Free Markets, Free People

Fantasy? Meet reality …

One of the more persistent myths about the push for universal health care is its provision will solve our medical care problems and improve our overall health.  Well there’s one problem with that – medical care depends on the availability of medical care providers, and we have a shortage of those.  So while everyone may have insurance, insurance doesn’t guarantee access.

Massachusetts offers a snapshot of how giving more people insurance naturally drives demand. The Massachusetts Medical Society last fall reported just over half of internists and 40 percent of family and general practitioners weren’t accepting new patients, an increase in recent years as the state implemented nearly universal coverage.

The entire push of the new law is to shift the country from seeking care when they’re sick to seeking preventive care to help prevent sickness.  That means a shift from primary care physicians who are essentially gate-keepers (to specialists) to primary care physicians as, well, the primary care source for the patient.  One problem – primary care physicians only make up 30% of the physician population.  Couple the shift in emphasis with the addition of 30 million newly insured and you can do the numbers yourself.

So how is this going to be reversed?  Well here’s the plan:

Yet recently published reports predict a shortfall of roughly 40,000 primary care doctors over the next decade, a field losing out to the better pay, better hours and higher profile of many other specialties. Provisions in the new law aim to start reversing that tide, from bonus payments for certain physicians to expanded community health centers that will pick up some of the slack.

Or, in other words, government plans on incentivizing primary care with “bonuses” and essentially deincentivizing specialists.   The obvious hope is some specialists will go back to school and become primary care physicians.  But there’s a culture at work within the physician community which is going to resist that.  The other hope is more will choose primary care in medical school.  Again, that cultural hierarchy will, at least initially, resist that.   The hoped for result is a flock of primary care physicians and far fewer specialists.  Market forces? Ha!  And ignore those doctors who aren’t taking any new patients or are dropping out of the insurance game altogether to charge annual fees for unlimited visits and consultation.

Anyway, the grand plan, once this shift begins taking place, is to take a team approach to your care in something you will lovingly call your “medical home”:

Instead of the traditional 10-minutes-with-the-doc-style office, a “medical home” would enhance access with a doctor-led team of nurses, physician assistants and disease educators working together; these teams could see more people while giving extra attention to those who need it most.

I don’t know about you, but that’s pretty much how my care works now.  I see a PA.  She refers me to my primary care physician only if there’s something out of the ordinary for which his expertise is needed.  Otherwise it is the rest of the team that takes care of me.  The only thing this law changes is the number of people out there seeking this sort of care as far as I can tell – and oh, yes – this system has been in place with my physician for years.  So somehow I’m missing how what they’ve been doing for years has been inadequate, but now that government thinks it is a good idea and it will suddenly take care of all our problems concerning access, and improved care, etc.

Your “medical home” will also include the following.  Now I’m a bit of a student of human nature – but this too seems to be a bit of a fantasy:

Rolling out next is a custom Web-based service named My Preventive Care that lets the practice’s patients link to their electronic medical record, answer some lifestyle and risk questions, and receive an individually tailored list of wellness steps to consider.

Say Don’s cholesterol test, scheduled after his yearly checkup, came back borderline high. That new lab result will show up, with discussion of diet, exercise and medication options to lower it in light of his other risk factors. He might try some on his own, or call up the doctor — who also gets an electronic copy — for a more in-depth discussion.

Tell me – if Don is concerned about such things and willing to search out and consider options to help his condition, don’t you reckon he might already be on WebMD or a similar site right now doing that?  And if Don isn’t likely to do such a thing, is this “custom Web-based service” likely to entice him to log on and do so?

That’s the whole fallacy behind preventive care – it assumes that if it is offered it will be sought out and its recommendations followed – without exception.  The assumption is that Don, who has never followed the advice of his doctor about his cholesterol will suddenly do so because we’ve shifted the emphasis of his care to prevention and provided him access to information.


