(If I fellow could keep his head and not get caught up in the hysteria surrounding health care, if he could just keep his mouth shut and his eyes open he might see the real problems in the system without being blinded and deafened by the usual propaganda from the usual suspects using Health Care as a fulcrum to leverage their way into political power. Unfortunately, the solutions being proposed to solve the problem of increasingly expensive health care and the so-called “lack of access” are going to compound the very problems they are supposed to fix.-PB)

The Paper Mill

In a proprietary process understood by few but a marvel of unintentional design, living patients are turned into paper. I read the chief complaint and open the chart, already primed with fifty pages of seed paper, and go to work sifting through the catalogue of promises, obligations, and warnings, every action of mine laying the groundwork for the creation of even more paper. From the Diversity affirmations to the pre-printed discharge instructions that nobody ever reads, the chart is a masterpiece of bureaucracy and wasted effort. The HIPAA section alone spans nine pages that no patient has ever read and could be Proust for all they care. And yet to not initial and sign where appropriate will cause the heavens to weep and the hospital attorneys to gnash their teeth in fury.

I would not be exaggerating in the slightest if I said that for every hour of direct patient care, things like obtaining a history, doing a physical exam, and performing procedures, I spend three hours manufacturing paper, some of which is necessary documentation but most of which will never be used for anything and will end up mouldering in the crypt known as medical records until the sun should fail and the sea shall give up her dead. That is, unless it is dredged from that antediluvian mire as evidence for a spurious lawsuit against a doctor who was only guilty of doing the best he could with a patient who would have made William Osler himself cringe and the Great Galen’s blood run cold.

In fact, there is no part of the hospital or the clinic not primarily dedicated to the paper trade. Ask any nurse and she will tell you that most of her time is spent sorting through the increasingly arcane compliance and safety documentation which is the delight of bureaucrats and thier familiars but contributes nothing to the medical care or safety of patients. Twenty minutes here to fill out a medication reconcilliation sheet, fifteen minutes there to document that she has had her hand washing refresher training and pretty soon we’re talking hours that could be used for direct care of the increasing numbers of patients they tell me are clogging our hospitals.

Judging by the incredible cost of in lost productivity as well as the very real opportunity cost of treating paper instead of additional patients, the most expensive phrase in the history of the world has to be “If you didn’t document, it wasn’t done.”

What does this mean, anyways? That good medical care wasn’t delivered if you didn’t spend an hour writing pointless notes? That because you didn’t meticulously copy lab values from the computer onto another piece of paper that you didn’t look at them? Or does it mean that if you didn’t document that the surgical field was “prepped and draped in a sterile manner” that you ate a taco over the incision?”

What it really means is that the legal environment has become so stifling that nobody trusts anybody and huge amounts of money are wasted covering our asses. Forget the money awarded to plaintiffs and their attorneys in malpractice suits. Forget the cost of defending against lawsuits where the defendant is held harmless. As our lawyer friends are eager to point out in order to distract the public from their depredations, these direct costs are chump change. Even malpractice insurance, although it can be as high as a quarter of a million dollars for an obstetrician in Florida (and is a cost, like most business expenses, that is passed on to the consumer, whether private of government) does not come close to the cost of the bureaucracy which is necessary to keep the inquisitors at bay.

It is a difficult problem to correct. Like vultures to carrion, lawyers will follow the cloying smell of money rising from the hospital. Lawyers run government and unlike physicians who have real jobs, a lawyer can make a career blocking meaningful tort reform and get paid for it, not to mention winning the adulation of people who on one hand view the right to sue as inviolable but on the other would have no problem appropriating private property (the doctor’s time and labor) and as much of other people’s money they can possibly steal to pander to their own narrow interests. As for Alexander Hamilton’s great beast, the people, they are unfathomable. The number of people who have hit the malpractice jackpot, winning big awards after a bad neurosurgical outcome for their wino uncle who they ignored until he was found unconcious under a bridge, must be very small and yet appeals to the greater good, cheaper more efficient medical care in exchange for a cap on compensatory damages, fall on deaf ears.

Apparently, nationalizing health care under the false flag of Single Payer and redistributing several trillion dollars a year through the federal sausage mill is easier than passing a few legal reforms.

