A familiar story I like to tell about the fundamental character of health care in the U.S. concerns orthodontics. Braces are a life experience for millions of American adolescents every year, and yet most dental insurance plans fail to cover orthodontic care on the principle that it is effectively cosmetic. With this in mind, I was born without one of my lower permanent incisors, causing all of my teeth on this side of my mouth to shift. Numerous dental professionals have advised me to consider braces, but I have resisted the move both for cost considerations and for the larger inconvenience. As a result, I have a somewhat unsightly gap between some of my teeth where the gums are somewhat more vulnerable to gingivitis, but, on the whole, I haven't suffered any significant health issues from my decision not to correct my teeth.
My brother Norm's children, by contrast, have each gone through orthodontic work. I cannot blame my brother and sister-in-law for choosing to invest in the straightening of their kids' teeth, especially when dental professionals, no doubt, advised them to do so. Just the same, I can remember several years back that my mom and dad would take their grandchildren along for the ride up to the Mondiale des cultures festival in Drummondville in Québec, my mom's hometown. It seemed like every time they would go, they would invariably meet up with the grandchildren of one of my mom's friends about the same age, and not one of these Québécois youngsters had braces, however straight or crooked their teeth were. The interpretation seemed pretty clear to me. Orthodontics is an investment that the single-payer health care system in Québec has largely chosen not to invest in, and, given the income levels of these youngsters' family, there simply was not going to be a private investment made in this direction. Perhaps they would have wanted to, but the cost precluded the possibility. More over, it seemed like this was a regular outcome in Québec with regard to orthodontics, which did not appear, on its face, to be as prevalent a subset of the medical establishment, at least in Drummondville.
This conclusion is pertinent to a larger evaluation of medical expenditures in the U.S., and, in particular, of our propensities to accept the diagnoses of medical professionals advising expensive treatments for conditions that are neither life threatening nor particularly debilitating to the everyday lifestyle of the patient. Emphatically, our health care system is so expensive, in large part, because patients undergo a variety of procedures that may be unnecessary to the general maintenance of their health on the advice of medical professionals who prescribe treatments and/or diagnostic tests for diverse reasons but, pointedly, in the hopes of skirting medical liability from the experience of an unhappy patient who might conclude that their physician was negligent in identifying treatment options and thoroughly diagnosing their condition. We can, in this manner, conclude that this is another side effect of our relatively litigious culture, but it also tells us something important about our conceptions regarding the integrity of our bodies in relation to medical science's capacity to repair every malady and physical shortcoming, conferring on medicine a more profound stature of objectivity as a science and a more expansive capacity to achieve improvements on the human condition than it might otherwise deserve.
That is not say that medical science does not deserve credit for its vast accumulation of knowledge on the human body (and, for that matter, the human mind if we include mental health) and for its striving to research the causes and cures for numerous deadly maladies. On the other hand, all of the research conducted by medical professionals carries a substantial bill for services rendered that invariably filters down to every patient receiving medical care, partly reimbursed from patients themselves and partly covered by the financial sector through health insurance. Every penny of capital sunk into medical research or specialized facilities for cutting edge diagnostic technologies or treatment regimens demands a rate of return, frequently recovered by cross subsidization, charging higher rates for more conventional procedures to patients and/or third party payers. Again, this is not to say that we should not make such investments, but we need to recognize how the normative practices of finance pervert the aims of erstwhile humanists, researching cures to cancers, Parkinson's disease, Alzheimer's, and other chronic maladies impacting humanity (at least among those quarters most able to cough up the cash required to start a research agenda).
Beyond the pure economics of health care, the rigorous ethos of professionalism exuded by physicians and other highly trained front line care givers conveys an impression of infallibility that, to some degree, shapes the expectations of patients in ways that may be unrealistic. This sense of total expertise is the thing that most concerns me in this post. Again, this is not to say that patients should not listen to the advice of their physicians or entrust them with an expectation that their accumulated training and experience will lend credibility to their diagnoses. However, no science can ever claim absolute objectivity. The best that medicine can claim is to possess extremely reliable experiential and research-driven points of reference in regard to particular physical conditions and the infliction of such conditions on individual bodies. Conceding as much, every human body is different and constituted as much by micro-level interactions with microbial species as with macro-level social/ecological effects on the body.
