Money Squawks

The February issue of The ACP Internist contains an article Adding cosmetic procedures lifts internists’ sagging incomes that defines the decline in morale of our country’s most important profession. Click on the link and you can read the whole sad story and make up your mind about what’s happening to medicine.

The article reflects a reality that few wish to confront directly – people don’t want to pay for medical care. They are willing to pay whatever it takes to look better. When they get sick and must have care they expect someone else to pay for that care. They are a mess of tangled contradictions. They want affordable care that is readily available. They want to be able to pick and change their doctors. They want portable health insurance that doesn’t cost too much. Half of them want the government to stay out of paying for the 50% or so of medical care they don’t already pay for, while the other half wants the government to take over the whole kit and caboodle.

The public doesn’t mind spending a lot of money on veterinary care for their dogs and cats, but resents having to pay for medical care for their children. They don’t want to pay for management of their diabetes or hypertension, but will pay cash for Botox or cosmetic laser surgery or skin peels. These types of cosmetic overhauls seems to be spreading to all layers of the socio-economic pie.

The New England Journal of Medicine published two papers in back to back issues of the journal which illustrate how conflicted we are. In the February 7th issue they published a piece by Robert Kuttner: Market-Based Failure — A Second Opinion on U.S. Health Care Costs. Asking Robert Kuttner to write about health care is like asking me to critique the design of the latest atomic reactor. He’s never met a problem (outside of the Pentagon) that he doesn’t think requires a government solution. Of course he thinks that market driven mechanisms to provide medical care have failed (how he knows is mysterious since we’ve never had a market driven system) and that a national single payer health care system is the only civilized solution to our medical woes. What he thinks is predictable before he writes anything. If you want a contrary opinion ask Thomas Sowell. What’s interesting is that the NEJM asked Kuttner for the piece since even a first year medical student could have told you exactly what he would say. I’ve already mentioned in a previous post that the NEJM wants national health insurance.

“Great health improvements can be achieved through basic public health measures and a population based approach to wellness and medical care. But entrepreneurs do not prosper by providing these services, and those who need them are the least likely to have insurance. Innumerable studies have shown that consistent application of standard protocols for conditions such as diabetes, asthma, and elevated cholesterol levels, use of clinically proven screenings such as annual mammograms, provision of childhood immunizations, and changes to diet can improve health and improve outlays later on.”

To begin with, that statement is not necessarily true. Second people don’t want to pay for preventative maintenance out of their pockets especially if it comes to choosing between “wellness” and good looks. Behavior modification is harder than diamonds. Yes millions have stopped smoking, but health insurance wasn’t the reason. Regular medical care seems more palatable if we can get someone else to pay for it. To muddy the waters more the February 14th issue of the NEJM has a paper Does Preventative Care Save Money? The answer – maybe, sometimes, other times no. And we’re not really sure which is which. The paper’s revolutionary conclusion – get more evidence before making recommendations about how to restructure the medical system.

Internists have turned to Botox because “wellness” doesn’t pay much. This is so irrespective of insurance status. In fact those most likely to benefit from “wellness” programs are those least interested in it with or without insurance. How do I know? Fifty years of personal observation, which is 50 years more than Kuttner has. Sure I could be wrong, but we didn’t become the fattest nation in the known universe because we were in love with “wellness.”

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