Somewhere in the rat’s nest of paper originally created by your hospital’s risk managers but now continuously growing as if alive is your patient, protected from your depredations by paper; the sword, the shield, and the strong arm of the bureacracy.

Next: Charles Ponzi Would be Ashamed

(The third time’s a charm as they say. Again, from the tone of many of my emails, not all of them as polite as you would imagine coming as they do from people who make it their business to be compassionate, I can see that many of you are still not getting it. Let us try one more time to show those of you who worship at the altar of public policy, any public policy, that your gods are mererly hollow brass castings which, although they make mystical noises when the wind blows a certain way, are as empty as a French Army recruiting office after the Germans have invaded.-PB)

Potemkin Health Care

Before the United States can have anything approaching the obvious perfection of European-style universal health care, our people are going to have to learn some good manners. While I am a fierce patriot and love America before all other countries, I cannot help but to admire the urbanity and the insouciance with which Europeans obligingly die before they can become a burden to their nanny states.

In truth, I am ashamed to report that where Americans, in a typically boorish fashion, will insist on hundreds of thousands of dollars of medical care to preserve their shameless lives beyond the point where it would be convenient for society, in Europe not only are many procedures and medications unavailable to patients over a certain age but some of those elegant continentals have even hit on the money-saving idea of offering a couple of hundred guilders worth of euthanasia drugs to politely eliminate those who might otherwise become a burden.

The problem with offering universal access to health care, which should be obvious to anyone with good manners, is that there is an almost inexhaustible demand for it. Maybe you, oh loyal and patient reader, don’t think about this as you are no doubt a veritable Hector or Andromache, in the prime of your life and about to conquer the medical world, but the old and the infirm, with stunning bad manners, do want their hips replaced, their coronary arteries vigorously scrubbed, and their expensive sojourns in the intensive care unit. Sadly, there is no end to their demands as they clamour for more and more precious health care, grimly hanging on just for spite until at around 90, eighty if we’re lucky, their bad manners finally catch up to them like their mothers from the turn of the last century said they would.

It’s shameful. The demand may be inexhaustible but the supply cannot possible keep pace. Certainly not now where, with typical American insensivity, we structure our society around merit and allocate services to those who earn them and certainly not under a single payer system where there is no restraint on demand whatsoever…except that it is to be hoped we learn some European style-good manners.

And quickly, too, because lurking in the demographic shadows is a huge bolus of rapidly aging baby-boomers, perhaps the most self-centered generation our country has ever produced, and they, of all people, will not go quietly into that good night…at least not unless shuffling off of your mortal coil becomes a hip-and-trendy lifestyle choice. It will be the largest eat-and-run the nation has ever seen and somebody is going to have to pick up the tab.

So, it may come to pass that our country adopts a single payer system in our impossible quest to provide high quality health care for all. The result will be pretty much what anybody who thinks about it could predict. We will have a lovely little health care system that looks nice, sounds nice, and finally wins us the adulation of our charming European friends that many of us so ferverently desire. But please don’t have the bad manners, the unmitigated gall, to get sick and require anything that can’t be provided at a simple visit to your barefoot doctor. You will find your marvelous access is nothing more than a creaky rationing scheme and your shining medical city on a hill is really a Potemkin Village.

(Judging from my email, the previous article was poorly understood even though I tried to break things down to the most fundamental level possible. I used little, easy-to-read words and I even made mention of dogs biting scrotums for crying out loud. Let me take another crack at it for the sake of those of you who need to have things explained a few times. -PB)

Universal Access, Tatooed Ladies, and the Dreaded “R” Word

Let us consider how the typical uninsured patient accesses health care. Arriving at the Emergency Department after a brief stop at the tatoo parlor for the finishing touches on a modest tiger motif around her left breast, our patient stubs out her cigarette, throws the scanty remains of her super-sized Big Mac meal into a nearby trash can, and with her three disheveled children in tow waddles to the triage desk where she presents for some common complication of her smoking and her non-insulin dependent diabetes. After a brief assessment by the triage nurse, she is directed to a row of grimy plastic chairs where she and her three children, Kristal, Alexa, and Deshawn will spend the next six hours watching The Fresh Prince of Bel Air while eating stale chips from the vending machines.