And, with the shortage of doctors and increased demands on their time, how likely is Don to really get that “in-depth discussion” he wants from his doctor?  Yeah, not very.  So how likely is Don to get frustrated with all of this and revert to his old and more comfortable (albeit less healthy) lifestyle?  Meanwhile, doc has lots of new patients admitted into the “home” that his “team” is trying to deal with preventively or, doc is simply not taking any new patients because he or she can’t spend the time necessary with those already in the practice.

The point?  As with most things centrally planned, it sounds good on paper.  But such plans tend to discount human nature.  They also tend to be overly optimistic.  And lastly, they usually underestimate or ignore the true numbers involved in favor of some fantasy result where everything works as planned despite those numbers.  That’s what we see here.



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43 Responses to Fantasy? Meet reality …

  • No one thinks the recently passed health are reform will solve all our problems, and Obama himself says that most people won’t even notice a change.  It’s a lie to say it’s a government take over, most of us will continue to get our usual care from our usual insurance companies, most physicians will continue to make a lot of money, and the bill does not promise radical change.    It is true that there are too many specialists out there, in part because that’s where the money is.  Physicians, fearful of law suits, tend to refer.   That’s why it’s important to build into reform a much stricter limit on law suits.   Moreover, there is a shortage of doctors now, in our current system, and that’s been getting worse.   But while no reform is a panacea, this at least is a step in the right direction if we’re going to contain costs and finally have a first world health care system.

    • Yeah Erb.  Sure it’s not a government takeover .. in the same way the 9/11 hijackers didn’t takeover those planes, since they weren’t able to land a single one safely.
      This is a government inspired “train wreck” in the same fashion as Freddie mac and Fannie Mae, except this will be bigger.

      • Yet all over the industrialized world plans with much more government involvement have been in place for decades (Switzerland only a decade), are popular even with conservatives, keep costs down, have no waiting lists (except the UK for elective surgery), and yield better results according to overall statistics.  The key is not to pull wild predictions from the air according to ideology, but use comparative analysis with what exists in the real world – in every major industrialized country.   Moreover, very few use single payer systems, most have a functioning insurance companies, competition, and well paid physicians.
        So forgive me if I find wild gloom and doom predictions tied to this health care plan not to be credible or supported by evidence.

    • And you, unable to see the trojan horse in the Med care bill – BMI – go look yours  up, and then think about what it means that the government can now tell you what yours damn well needs to be or else (additional fees, penalties, taxes, restrictions, regulations).  Very small provision, very large consequences once it sinks in what they can use it to do and they start doing it.
      “Contain costs” – you’re a boob, there’s nothing else that needs saying.

    • Scott, I am surprised at your thinking.  The claim “most people won’t notice a change” is laughable on its face.  We have just talked about the over utilization of primary care and how there will need to be changes.  Your claim there are too many specialists is pretty hard to substantiate given how fast technology moves. 

      Here is my experience with specialists.  on 12/1, I went to my primary because several times my BP and heart rate had spiked.  He set up a stress test with a cardiologist for the next morning.  The cardiologist stopped the stress test and told me to go straight to the hospital.  I would be admitted through the emergency room and they were expecting me.  there i was fitted with a 4 lead wireless heart moior and monitored continuously.  The next day, Wednesday, the cardiologist did a catherization and determined there were four blockages.  Thursday, there was a series of test to make sure I was strong enough for surgery.  Friday, the heart surgeon operated and did a quadruple bypass.  A couple of weeks later I had the electrical test (done through a vein) and that specialist implanted a pacemaker/defibulator.  Now, Scott, if it were you, which specialist would you do away with.  Which one do you think would be “too many”.  If you have any sense at all, the answer should be “none”. Physicians refer because of complexity and technology, not to pass patients amongst each other. I seriously doubt any other health care system could have performed as quickly and as efficiently as ours did.  I was surprised too because I had not been in the hospital in over 40 years.   In fact, the last time I was there was 1971 and arthroscopic surgery had not yet been invented.   However, feel free to find a primary that is capable of doing everything you will ever need.  But, I expect, like me, you have no idea what you will some day need and what it will take to provide it.

