do not like the idea of the government taking over health care.
And with medicare for all - hello - all I read is that medicare is going to go bankrupt before social security. How's that working for us, then?

Do you favor having several profit making fire departments as they had in colonial Philadelphia? Profits work in some industries not in others.

The record is indisputable: other countries with government run health insurance systems spend much less and they get better care.

Think about your statement that Medicare is going bankrupt. Obvioulsy what we spend depends on what we can afford. Go to http://www.cepr.net/calculators/iousadeficit/calc_iousa_deficit.html which will allow you see if we can afford a government run system.

You're not really arguing the correct things.
My opinion is that typically, a market run system is better than a government run system. Changes have not been made speedily enough to social security and it's a disaster. No politician wants to do the right thing, and it's terribly run (seriously, when you have the population working for only 1/2 their life, well, then who's going to support them the other half? NO we can't afford everything).

Part of the problem with health care is the horrific regulations that are involved. Created by the govt.

I think it's possible we should be able to come up with something other than employer pays everything and government pays everything. Seriously.

People have no idea what things cost NOW - when/if the government takes over, they will be more beholden to the govt than they are no, and they will have even less knowledge of how much things cost. And they won't care.

Again, we can't do everything.
Why does anyone care about people having INSURANCE? I have said for quite some time - people don't need insurance, they need health care.
So if our government cared all that much about everyone getting health CARE - why don't they just open up clinics around the country?

"The record is indisputable: other countries with government run health insurance systems spend much less and they get better care."

Something tells me that's more than just a little bit "disputable."

And, also, other countries may have functional governments.
You do things with the government you have, not the one you wish it could be.
With our CURRENT government (and I said this under Bush, too, it has NOTHING to do with the president, it has to do with the fact that these people are career politicians, that our system does not allow for other candidates to run, that most people in this country have no choice for their representatives, state or local or federal) - should not have the power. Is not functional. Does not do these things well.

What we do not need are politicians who are in office for 20 or 50 or more years. What we need are people who make laws who have some concept of how the rest of the country works. And we do not have that.

And I've said THIS before too: why and how are we even considering having the federal government make at least a trillion dollar IOU (at least, that's what they say now, it will be 2 or more trillion soon enough). Why are there no pilot programs? How can we possibly think that what works in one area of the country would work in another?

Any other country you compare us to doesn't work...all the other countries have very specific populations, not the diversity we have.

We have shortages of doctors in some areas (with or without insurance, it's hard to get an appointment). How will that possibly change with a government program? Are we going to force people into med school? Tell them where they should live?

Look in the '50"s we had the highest life expectency in the world and were right up near the top in the other public health statisitcs. We were just as diverse and if anything other countries are more diverse now than they were then. But we slowly let for profit companies take over the health insurance industry and other countries went to more efficient government run programs, and then they pulled ahead in health care.

I have to end this now, but you really ought to look at the data. More people are turned down for medical school than are accepted because the medical establishment has limited the places. People want to go to medical school.

Finally the data and the examples of others show it will cost us less to have, say, Medicare for All than we are now paying. Look up the "medical loss ratios" of private insurance companies. Check on the studies of the vast physician and patient compliance cost caused by these companies. I've already talked about drug companies.

In the 50s, again, the 'evil' for profit companies existed - the health care industry was definitely NOT run by the government.

All I'm saying is this: What we have is terrible. But the answer in my opinion is not to have the government take over every aspect. There is something in between, but no one seems to be discussing it.

And again, perhaps we should just have the govt set up clinics. Those who want govt run health care can have it, and the rest of us can figure something else out.

"I've already talked about drug companies."

LOL. You said something irrelevant about marketing. You made no attempt to explain how drug commercials translate to costly insurance coverage.

Just as you made no attempt to explain how Obama is out there acknowledging liability as a factor to unnecessary procedures (as does the president of the AMA, btw).

If you have it all figured out, then you should have explanations for these inconsistencies. Or perhaps it's more convenient to your preselected outcome to just ignore facts.

BTW, when's the last time you acknowledged a problem -- anywhere -- caused by excessive regulation?

All the healthcare systems you admire are relying on advancements that originated in the private sector. By capitalists. When we sign on to the not-for-profit model, mark that date. That is the day medical advancement slows to a crawl.

whosjohngaltcom: There's no need to be so dramatic. Seriously. Capitalism will always win out.

People will travel to other countries (as they are currently doing) where there is advancement going on. Medical advances will happen, because you have many people who are wanting to work on them, who have the drive to do so. Okay, it may not be here in the US - but it will happen.

So the footnote is, we may not have access to that care, but it will exist (see FDA approvals...)

Just a few comments before this thread leaves for Pluto.

First, there are abundant data that show that if people are given more responsibility in choosing how to spend money for health care, they often make poor choices, avoiding lower cost prevention and early intervention because they are not convinced they are "sick," and ending up using a lot more health care in the end when they present with more advanced problems. Almost all health care economists admit that moral hazard does not work well in health care because one of the primary requirments, good information, is missing. Consequently, plans that involve passing more financial responsibility to the consumer are not good ideas.