Particular strains of the influenza virus, for example, may have a relatively predictable infection pattern on the human body, in the abstract, but when the same strain of influenza infects a particular individual, its progression must, necessarily, depend on the mix of microbial species already coexistent with the individual, with the individual's broader health habits (e.g. diet, sleep, work routines, etc.), and with weather, ecological factors (e.g. exposure to higher levels of air pollution), and social interaction with other infected individuals. No matter how educated a medical professional might be, it is extremely difficult to isolate and control all of the determinants of an individual's health in order to effectively, precisely diagnose such an infection and prescribe the precise recovery plan, including use of antibiotic and/or anti-viral medications, best suited to that individual without generalizing across unrelated patients in ways that may be unhelpful to the patient's treatment. In the end, medical diagnostics may reduce itself to a practice of trial-and-error, where multiple diagnoses accompanied by multiple unsuccessful treatment regimens precede a successful resolution of a particular malady, not because the medical professionals treating the malady are incompetent but because the physical constitution of an individual is a complex interrelation between myriad factors that are difficult to analyze.
Part of the problem here is that the inherent complexities of medicine are difficult to disentangle from claims of incompetence and/or negligence as a matter of civil liability, especially when, as an especially litigious culture, we place so much faith in the capabilities of medical professionals to cure every ill and fix every physical and/or mental impairment. For medical practices, testing our faith that the powers of medicine are effectively limitless can get expensive and, collectively, drive up rates for malpractice liability insurance. So, if you cannot achieve an iron clad diagnoses of some patient's condition, it makes sense that you would exhaust every avenue in diagnostic testing, however expensive for the patient and his/her insurer, to make sure that the diagnoses was correct.
This brings me to another example in medical care involving myself and multiple coworkers. I noted on this blog that, about a year and a half ago, I broke my wrist (a distal fracture of the radius at the wrist joint). Coincidentally, no sooner did I return to work than one of my coworkers take a tumble over the handle bars of her bike while trying to avoid a dog along a bike path, in turn, achieving a small radial fracture for which she did not require a cast. Finally, again by strange coincidence, this coworker's son (with whom I also work) had had an accident while snowboarding that, apparently, resulted in a fracture of some sort to his radius for which he went untreated for almost an entire year, until, after a prolonged history of soreness in that wrist, his physician determined that the radial bone had been fractured, had healed incorrectly, and would require surgery to repair the damage to his wrist joint. The three wrist fractures in question are pertinent to my larger argument here if only because they show different approaches to the resolution of a common medical problem and different negotiations of health care costs, all under a shared, employer sponsored health insurance plan.
My brother Norm's children, by contrast, have each gone through orthodontic work. I cannot blame my brother and sister-in-law for choosing to invest in the straightening of their kids' teeth, especially when dental professionals, no doubt, advised them to do so. Just the same, I can remember several years back that my mom and dad would take their grandchildren along for the ride up to the Mondiale des cultures festival in Drummondville in Québec, my mom's hometown. It seemed like every time they would go, they would invariably meet up with the grandchildren of one of my mom's friends about the same age, and not one of these Québécois youngsters had braces, however straight or crooked their teeth were. The interpretation seemed pretty clear to me. Orthodontics is an investment that the single-payer health care system in Québec has largely chosen not to invest in, and, given the income levels of these youngsters' family, there simply was not going to be a private investment made in this direction. Perhaps they would have wanted to, but the cost precluded the possibility. More over, it seemed like this was a regular outcome in Québec with regard to orthodontics, which did not appear, on its face, to be as prevalent a subset of the medical establishment, at least in Drummondville.
This conclusion is pertinent to a larger evaluation of medical expenditures in the U.S., and, in particular, of our propensities to accept the diagnoses of medical professionals advising expensive treatments for conditions that are neither life threatening nor particularly debilitating to the everyday lifestyle of the patient. Emphatically, our health care system is so expensive, in large part, because patients undergo a variety of procedures that may be unnecessary to the general maintenance of their health on the advice of medical professionals who prescribe treatments and/or diagnostic tests for diverse reasons but, pointedly, in the hopes of skirting medical liability from the experience of an unhappy patient who might conclude that their physician was negligent in identifying treatment options and thoroughly diagnosing their condition. We can, in this manner, conclude that this is another side effect of our relatively litigious culture, but it also tells us something important about our conceptions regarding the integrity of our bodies in relation to medical science's capacity to repair every malady and physical shortcoming, conferring on medicine a more profound stature of objectivity as a science and a more expansive capacity to achieve improvements on the human condition than it might otherwise deserve.
