Friday, July 25, 2014

Great Expectations and High U.S. Health Costs

Great Expectations

Title of Charles Dicken’s Novel

Great Expectations is regarded as Charles Dicken’s greatest novel. It concerns relationships of man and society in Victorian London , and what Victorians expected of that society.

This blog is about what Americans expect of their health system. We expect convenient high tech care from specialists with near perfect results. These results may include complete cure of disease, return to normal function, perpetuation of youth and beauty, avoidance of complications and of death, and relief of pain and discomfort.

When these great expectations are not met, Americans, more than citizens of other developed nations, sue their physicians ,their health institutions, and anybody or anything associated with their care.

America’s malpractice lawyers, under the rules of American jurisprudence, which do not require lawyers and clients to pay if a suit is lost, potentially reward plaintiffs with huge open-ended settlements. The number of law suits in the U.S. exceed numbers in other nations, for attorneys in America have much to gain and little to lose. The fact that U.S. trial lawyers have a powerful political lobby and are major contributors to political parties, tends to perpetuate the culture of great health care expectations.

This culture also contributes to a society in which “more” is expected. As Dicken’s Oliver Twist said, “Please, sir, I want some more.”

In the current issue of Atlantic, Victor Fuchs, the renowned health care analyst from Stanford and prime promoter of the idea of managed competition, says U.S. citizens and providers always want more: “We deliver three times as many mammograms, two-and-one-times as many MRIs, and a third more C-sections than the average OECD country (“Why Do Other Rich Nations Spend So Much Less on Health Care,” Atlantic, July 23, 2014).

Why does the United States spend so much more?

According to Fuchs, “ The biggest reason is that U.S. healthcare delivers a more expensive mix of services. For example, a much larger proportion of physician visits in the U.S. are to specialists who get higher fees and usually order more high-tech diagnostic and therapeutic procedures than primary care physicians.”

We have more technology of every kind, more aggressive treatments of the sick and dying, more treatment in intensive care units, more physician visits, more hospital days, more expensive drugs, more expensive administrative costs, but less government spending on health care - 50% compared to 75% on total costs than other nations.

Fuchs answer to all of this is a more powerful role for government and more managed competition in the private sector.

“With regard to healthcare, the United States is at a crossroads. Whether the Affordable Care Act will significantly control costs is uncertain; its main thrust is to reduce the number of uninsured. The alternatives seem to be a larger role for government or a larger role for managed competition in the private sector. Even if the latter route is pursued, government is the only logical choice if the country wants to have universal coverage. There are two necessary and sufficient conditions to cover everyone for health insurance: Subsidies for the poor and the sick and compulsory participation by everyone. Only government can create those conditions.”

Nowhere in his piece does Fuchs mention the great expectations of the America people or the role of American malpractice attorneys. Yet we as a people, our culture, expects more specialty care, more high tech, more drugs, more intensive care for the sick and dying, and more perfect results. If we do not get more, someone has to pay the consequences.

Our health system is a creature of our culture. We are pro-democracy and anti-government. We are anti-authority and desire a government that governs least. We look to local solutions, reject federal mandates, prefer equal opportunities over equal results, feel capable of making our own decisions, seek access to high tech solutions, rely on specialists rather than generalists, and are victims of our great expectations. With regard to high health costs, as Walt Kelly’s Pogo remarked, “We have met the enemy, and he is us.”

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