Saturday, September 12, 2009

A Unique Perspective on the Delivery of Medical Care

"In a private fee-for-service medical system, a dead patient is a revenue loss. In the National Health Service (UK), a dead patient was a cost savings." -Harry Bailey MD 1930-2003, Sheffield (England) University Medical School 1950-1956; Harvard Medical School 1958-1981, US Navy Medical Corps 1982-1991.

The above quote is from my late father. He had a very unique perspective on the practice of medicine, especially as it relates to the various delivery systems. He was born and brought up in England and entered medical school there in 1950, training under the National Health Service and graduating in 1956. He emigrated to the US in 1957 and went into private practice for 24 years, 8 years pre-Medicare and the period after until 1981, becoming a clinical instructor at Harvard Medical school and a US Citizen along the way. In 1982 he decided he wanted to give something back to his adopted country in gratitude for the wonderful opportunities it had given him, so he joined the US Navy at age 52 and served first as the head of the Radiology residency program (27 residents and the largest program in the military) and then Chairman of the Radiology Department at the Balboa Naval Regional Medical Center in San Diego until his retirement at the rank of captain in 1991.

That is at least three different systems my father practiced under, four if you count the pre and post Medicare private practice period as two. His views of each were formed from the perspective of someone on the inside who lived and worked within them every day, not some ivory-tower theorist.

We’ll leave the military system out of this discussion for now as it would only be a distraction from the question of whether the US private health care system or a socialized model like Britain’s NHS is better. The fundamental distinction Dad was making is how differently the two systems view the patient and the incentives that view creates in each. The private fee for service system has more incentives to keep its patient alive and help them get better. Under socialized systems, and Medicare/Medicaid is a socialized-lite system, the overriding incentive is to control costs because the funds are finite and the needs are not.

I don’t think I need to tell you which system Dad thought was better.

Of course he thought the private system vastly superior, even though he had his issues with that too. However, most of the issues he did have with it were created by government interference in the period after Medicare was enacted. Medicare doesn’t control costs, it controls prices. The costs just get shifted to someone else. The decisions on what to pay for exams were more or less completely arbitrary. Any time Medicare was looking for “cost” savings it simply dictated them by reducing reimbursement rates or, in other words, price fixing. The costs didn’t actually disappear though. They just had to be shifted to the private patients who ended up subsidizing the Medicare patients. It is in this way that healthcare has become so expensive in the private sector. We pay for our own healthcare, subsidize the Medicare/Medicaid patients and carry the full freight on the people with no insurance who show up in the ER and must, by law, be treated.

Rationing is what we will get if we go down the socialized healthcare delivery path, the dead patient as cost savings view is likely to become dominant because the government, as single payer, is going to be forced to ration. The funding available to pay for medical care will be finite yet demand for “free” services will be infinite. The government will tell us if and when we may see a doctor. It will tell us what care and what procedures we will receive. That is the only possible outcome of a complete nationalization of our medical care delivery system. True healthcare reform will only come about by reducing government involvement in delivery, not further encroachment or a complete takeover.
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Todd said...

Very nice comments on your dad. I think commentary like his should be a major part of this "debate" on healthcare.


Megan B-G said...

Great job, JB. We had so many great conversations with Dad on this topic, especially during the last Democrat attempt to take over the healthcare system under Pres. Clinton. This piece nicely distills what Dad learned and tried to teach all of us.

Little Sis.

Saltydog said...

Words of wisdom that Americans will easily understand.
It really is that simple.