That is not say that medical science does not deserve credit for its vast accumulation of knowledge on the human body (and, for that matter, the human mind if we include mental health) and for its striving to research the causes and cures for numerous deadly maladies. On the other hand, all of the research conducted by medical professionals carries a substantial bill for services rendered that invariably filters down to every patient receiving medical care, partly reimbursed from patients themselves and partly covered by the financial sector through health insurance. Every penny of capital sunk into medical research or specialized facilities for cutting edge diagnostic technologies or treatment regimens demands a rate of return, frequently recovered by cross subsidization, charging higher rates for more conventional procedures to patients and/or third party payers. Again, this is not to say that we should not make such investments, but we need to recognize how the normative practices of finance pervert the aims of erstwhile humanists, researching cures to cancers, Parkinson's disease, Alzheimer's, and other chronic maladies impacting humanity (at least among those quarters most able to cough up the cash required to start a research agenda).
Beyond the pure economics of health care, the rigorous ethos of professionalism exuded by physicians and other highly trained front line care givers conveys an impression of infallibility that, to some degree, shapes the expectations of patients in ways that may be unrealistic. This sense of total expertise is the thing that most concerns me in this post. Again, this is not to say that patients should not listen to the advice of their physicians or entrust them with an expectation that their accumulated training and experience will lend credibility to their diagnoses. However, no science can ever claim absolute objectivity. The best that medicine can claim is to possess extremely reliable experiential and research-driven points of reference in regard to particular physical conditions and the infliction of such conditions on individual bodies. Conceding as much, every human body is different and constituted as much by micro-level interactions with microbial species as with macro-level social/ecological effects on the body.
Particular strains of the influenza virus, for example, may have a relatively predictable infection pattern on the human body, in the abstract, but when the same strain of influenza infects a particular individual, its progression must, necessarily, depend on the mix of microbial species already coexistent with the individual, with the individual's broader health habits (e.g. diet, sleep, work routines, etc.), and with weather, ecological factors (e.g. exposure to higher levels of air pollution), and social interaction with other infected individuals. No matter how educated a medical professional might be, it is extremely difficult to isolate and control all of the determinants of an individual's health in order to effectively, precisely diagnose such an infection and prescribe the precise recovery plan, including use of antibiotic and/or anti-viral medications, best suited to that individual without generalizing across unrelated patients in ways that may be unhelpful to the patient's treatment. In the end, medical diagnostics may reduce itself to a practice of trial-and-error, where multiple diagnoses accompanied by multiple unsuccessful treatment regimens precede a successful resolution of a particular malady, not because the medical professionals treating the malady are incompetent but because the physical constitution of an individual is a complex interrelation between myriad factors that are difficult to analyze.
Part of the problem here is that the inherent complexities of medicine are difficult to disentangle from claims of incompetence and/or negligence as a matter of civil liability, especially when, as an especially litigious culture, we place so much faith in the capabilities of medical professionals to cure every ill and fix every physical and/or mental impairment. For medical practices, testing our faith that the powers of medicine are effectively limitless can get expensive and, collectively, drive up rates for malpractice liability insurance. So, if you cannot achieve an iron clad diagnoses of some patient's condition, it makes sense that you would exhaust every avenue in diagnostic testing, however expensive for the patient and his/her insurer, to make sure that the diagnoses was correct.
This brings me to another example in medical care involving myself and multiple coworkers. I noted on this blog that, about a year and a half ago, I broke my wrist (a distal fracture of the radius at the wrist joint). Coincidentally, no sooner did I return to work than one of my coworkers take a tumble over the handle bars of her bike while trying to avoid a dog along a bike path, in turn, achieving a small radial fracture for which she did not require a cast. Finally, again by strange coincidence, this coworker's son (with whom I also work) had had an accident while snowboarding that, apparently, resulted in a fracture of some sort to his radius for which he went untreated for almost an entire year, until, after a prolonged history of soreness in that wrist, his physician determined that the radial bone had been fractured, had healed incorrectly, and would require surgery to repair the damage to his wrist joint. The three wrist fractures in question are pertinent to my larger argument here if only because they show different approaches to the resolution of a common medical problem and different negotiations of health care costs, all under a shared, employer sponsored health insurance plan.
When I broke my wrist, I required a cast and my treatment precluded me from working at my job for six weeks. Moreover, I encountered substantial out of pocket expenses in addition to my copays, especially for diagnostic tests (x-rays to determine the progress of healing). After my cast was removed, I experienced some soreness in the wrist joint attributable to immobilization of my tendons. The orthopedic surgeon who treated me had prescribed occupational therapy to ensure that I would regain my full range of motion, but, after the expenses I had already incurred, I concluded that it was simply cost prohibitive to undergo such treatment. I downloaded a video off YouTube showing therapeutic exercises for recovery from radial fractures, committed to doing such exercises for a couple of weeks, and went straight back to work. I have not encountered any wrist pain since, even when doing push ups.
