I agree, this is getting ridiculous: our colloquy on the ethical and policy complexities of health care policy has created the first Ethics Alarms Comment of the Day on a Comment of the Day on a Comment of the Day. Nonetheless, John Billingsley’s COTD is deserving, as well as interesting and informative. Here it is, his comment on Comment Of The Day: “Comment Of The Day: ‘No, Insurance Companies Treating People With Pre-Existing Conditions Differently From Other Customers Is Not Discrimination’”—which in this case you really should read Charlie Green’s post that prompted it.
I have a few comments on specific points.
“New diseases like RLS”
RLS was first described in 1685 and the first detailed clinical description was in 1944 and it was shown in test recordings in 1962. Not really a new disease but a newly publicized disease. Once a medication was developed that was effective at relieving the symptoms, it became profitable for a pharmaceutical company to target it and raise awareness. The company was not being altruistic, but is it wrong to make money by informing someone that there is a way to relieve the distress they are experiencing? If you have ever talked to someone who really has this disorder, you know how much it disrupts their lives. Is it over diagnosed? Possibly, but polysomnography to make a firm diagnosis is expensive and it is a condition where the clinical symptoms are pretty reliable. Probably cheaper to just treat it.
“Because who’s still going to argue with your doc? Especially when he or she gets side benefits from giving in to the latest DTC ads on network news programs?”
I hate DTC ads. I would be good with a spot that just said, do you experience these symptoms (of RLS perhaps)? If you do, tell your doctor. I actually spent quite a bit of time telling patients why they did not need the newest, expensive drug they heard about on TV or in a magazine either because they didn’t meet the criteria for it or because I felt that the cheaper alternatives were just as effective and needed to be tried first. It was a hard sell, particularly when the patient would say, “but my insurance will cover it.” I, and I think most doctors, take being a good steward of the healthcare dollar seriously. In the past there were sometimes substantial “side benefits” from drug companies especially if you used really expensive things like artificial joints or pacemakers. The most I ever received was dinner in a restaurant and things like cheap pens and sticky note pads. These days there are no more cheap ballpoint pens and meals typically are take out from Newks or equivalent in the office during a presentation. Not something I am likely to sell my soul for although I understand the implications.
What about when a patient really needed the expensive spread but their insurance didn’t cover it? I was almost always able to ensure they received the medication. Sometimes it was by doing the work to get an authorization from their insurance, sometimes it was by getting vouchers from the drug company, and in some cases where there was no insurance coverage at all, the company just provided the medication free. I had patients who received thousands of dollars worth of medication a month totally without charge to them. I know the drug companies were not doing that purely out of the goodness of their heart but for that patient it made a huge difference in the quality of their life.
“The AMA limits the number of doctors.”
I would like your citation for this frequently bandied about statement. I replied to Alex’s comments about this but I think it is important enough to cover in more detail. Basically the AMA is the professional organization for doctors the same way the ABA is the professional organization for attorneys. They represent people who are doctors and medical students but they do not decide who becomes a doctor, license doctors, discipline doctors, test doctors, or decide how many doctors there are. Through lobbying they have influence on health care legislation but they do not make the laws or the regulations. By the way, there is also an American Osteopathic Association (AOA) that fulfills the same function for osteopathic physicians (DO) that the AMA fulfills for allopathic physicians (MD).
In the early 2000s, it was projected that there was going to be a doctor surplus. At that time efforts were made to decrease the number of doctors being trained. It later became apparent that there was going to be a deficit and the American Association of Medical Colleges set the goal of increasing the number of doctors. New schools were opened and the total number of graduates rose from 16.140 in 2007 to 18,938 in 2016. Don’t forget that there are also International Medical Graduates (IMG) who come to the US for residency training. I am not familiar with the rules that govern how many IMG are admitted and what the criteria are. In 2015 there were 12,397 IMG participating in the match for residency positions and 6,302 obtained a position.
The limiting factor in how many doctors can be produced is the number of residency positions available. A graduate of medical school can fulfill every other requirement but if they don’t get a residency they cannot complete training to practice medicine. The AMA does not control how many residencies there are. I think it is an important enough point that I will repeat what I said above; Dr. Bruce Koeppen explains, “Medicare covers the majority of the cost teaching hospitals spend on training medical residents, but the Balanced Budget Act of 1997 capped the number of residency slots the federal government would fund. The shortfall-what is not covered by the Federal government-is paid for by the hospitals where residents train. While it is possible to increase the number of residents they train, to do so, hospitals must fund the entire cost of those training positions.” That represents a lot of money that has to come from somewhere.
“Both parties don’t like to admit it, but there has to be what the GOP used to derisively call “death panels.””
Agree, but I think of them more as “who is gonna die sooner rather than later panels” since we all got to go some day. Health dollars can be spent various ways. A whole lot for a few, a lot for a moderate number, enough for the basics for everybody, or some combination of the above. Except for the basics for everybody the decision has to be made who gets what and who gets to decide who gets what. Clearly, decisions should be made on the basis of a cost benefit analysis but evaluating the benefit is going to be the sticky part. Just one example, a million dollar heart transplant for a young parent who may be able to return to work to support his or her family or a million dollars worth of care to a premature infant with Trisomy 21 and multiple congenital heart defects. Somebody is going to have to be willing to be seen as a really heartless bastard. Ethicists are going to earn their money.
Again, thank you for your insightful and thought-provoking comments.