Second, doctors in Canada do not work for the government. They are independent. The insurance is run by the government, just as almost 50% of our health insurance is. Canada is much more like France, where the insurance is private but is tightly regulated by the government, than England, which has a true government health care system -- which works very well, thank you.

Third, there are 500 million people around the world in government controlled health systems. They are happier than Americans with their health care, based on polling, and they do not get up each morning to march to government exercises. One of the reasons they are happier than Americans is that they enjoy better results. (BTW, Cuba is not one of the countries I am counting. There are 36 countries ahead of us in statistics, but Cuba is slightly behind. It is, after all, a third world country.) Almost all of these countries are vigorous capitalist economies.

Finally, to restate what has already been noted, there is no convincing link between malpractice and overuse in medical care. Many of the worst states for overuse have had strict malpractice reform. There are institutions with very efficient performance embedded in settings that have high overuse statistics all around them. Mayo Clinic in Scottsdale is a classic example. It has better efficacy statistics than the main Mayo in Rochester, despite being in the middle of an overuse hotbed.

BTW -- someone linked a reference to the Wall Street Journal editorial page. Please spare us. The WSJ editorial page has about the same level of credibility as the Daily Worker's editorial page, for exactly the same reason: ideology trumps rationality.

The WSJ editorial page has had a miserable record even in areas of finance, where they should have some credibility. As a rule of thumb, assume that they are wrong, and you will do pretty well.

The rule is: WSJ news pages -- reasonable, especially regarding finance. WSJ editorial -- useful for wrapping fish, otherwise without merit.

"They are happier than Americans with their health care, based on polling"

And Americans are actually quite happy with their own care, as evidenced by their demand that they be permitted to keep their existing plans.

"One of the reasons they are happier than Americans is that they enjoy better results."

Invariably, statements like this one rely on "access" as a metric. Freedom lowers America's score, but it doesn't lower the quality. You put us on par with Cuba? Are you friggin' joking???

"no convincing link between malpractice and overuse in medical care"

Unless, of course, you ask the president of the AMA. Or unless you listen to Barack Obama address the AMA. But then, what would the AMA know about it -- or Obama, huh?

"BTW -- someone linked a reference to the Wall Street Journal editorial page."

Read it and rebut it. God knows you need it.

LOL. I still can't believe you'd buy anything that ranks us alongside Cuba.

As if you would send one of your own family members there? Seriously -- get real. How stupid do you think people are?

Oh, yeah, and where exactly do you think you're posting, if not on the equivalent of WaPo's own editorial section???

You know what they say about opinions. Maybe you need to be practicing a little more proctology.

We don't really know the extent to which overutilization is due to doctor incentives, fear of lawsuits or simply fear of being mistaken, a culture where an oversight is implied where none reasonably exists, or pressure from the patients themselves.

We don't know.

Some say it is money driven.
Some say it is malpractice driven.

Both are political answers. States which have had malpractice reforms for a long time have lower growth in malpractice expenses than those that don't. In general, the higher we set the minimum standard of care, the more expensive healthcare is going to be, with little evidence of improvement. Law of diminishing returns...

You can't reduce utilization when there is a prospective medical standard of care and a retrospective 20-20 hindsight legal standard and expect utilization to go down. It defies logic.

Sometimes states like Texas pass tort reform BECAUSE they have a problem. Other states, like Michigan, pass tort reform (for drug companies) to attract industry.

It can't be a coincidence that Miami is the capital for both medical overutilization and for aggressive malpractice lawyers, can it?

Besides, none of the other government programs for healthcare allow lawsuits, so why would we need to?

"Some say it is money driven."

You know, in my whole life I've never had a doctor allow an illness to fester, worsen, or progress with even the slightest hint that if it gets much worse he'll have something much more expensive to bill my insurance company for.

Yet I'm supposed to think that he orders procedures and tests -- many of which are completely outsourced through referral -- for profit???

I don't know what kind of relationships you guys all have with your doctors, but I've got a doctor who routinely tells me things like, "Well, you don't really need x test, but I have to give it to you before I can order y treatment." And more importantly than the justification he has for the treatment he prescribes is the fact that he's been my family doctor for decades. We have a relationship.

I don't have a trial lawyer, so I can't talk about that relationship. But I do note that their fee schedules are pretty high, as are the awards. I wouldn't want to pay one over a third of my award if I was suffering, and I can easily see a doctor going the extra mile to afford paying too much to one, too.

But I'm sure it's not about the lawsuits.

It does boggle the mind, this nonsensical certainty that litigation plays no role in overtreatment. You'd have to be a complete idiot to believe that. Literally.

There is nothing to refute in the WSJ editorial. It does not contain one fact or factual reference. It is 100% opinion. So of course is most of what is posted here. However, there is a lot of FACTUAL information and DATA out there. The level of discourse could be improved by more reference to facts and less reference to ideology.

Also, I specifically said that Cuba is behind the US. If you are going to criticize, at least read the whole sentence. Don't just become agitated because you see the word "Cuba."