By contrast, Cathy, who broke her wrist just after I returned, apparently had such a minor break that she returned to work immediately wearing a brace. In hindsight, it might have been the case that her treatment was inadequate to the injury, but, again, she got the full account from me on how expensive my treatment had been, and, maybe as a result, she was trying to avoid significant expenses for an injury that just was not very severe to begin with. On the other hand (figurative, not literally), she apparently still has some discomfort in her wrist, especially when she exercises.
Finally, Cathy's son, David, apparently had such a minor break that it went completely undetected for almost an entire year, during which time he worked for a moving company! After he had left the aforementioned job, he apparently had a stretch of real discomfort in his wrist, which prompted his mother to suggest that he should have that checked out. There was apparent evidence of a fracture that had healed improperly, suggesting that David would experience lifelong problems with his range of motion if it was not surgically reset. So, he underwent surgery, has been in a cast/brace for the last four months, and has been undergoing repeated (expensive) diagnostic testing to ensure that the joint is indeed healing properly this time.
A principal motivation for writing this post has been the repeated conversations that I've had with Cathy about the medical expenses from David's surgery and from all of the follow on therapy and examination, including the orthopedic surgeon's decision to send David a bone stimulator machine, apparently all on our insurance company's tab(!). Noting that they had no idea what the device was for or how it was supposed to assist in David's therapy, Cathy further offered, in exasperation, the question of who is supposed to pay for all of this. Honestly, that tends to be a question that repeatedly gets aired when Cathy and I talk about David's wrist!
To be fair, Cathy has bent over backwards to ensure that her son could get the treatment that he needed for his wrist and to follow through, making sure that David goes to all of his orthopedic appointments, only to hear all over again that the joint is healing just fine. Moreover, as she has pointed out, given that David remains on his parents' health insurance policy and they have invested their money into David's treatment to cover out of pocket expenses, the proper healing of David's wrist has become a real investment for her and David's father. At the end of all our conversations, however, I always seem to end up coming to the same conclusion, and it is one that ultimately sums up the point that I have been trying to make about American health care over the entire course of this post. First, every penny of capital that is invested in medical research or the provision of medical services to patients in the U.S. demands a rate of return, and, collectively, as an incompletely but substantially integrated market structure, every patient and every third party payer is on the hook to reimburse every penny of capital invested when patients utilize the health care system, if only by virtue of the accumulation of claims to reimbursement along the long course of a medical industrial supply chain. As long as medicine continues to attract such heady quantities of capital looking for a decent rate of return, American health care consumers will continue to pay higher and higher health insurance premiums, higher and higher copays, and higher and higher deductibles on annual health insurance benefits, as well as restrictions on certain categories of care.
The point here is that, at some point, someone on the demand side of the health care market place has to put their foot down and say "no." "No, I am not going to pay for a bone stimulator when I have no idea what it's supposed to do or how it is supposed to help." "No, I am not going to pay for braces or clinical teeth whitening." "No, I am not going for another CT scan, after I have already had two negative scans." "No, I am not going to pay for the most high tech, new circulatory anti-coagulant medication when older medications work just fine and are available as lower cost generics." In other health care systems, like the Canadian and Québécois single-payer systems, the problem of saying "no" is easily resolved. A government bureaucracy is always available to be an ever present gatekeeper to health care services in order to control the expansion of costs. Likewise, in other health care systems with third party payment by private insurers like, say, Germany, the health insurance industry seems to be readily able to exercise its capacity to say "no" when medical professionals prescribe treatments regimens of questionable merit that will extraneously tax the ability of the health insurance establishment to cover the full range of its expenditures.
To a certain degree, health insurers in the U.S. are also willing to exercise their authority as the gatekeepers to medical treatment. The health maintenance organization (HMO), pioneered by Kaiser Permanente in California, for example, was predicated on the principle of controlling expansion of health care expenditures by controlling the terms of health care provision within organizations of salaried medical professional employees. However, the HMO lost favor quickly because it did not conform to the preferences of American consumers for more choice in selecting medical professionals across the larger span of the market place. Greater market freedom in American health care means that opportunities always potentially exist to profit from investments of fresh capital. When health insurers cannot control this process because they cannot control the provision options demanded by policy holders, the only choice they have is pass on an ever increasing share of costs to patients. In this manner, the ultimate gatekeeper in the American health care is the patient, and the problem is that American health care consumers are inadequately invested, as a whole, with knowledge on medical conditions and treatment options to make informed decisions that will mutually respect their own needs and the imperatives of the larger system to maintain good cost control. This is a tall order when the American health care consumer/patient demands both the objective truth with regard to any particular physical condition that ails them, expects that their medical professionals can provide that truth, and then uses the recourse of civil litigation when they fail to meet their promises!