      It is cute to see your claim that we will “control costs” and have a “world class health system”.  I need some of that pixie dust you use.  We are going to add around 30,000 people to the primary care doctors, we are going to radically increase insurance premiums with new requirements, force state Medicaid budgets to explode, force retirees on to Medicare part D, increase federal taxes substantially, and claim we are not going to pass the “Medicare Doc Fix”, but you think we will control costs and maintain our world class health system.  You are going to need a lot more pixie dust, Scott.

      • Again, Rick, look at how other systems work.   They get quality care, at a lower cost, without waits.  You have heart problems in Germany — you’ll get basically the same kind of care there that you get here.    The statistics bear it out.   Your argument is on its face illogical.  Because a specialist was able to treat you then you conclude we don’t have too many specialists compared to general practitioners, and apparently you conclude that health care reform can’t work.   Yet you ignore the rest of the world, where health care systems more government oriented than this reform work well and are popular even amongst conservatives.     By the way, our health care system isn’t world class — the statistics bear that out, it costs way too much.  It does give excellent care to those with good insurance policies, but we can do much better.   We’re behind the rest of the industrialized west.

        • Scott, I do look at other systems.  I see Canadians coming to the US for immediate care.  I also see Canadians leaving Florida in the spring to get home for their doctors appointment becuase if they miss it, it will take months to get another one.  I see babies being born in the US because there are not enough maternity beds in Canada.   I don’t want that in the US.  Do you?
          I see how England is constantly complaining about the quality of care and even the sanitation of hospital.  I see how during question time, many of the questions focus on the health care system.   I see statistics of many early deaths because of lack of care and because new medicines “cost too much” and if the patient buys those meds himself, he loses all rights to medical care.  I don’t want that in the US.
          I also see how the bulk of new pharma and medical devices come from the US because we reward R&D.  Take that reward away and see how precipitous the drop in R&D, worldwide, becomes.    I see how wait times are much less for us.  Go to Canada and tell them you want a “what if” MRI because something is bothering you.  Then prepare to leave Florida and go back in to the snow when you appointment finally comes available.
          I do not accept your claim of quality care.  The statistics do not show what you claim.  Absent homocides and accidents, the US has equally good life statistics.  We also measure things like live births much more strictly than other countries and try to save more babies than other countries.
          Another example, it costs more to have highly trained EMT’s on the ambulance.  Now, if you could , ask Princess Diana if she would have preferred to be treated on scene or wait until she got to the hospital.
          I have no idea if I would have gotten equivalent care in Germany (nor do you), but I am very sure it would have been no better.  So, I will go with what I know worked rather than what you think would have worked.  The only way we are behind the rest of the world is if you define being behind by whether the government controls the system.  But, that is a bug, not a feature.

      • Simple. If you were treated after Obamacare comes full into being you would be dead.  Basically the same as in Britain or Canada

    • Spoken like an old Soviet bureaucrat, Scott.

      • When you see Soviet style trappings in something that every other capitalist industrialized country has, then you have proven yourself silly.

        • NO, Every other “capitalist” country is as bad off or in even worse shape than us with huge debt. And they don’t spend nearly as much as we do on defense. So who is the silly one? the person who believes in free markets, or the person who believes in perpetual give away fantasy land?

          • “Believing in free markets” is like believing in magic fairies.   There can be no purely free market.   There are markets, and every advanced industrialized country has a market economy.   Markets only work well when regulated.   Yes, all countries have debt levels that are relatively high (though many are lower than ours).   But they spend LESS on health care and cover everybody, with results that are often superior to ours.   And they know they’re paying for it with taxes and insurance fees — but they like their system, it works.   It’s good others spend less on military — we spend far too much, and it’s lured us into conflicts that have done us more harm than good.   We could make significant cuts there.
            The people who really believed in “something for nothing” were those who bought the argument that investment was an easy path to wealth, first in the stock bubble and then the property bubble.   They actually believed that all you needed to do was be clever enough to invest, and with no work you’d get rich.   They thought themselves believers in markets, but they just wanted something for nothing in a perpetual give away fantasy land.