While there is no shortage of health care in our patient’s city it is still, like every other good or service, scarce meaning that there is not enough of it to completely meet the demand at the price that people are willing to pay. In our patient’s case, she is unwilling (and unable) to pay anything at all for this scarce service. From her perspective, health care is tightly rationed and although she is going to eventually receive top-notch care, she will end up spending eight good hours (at least) of otherwise productive time essentially standing in line for a few minutes of the Emergency Physician’s time. That’s how the poor pay for their rationed health care, with time and inconvenience.

The key concept to keep in the back of your mind (with the scrotum biting dog) is that every good or service is rationed in some way or another. In a free market system, it is the invisible hand of the market, the collective wisdom of millions of buyers and sellers deciding what something is worth, that sets the price and determines access. If you have, for example, the money for insurance and your copay you can generally make an appointment with your doctor and avoid the plastic chairs and stale chips. We also, however, live in a society that provides government funded charity as our finer impulses compel us to provide medical care (along with other goods and services) to the poor. But as this kind of charity work doesn’t pay very well, with the exception of a zealot or two the enthusiasm to provide it is not strong.

Which explains the plastic chairs, the chips, and the wait.

Now imagine our tatooed lady along with every other uninsured person in the United States waking up to find themselves the beneficiaries of a health insurance policy paid for by Uncle “Single Payer” Sam. A year later and they will still be sitting in the same plastic chairs in the Emergency department because the government cannot provide access to additional services that don’t exist. Unfortunately, not only does a single payer system do nothing to increase the supply of the service it purports to provide but the benevolant teeth of the government dog biting the important parts (the money, for those of you not following along) will limit the financial incentive to produce more of the service.

In a rational system, an increase in demand would be met by an increase in production (spurred by an increase in price) to meet the demand. The production of health care, however, is relatively inelastic. Doctors, midlevels, and nurses can only see so many patients. I don’t know too many doctors, for instance, who have a shortage of patients. To the contrary, the number one complaint of most health care providors is the need to run patients in and out like cattle to make a living.

There is a some elasticity in supply but not much. For the right price, most health care providers will see more patients, the key being that the incentive to stay at the clinic another three hours or work on Saturday has to outweigh the desire for leisure. Still, as it takes a minimum of seven years to train a doctor, three to train a Physician Assistant and somewhere in between for a nurse practioner, unless we want to have motivated junior college graduates as primary care providers the ability to increase the production of health care will always be limited.

Unfortunately, when the government controls the price of anything for which it must pay, the overwhelming tendency is to decrease the price even at a time when to meet increased demand the correct play is to increase the price to encourage the producers. Money itself is a scarce resource to a government and must also be rationed, usually in a way that panders to one constituency or another. (Governments cannot create money, although some have tried with disasterous economic consequences.)

In the quasi-single payer system of Medicaid and Medicare we have today, the goverment fixes the price at such a low level that those who decide to let the dog into their practice have to run a high volume business. If the last vestige of restraint was removed from the government to at least pretend to meet a reasonable market price, the bid price for health care would fall so low that any available excess production capacity would be held back from the market in the ancient tradition of all producers in the face of price fixing, to be sold for the real price to those who can afford it. In this case this would be the same people who have health insurance now, except in a Single Payer world this would be through supplemental insurance or its functional equivalent. That is until the government that promised not to get involved in any other way but providing insurance outlaws this practice.

Does our tatooed patient care about any of this? Probably not. She doesn’t pay a dime now. She won’t pay a dime in the future. The care will still be rationed and she will still sit on plastic chairs waiting…except now she’ll have a lot more company.

The Bureaucracy That Dare Not Speak Its Name

To hear its proponents describe it, under a Single Payer system of national health care the government wouldn’t even be involved. Apparently, even though such a system designates the government as the eponymous Single Payer who would pay everybody’s health care costs from tax revenues, the private sector will still be fully in charge as the government will neither run the hospitals nor employ doctors as they do in those creaky, decaying socialist countries. In fact, the hand of the government would be as soft as the milky fingers of a sixteen-year-old Lithuanian Virgin on her wedding night.

You’ll hardly notice.

Now look, I don’t have a degree in economics and I don’t belong to a think tank where I am paid to shill my particular brand of public policy. On the other hand, I have a little common sense and have kept my eyes open.