Concluding, it is the peculiar structure of incentives in American health care that is really dooming us to a system where costs rise out of anyone's control because, at the end of the day, too few people are willing or adequately informed enough to say "no." With this in mind, there is something to be said for reform of medical torts if only because tort reform would place much greater responsibility in the hands of patients to account for the treatment options they've selected. On the other hand, it would also have to be accompanied by a much greater effort by medical professionals to educate their patients, in particular, on why they are prescribing certain options in treatment of medical conditions, both when such conditions are life threatening and when they are merely cosmetic resolutions to common physical deficiencies.
To be fair, Cathy has bent over backwards to ensure that her son could get the treatment that he needed for his wrist and to follow through, making sure that David goes to all of his orthopedic appointments, only to hear all over again that the joint is healing just fine. Moreover, as she has pointed out, given that David remains on his parents' health insurance policy and they have invested their money into David's treatment to cover out of pocket expenses, the proper healing of David's wrist has become a real investment for her and David's father. At the end of all our conversations, however, I always seem to end up coming to the same conclusion, and it is one that ultimately sums up the point that I have been trying to make about American health care over the entire course of this post. First, every penny of capital that is invested in medical research or the provision of medical services to patients in the U.S. demands a rate of return, and, collectively, as an incompletely but substantially integrated market structure, every patient and every third party payer is on the hook to reimburse every penny of capital invested when patients utilize the health care system, if only by virtue of the accumulation of claims to reimbursement along the long course of a medical industrial supply chain. As long as medicine continues to attract such heady quantities of capital looking for a decent rate of return, American health care consumers will continue to pay higher and higher health insurance premiums, higher and higher copays, and higher and higher deductibles on annual health insurance benefits, as well as restrictions on certain categories of care.
The point here is that, at some point, someone on the demand side of the health care market place has to put their foot down and say "no." "No, I am not going to pay for a bone stimulator when I have no idea what it's supposed to do or how it is supposed to help." "No, I am not going to pay for braces or clinical teeth whitening." "No, I am not going for another CT scan, after I have already had two negative scans." "No, I am not going to pay for the most high tech, new circulatory anti-coagulant medication when older medications work just fine and are available as lower cost generics." In other health care systems, like the Canadian and Québécois single-payer systems, the problem of saying "no" is easily resolved. A government bureaucracy is always available to be an ever present gatekeeper to health care services in order to control the expansion of costs. Likewise, in other health care systems with third party payment by private insurers like, say, Germany, the health insurance industry seems to be readily able to exercise its capacity to say "no" when medical professionals prescribe treatments regimens of questionable merit that will extraneously tax the ability of the health insurance establishment to cover the full range of its expenditures.
To a certain degree, health insurers in the U.S. are also willing to exercise their authority as the gatekeepers to medical treatment. The health maintenance organization (HMO), pioneered by Kaiser Permanente in California, for example, was predicated on the principle of controlling expansion of health care expenditures by controlling the terms of health care provision within organizations of salaried medical professional employees. However, the HMO lost favor quickly because it did not conform to the preferences of American consumers for more choice in selecting medical professionals across the larger span of the market place. Greater market freedom in American health care means that opportunities always potentially exist to profit from investments of fresh capital. When health insurers cannot control this process because they cannot control the provision options demanded by policy holders, the only choice they have is pass on an ever increasing share of costs to patients. In this manner, the ultimate gatekeeper in the American health care is the patient, and the problem is that American health care consumers are inadequately invested, as a whole, with knowledge on medical conditions and treatment options to make informed decisions that will mutually respect their own needs and the imperatives of the larger system to maintain good cost control. This is a tall order when the American health care consumer/patient demands both the objective truth with regard to any particular physical condition that ails them, expects that their medical professionals can provide that truth, and then uses the recourse of civil litigation when they fail to meet their promises!
Concluding, it is the peculiar structure of incentives in American health care that is really dooming us to a system where costs rise out of anyone's control because, at the end of the day, too few people are willing or adequately informed enough to say "no." With this in mind, there is something to be said for reform of medical torts if only because tort reform would place much greater responsibility in the hands of patients to account for the treatment options they've selected. On the other hand, it would also have to be accompanied by a much greater effort by medical professionals to educate their patients, in particular, on why they are prescribing certain options in treatment of medical conditions, both when such conditions are life threatening and when they are merely cosmetic resolutions to common physical deficiencies.
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