    • “a custom Web-based service named My Preventive Care that lets the practice’s patients link to their electronic medical record,”

      So much for privacy of medical records. Do those fools actually believe that anything accessible by the general public can be secure?

      “It’s a lie to say it’s a government take over”

      I may be mistaken, but it isn’t a lie. Lies require an intent to decieve.You are awfully quick to question the morality of those who disagree with you.

      “this at least is a step in the right direction if we’re going to contain costs”

      By including preexisting conditions and eliminating lifetime or annual limits (among other things) this law has guaranteed that premiums will go up.  

      Increasing the availability of GPs is not just a matter of money. Most, if not all, already  make a comfortable living. Working conditions are more important. Many have cut back on the number of patients they see. My own primary care physician dropped about 1,000 patients (yep, that’s 1K) when he changed his practice to one of those ’boutique’ practices.
      Paperwork and administrative requirements are also a major deterrent.

    • No one thinks the recently passed health are reform will solve all our problem

      >>> What a pathetic, bald-faced lie, even by your standards.

      • Who thinks it will solve all our problems?   Name names, give quotes.   You claim I lie, prove it.  You can’t.

        • Of course it won’t solve everything – that’s why they’ll need to extend government power by several factors in the future – to fix their current screwups, ad infinitum.
          Erb probably doesn’t realize this so called “reform” isn’t reform at all. It’s hard to figure that out when his head is so far up Bambi’s rectum.

        • Don’t be as obtuse as you are ignorant. We all know that this health care fiasco was sold by the democrats as the solution to a problem(the uninsured), and as a way to get costs down. Neither of which it will do.

          • You are the one being ignorant, Kyle.   Every step of the way Obama and others said this is not a solution to all our problems, but a step.   So clearly, the original statement by shark was wrong.   Have the integrity to admit it, rather than hiding behind insults.  That’s pretty lame — you’ll get cover for that behavior in partisan blogs, but in the real world it would look pathetic.

    • Obama himself says it!  It MUST be true!

      • Close, but the formula is, “If Obama says it, it must be right” with a short form of “Obama is always right.”

  • Thousands of Cuban Doctors and Med Students from universities in India – coming soon to a neighborhood near you, doing work “American’s won’t do”.   Heh.

    •  “doing work “American’s won’t do””

      Somehow I don’t think that medicine was what those who coined this phrase had in mind. Sadly though, it is true and accurate.

      • No, I’m sure it isn’t what they had in mind.  But I’m not kidding about the ‘shortage’ and how I imagine the current administration (White House and Congress) will deal with it.  And furthermore, I’m not at all kidding about the justification they’ll use.
        Like any good ‘factory’ it’s going to take a while to crank out GP’s, assuming they start RIGHT NOW, TODAY.  It’s in shortage already, I foresee it will continue to fall short.  I foresee they’ll  provide incentives for skilled foreign professionals to fill the positions just as the high tech industry did  to bridge the gap.  I foresee they’ll offer educational incentives to increase the number of American students.  There is NO alternative, if they can’t MAKE Americans take those jobs.  So those are your options,economically shanghai foreigners and turn them into US Citizens to fill the jobs, try to lure Americans into those positions by making it very attractive, or FORCE Americans into those lines of work “for the greater good” (you know, start educating the kiddies now, green world, captain planet, Dr. Self Sacrifice for the Greater Good, MMM MMMM MMMM  Barack Hussein Obama).
        Of course you can also lower the standards for some things, let PA’s fill the stuffy nose, achy back, “Dr. It Hurts when I do this” gap.
        I suppose we could have a lend lease program with Comrade Fidel, he hailed our system change recently, I’m sure he’d be amenable to renting us doctors for a fee.