If you were to get in a scrap with a mean old junkyard dog and he managed to sink his teeth into your scrotum, from that point forward the dog is totally in charge. You may have the complete use of the rest of your body and even though, from a real estate point of view, the dog has laid claim to a fairly small portion of your property, where that dog goes you will go and you heart, mind, and soul will follow willingly.

Money drives medicine. Not a nurse empties a bed pan nor a surgeon repairs a hernia without money changing hands. This is so obvious that it is almost insulting to mention it. And yet the proponents of a Single Payer system seem to believe that, although the government would have its teeth firmly embedded where it counts in every medical decision, nothing but good could possibly result. It seems, at last, that our ruling elites have devised a system of total control which is appealing enough to convince the ignoratti but from which no blame could ever be extrapolated to government (who don’t actually run the hospitals or employ doctors, you see) when things go south which they inevitably will.

South they will go because the premises of socialized medicine (which is what a Single Payer system is except for a minor technicality) are all wrong and will do nothing to correct any of the perceived problems of health care delivery, most of which are overblown anyways.

First of all, price fixing always leads to scarcity as there has never been a government in the history of the world that fixed the price of a good or service above or even close to the market price. If you don’t think this is true, ask yourself why so many doctors refuse to take Medicaid patients. The answer is simple; because the real cost to treat a Medicaid patient is often more than the government’s fixed price. In a Single Payer system, the government might not own the insurance company but this is about as relevant as the government’s non-ownership of hospitals or non-employment of doctors. Under the Axiom of the Junkyard Dog, the government has the important parts (the funds) clamped in its jaws and it can dictate terms to the insurance company (what they can charge) and the health care provider (what they can bill). Because money is also a scarce resource, the pressure on reimbursement will always be down with nothing to resist it. Certainly not any pressure from the electorate, most of whom want a free lunch no matter how much it actually costs them and who are pandered to shamelessly on a regular schedule of elections.

Decreasing reimbursements would be fine to the ignoratti, of course, as those rich doctors and capitalist-tool insurance executives would finally get their comeuppances but if you think it is hard to get an appointment with your doctor now, wait until your doctor’s economic incentive is completely removed and see how the system which currently can get a wino to the cath lab in about an hour and a half would slow to a crawl. This would be because a Single Payer system increase demand, as people will take more of anything if it is cheap or even free, without doing anything to address supply. In fact, the decreased reimbursements to health care providers that would certainly ensue as the dog ground its teeth would decrease supply at the time demand was increasing.

Does our country even need universal health insurance and will adopting it make us healthier and decrease expenditures for medical care?

No and no.

First of all, nobody is exactly clear on the number of uninsured, who they are, and the significance their lack of health insurance. Forty million is a number thrown around a lot but as most of the elderly are covered under Medicare, all poor children and those from the lower middle-class are covered (or can be) under Medicaid’s Children’s Health Insurance Program, and many of the poor themselves get Medicaid, the forty million includes a fair portion of people who make the choice not to buy health insurance, either because they don’t need it or because they make a rational decision to spend the money on something else.

As we are a charitable people and it would be demoralizing to our society to have people dying for lack of medical attention, we need to have the so-called safety net to take care of people who simply cannot, through some combination of bad luck and personal choices, take care of themselves. But what if this number is only 10 million, not forty? Rather than have the government suck up even more money for redistribution in a highly inefficient, wasteful, and nonproductive manner, why don’t we just identify the 10 million hard-core uninsured and give them all health insurance with no strings attached. Seems to me that this would be several orders of magnitude cheaper than running what amounts to fifteen percent of our GDP through the Federal sausage stuffer.

There has, in fact, never been a government program whose costs have not risen well beyond even the wildest speculations of its critics and Single Payer would be no different, with its proponents 10 years from now opining that we have too many aircraft carriers and that the several trillion dollars spent on health care is not enough.

As to improving the health of the nation, well, I get attacked as a heretic for saying this but there is probably very little correlation between access to health care and health, especially as people who make health care a priority are the kind of people who would take care of themselves even if they didn’t have health insurance. Having a nice government health insurance policy will do absolutely nothing to get people to lose weight, stop smoking, exercise, and stop using crack, which, along with other poor lifestyle decisions are what really drives health care costs through the roof. This is readily apparent to anybody who works in a hospital. If it wasn’t for booze, cigarettes, drugs, 64-ounce Colas, Big Macs, and sedentary lifestyles, we would be all out of a job.