I don't believe that overuse and high health costs in the US are due to greed by doctors or to fear of malpractice. Obviously, there is an impact, probably roughly equal, from those two factors, but I think that they are relatively low in their impact. This is an opinion.

I think that the overuse is due to cultures in US medicine. This is supported by some facts. The best evidence of that is that some US health care systems, all well identified in the Dartmouth Atlas data, are able to be much less expensive and have better results, even while working in geographic areas where other systems have much greater costs despite having the same malpractice environment.

Doctors are very upset by malpractice, since it scares all of us. However, there is very little hard data about the impact of malpractice on health costs, and most of what there is -- comparison of malpractice environments and correlation with cost information -- seems to suggest that its impact is small. I do not oppose reform of malpractice; it would be a useful step as long as it protects patients as well as doctors. Many doctors groups are very interested in malpractice reform and much less interested in other serious issues in US health care.

The Dartmouth data is one of the few bits of hard data about health care costs. There is no other good data about causes of high costs, except for international comparisons. Please, please, do yourselves and all of us a favor, and before you try to comment on health care costs in the US read some of the Dartmouth Atlas data. It is easily accessible if you know how to use Google. You can read as many of the reports as you like, but the message is always the same.

"There is nothing to refute in the WSJ editorial. It does not contain one fact or factual reference."

Nonsense. Absolutely untrue. What *is* there is common sense, easily refuted with explanations of why this parameter or that one defies supply and demand. That guy should be a sitting duck for you -- he's not just giving opinion: he's reasoning out loud. You should be pointing out the flaws in his logic; the fallacies, false premises, hasty generalizations, oversimplifications, etc. If your argument is built on reason, you should not be hesitating to apply it.

"less reference to ideology"

Basic economics is now an ideology? Do you think supply and demand are religious concepts??? Mere theory???

"Also, I specifically said that Cuba is behind the US."

No, you *specifically* said "*slightly* behind." "Slightly," as if in a pinch you might consider it the next best substitute for the care your family gets here. And in fact that's not the case at all; the only explanation for this comparison is dishonesty. You do NOT consider Cuban healthcare (based upon performance self-reported by an authoritarian dictatorship and heavily scored for accessibility? Give me a break!) comparable to US care. You wouldn't dream of taking your kids there and trying to tell them the care you'd give them yourself is only "slightly" better. That's complete crap. How can you even say it with a straight face???

So not only does that place actual US healthcare quality much further ahead of the third world than you suggest, but it also calls into question the rankings of the 36 supposedly "better" countries which, while not all dictatorships, are still heavily skewed by political self-reporting and irrelevant accessibility-bias.

I must also point out that under such scoring, if five more middle-aged breadwinners died on waiting lists while ten more bums received liver transplants, this absolute tragedy would show as a net gain. I'm not saying that would happen a lot, but it does point out the garbage that passes for evidence -- and which you readily cite with confidence.

"I think that the overuse is due to cultures in US medicine."

I agree. For starters, we need to drop the gold-plating for people who cannot afford it. Doctors need safe harbor for being economical with people who cannot pay for exahaustive care. That's a "tough decision" that needs to be legal for physicians and patients to reach together, and not merely relegated to bureaucrats (and needlessly imposed on everyone) as you guys are proposing.

It seems that my comments about "culture" in medicine are unclear. By culture I am not referring to insurance issues, rationing care for low income people, and so on.

What I am talking about is the tendency of many providers and systems to order thousands of dollars in tests and interventions that do not seem to have a beneficial effect -- for all patients, not just low income patients. At the same time, other systems -- Mayo Clinic is the poster child -- use far less of this high tech approach, cost a lot less, and have better results.

There may be as much as $800 billion a year at stake here.

As I said, I don't think this is due to greed. I think it is due to the way providers learn to think. In some ways overuse occurs for the same reason that a few years ago large numbers of teen age boys started wearing huge pants: it is the style.

Mayo and other providers -- and the Dartmouth studies can give you a list -- have avoided this style. They use a lot less high cost management but get better results.

This is where the real pot of gold in health care reform is: getting more and more providers to behave like Mayo. Obama is addressing that issue specifically, but it remains unclear whether the political process will support him, since there is a lot of money and a lot of ego at stake here.

Why shouldn't people who can pay more -- the middle class, example -- receive more treatment than the poor who cannot? And isn't it really between the doctor and the patient (considering the doctor's superior knowledge and his obligation to cover all the bases) what tests and procedures are done?

We should all be honest and admit that the goal is to give the poor equal access and quality of care as the middle class. Just like we gave them equal access to the same quality education by putting the entire middle class in public schools.

Well, everyone does get the same quality, but "quality's" not exactly the same thing when you start to measure it by who's getting it. Just like universal access supposedly establishes Cuba's healthcare as only slightly behind ours. You're not fessing up to your intellectual dishonesty.

Really good care (such as that enjoyed by most of the middle class today) will become tomorrow's private school equivalent of health care.

But at least the government will have control over the reporting which proves that our care will be at least as good as Cuba's. There's something I know you must be looking forward to.