    • Thousands of Cuban Doctors and Med Students from universities in India – coming soon to a neighborhood near you, doing work “American’s won’t do”.   Heh.
      For what it’s worth, all of the doctors I’ve seen in recent memory have all hailed from somewhere else.
      My GP is from Turkey, the one before that is a South African born Indian – his associate was also Indian.
      My neurologist is from Israel.
      My surgeon that took out my appendix a few years ago is from Argentina.
      My rheumatologist is from somewhere in Eastern Europe (I have yet to ask where exactly, but the accent is definitely EE).
      I have really good health insurance through my wife’s work; it costs us almost 3k a year just for me.  Aetna has the plan.  I can’t afford the same kind of health plan on my own as I run a small business.  (and for my employee(s), well… they are SOL)
      After writing this, and reading through all of the doctors I have and where they are from, I have come to the conclusion that … well… I have way more doctors than I should for a 38 year old man.
      A lifetime of hard and fast.  Guess I should have taken better care of myself as a young man.  But where’s the fun in that?
      Getting old sux.
      Come to think of it… the last time I can remember having a doctor with a last name remotely similar to mine was the doctor that gave me a lolly after the visit.
      I  don’t get lollies anymore.
      Getting old sux.

      • Getting old sux – don’t I know it….my nephew’s gone into doctrin, married a nice  Bengali fellow doctor lady, but while I can’t pronounce what his specialty IS, it’s not GP.
        Don’t mistake me Pogue, though I can’t speak for Cuban doctors, the Indian one’s I’ve visited haven’t done me any more harm than any MD descended from the bosom of Old Blighty has ever done (that is, they fixed me up just as good as any doctor named Neville-Smyth would have).  Chiefly I find irony in thinking that we will have to go abroad to fill our need for the massive influx of medical personal  for “American” Health Care.
        And with a name like Kiss my &*!, I’m not surprised they don’t have names like you!  – wink

        • And with a name like Kiss my &*!, I’m not surprised they don’t have names like you!  – wink

          LOL!  Well done.  Touche, sir.
          But to be more accurate, “My Ass” (Mo thóin) would be my surname, “Kiss” (Póg) would be the first.
          Yeah, my Turkish doctor is the bomb.  That may be a poor choice of words for a Turkish Muslim… at least in an airport.  But she is really good; smart, friendly, knows her stuff, and is more than willing to spend time on me and my ailments.  Unlike that South African born Indian quack I had before – he had his eye on the doorknob the whole time I was there.  The surgeon I had did quite well I guess, I mean… I’m still here, right?  There was little scaring after the procedure and his follow-up visits were as well as could be expected.  And the neurologist and rheumatologist are just fine.
          All of these guys treat me in the Houston metro area – and I know that Houston is a diverse city, so it is to be expected that a good number of doctors here are of a diverse background.  However, it is worth noting that the doctors I have now are the doctors I had before Obamacare even became a possibility.
          If Obamacare results in more foreign nationals coming in to fill the need for more doctors, then I truly will not know the difference.  In short, the level of care I receive now won’t change much at all regarding the origins of the doctors I receive it from.

      • 38? 38?! 38 Mo thóin!.

        • I know, I know.  We’ve met, so it may seem hard to believe, but I am indeed only 38 years old.
          Like I stated… hard and fast.  It takes its toll.
          Father time says, “Sorry son, but it’s a cash only business.  And you’ve bought more than you should have.”

          • Well Pogue, here’s hoping old Dad doesn’t appear any time soon to collect on the bill.  Sometimes you sound like a lefty loon, but for all that I bet you’re not a bad guy.

  • “That’s the whole fallacy behind preventive care – it assumes that if it is offered it will be both sought out and its recommendations followed. ”
    You missed one.  The assumption that we actually correctly identified the risk.  One of the greatest fallacies of pop medical knowledge is that we can prevent most diseases.

  • OK, I have Kaiser Permanente on an individual family plan with high deductible HSA.
    I already get the preventative care scheduled on the KP web site.
    I do see the doctor though and not a PA. Wait, maybe once my wife saw a PA. For most things, they are just as good and would not know the difference.
    Is it true that Obamacare will wipe out the HSA high deductible plans? I sort of like them. My wife is from a country with “free healthcare” and she would take the kids in for a doctor’s appointment at the first sign of a runny nose. Now that we have to pay for it, all of a sudden she thinks Dimetapp might be okay. Saves me tons of time and effort.

  • Guys, I’m fine. Except for some reason I’ve been drinking too much over this past year.

    • We’ll be the judge of that…fill out this form –
      How many times do you eat fast food a week?
      Do you supersize your meals?
      Do you salt your food?
      Would you describe yourself as active or sedentary?
      What is your favorite flavor ice cream?
      A train leaves Grand Central Station at 10:00 AM and goes west at 50 miles an hour for 12 hours, what’s the engineer’s name?

  • McQOne of the more persistent myths about the push for universal health care is its provision will solve our medical care problems and improve our overall health.

    The dems have promised a whole laundry list of things that ObamaCare is supposed to solve.  IMO, this is part of the reason that opposition to it wasn’t even greater than it has been: people were fooled into believing that it would do things that it can’t / won’t do.  O-care, at its heart, is about controlling the costs to the federal government by fobbing them off on the states and the people.  Some people have figured that out.  As more do, the blowback is going to be a sight to see.

    McQThe entire push of the new law is to shift the country from seeking care when they’re sick to seeking preventive care to help prevent sickness. 

    Well, that was an early, heavily-touted feature of ObamaCare: we’d all get such great preventative care that we’d never get sick and have to go to the doctor.  Unfortunately, people figured out that getting everybody tested for every possible disease would be a tad expensive; people tend NOT to listen to their doctor, anyway; and then there was that whole debacle about mammograms and the feds deciding that only women within a certain age range ought to get one whether they wanted it or not.  So, the dems sort-of dropped the preventative care thing and started yapping about how ObamaCare would save people money while providing the same level of care.  I’m reminded of Rodney Dangerfield’s old schtick about giving money to foreign charity: “I’ll give the money to Soo Goo if he can show my wife how to stretch a buck that far.”

    Rolling out next is a custom Web-based service named My Preventive Care…

    Ain’t it strange how the same people who obsessed over George Bush listening to their phone calls or knowing what library books they were reading have no problem letting Uncle Sugar have complete access to their medical records?

    • ” have no problem letting Uncle Sugar have complete access to their medical records?”

      Along with every other script kiddy in the world.

    • Oh, no, it’ll be totally private, honestly, trust us, the words written on the pieces of paper say so, and those words only change according to the latest bureaucratic whims.
      And it’ll be written by a bunch of guys in Mumbai or Krakow, or the cheapest, latest, greatest, Eastern European development center.

  • See, that’s the problem with you troglodyte tea-baggers on this site. You’ve probably been watching too much Sarah Palin on  your Faux News. Let me educate you on the genius of Obama, one more time.

    The health care bill will mandate the addition of millions of patients to the current medical system. The result will be BETTER care for MORE people, while simultaneously LOWERING medical COSTS (as well as the national deficit). The ratio of doctors to patients is irrelevant. What part aren’t you getting?

    If doctors refuse to take new patients, then the government will simply amend the current bill. We will mandate that each doctor must accept every person who applies to be seen at his/her practice. Logically, of course, that will mean that each doctor will be able t0 provide even BETTER care to MORE people, all while simultaneously LOWERING the COSTS incurred by his/her practice. 

    You see how that works, you racist hate-mongers?

  • Government Data Management example – nuff said?

  • capt joe: I WAS being sarcastic.

    The scary part is that I have encountered people who actually believe as fact that which I wrote in jest.

  • Are “regular” people really all that obsessed about their health care? By “regular” I mean people who have jobs, cart their children here and there, attend school functions, help with homework, mow the lawn, read books, listen to music, eat family meals, pay taxes, etc… I get a physical every five years so I can plot my decline. I know what foods are good for me and I know that, once in awhile, I can also have stuff that tastes great but would not be good for me in large or continuous quantities. I don’t go out of my way to exercise but I also don’t go out of my way to avoid walking a few miles or riding my bicycle. Am I weird?