Public Opinion And Payment For Medical Care

Just as in the previous post Megan McArdle is generally right but makes an error, the same can be said about this post from Ezra Klein on health care. Ezra looked at a Kaiser/NPR poll on health care and does make some good points, such as questioning why people have such little interest in  “in implementing the findings that emerge from cost effectiveness studies.” In this case it is more common for physicians than for the general public to be encouraged by cost effectiveness studies as we realize how much is done without good evidence. We want the data to make the best choices for our patients.

While Ezra reads a lot about health care and is very knowledgeable about the subject, such reading is often not a sufficient substitute for actual experience. This leads to his puzzlement over one issue:


Ezra writes in response to this question:

Honestly, I’m surprised patients even have an opinion on that. And it might be a very weak opinion. But for now, the public prefers that doctors get paid for each thing they do than on a salary basis. They prefer, in other words, that doctors have an incentive to do more rather than do less.

Here the majority of Americans are smarter than Ezra. Many have experienced the horrors of the HMO era in which doctors were actually paid based upon how little care they provided. Many also see the difference between the more old fashioned model of doctors in private practice as opposed to the increasing number of doctors who are employees paid a salary. They have seen the difference between a doctor who is motivated to work long hours to care for their patients and salaried doctors who check out at 5:00.

Imagine the negative incentives for being paid a yearly amount regardless of what is done. I’m often at the office past 8 p.m.  to see people who call with problems late in the day. If paid a fixed salary most doctors would tell them to take an aspirin and call (or preferably don’t call) back next month. I’ll often wind up  spending a  half hour to an hour with a patient who is having serious problems. If paid a salary doctors are encouraged to see the highest number of patients possible in as short a time as possible. The medical offices run by the local hospital (which has bought up most of the doctors in town) has nurses with stop watches monitoring office calls and knocking on the door to end the visit if it lasts over fifteen minutes!

Sure, when paid fee for service for taking care of patients this could lead to incentives to do too much to make more money. This is reduced by both utilization controls and by the fact that there is so much more to do than we have time for. Of course, as in the previous post, I’m writing from the perspective of primary care. There is undoubtedly far more waste in some of the high-priced procedures as opposed to primary care offices, but this is also the situation which most people are probably considering when responding to poll questions such as this.

Primary Care And Payment For Office Visits

Megan McArcle appears to have paged me, asking  Is There a Doctor In the House? She writes:

A lot of liberal blogs, and a few conservative ones, are discussing this article from the New York Times, which points out that if you look at actual economic resources, instead of prices, increasing health care utilitization isn’t going to be so easy, because there’s not a lot of spare capacity in the system…

It’s more reasonable to note that reimbursement structures are creating an undersupply of primary care physicians, compared to the number of specialists.  We reimburse for procedures, not wellness, so surgeons are well paid and GPs aren’t.  This has led to the bizarre fact that Medicare chronically underreimburses (and thus insures an undersupply of) geriatricians, which should be the one doctor a program like Medicare produces a lot of.

As she also notes, this is nothing new. There have been recommendations for years to increase reimbursement for primary care as opposed to subspeciality care. Medicare has made small moves in that direction, but typically the specialists put up enough of a fight to preserve higher pay for their procedures.

While Megan appears to understand the problems and is right about some of the responses, she makes one mistake in concluding:

Pay for office visits, and you will get a lot of unnecessary office visits.

The point is that we don’t have enough primary care people to handle all the office visits which would be needed if we expand health care coverage. If the capacity of primary care physicians to conduct office calls is already exceeded at current payment levels, paying more is not going to necessarily lead to unnecessary office visits. There is little need to preform unnecessary office visits when there is a demand for more necessary office visits than can be filled.

What increasing pay for office visits will do is to get more physicians to be willing to make their income from primary care office visits as opposed to from procedures.

Possibly The Most Delusional Blog Post Ever

John Hawkins writes The Right Needs to Play as Dirty as the Left. Beyond being wrong on most issues and being incompetent in office, their dirty politics is a major reason why most Americans are rejecting politicians of the right. Public attention to Sarah Palin’s family, which was more a national phenomenon than something coming from the left, hardly compares with the dirty tactics of Dick Tuck, Richard Nixon, Spiro Agnew, Karl Rove, George W. Bush, Dick Cheney, and the Swift Boat Liars.

It gets even more ridiculous. Hawkins’ recommendations include:

Instead of continuing to complain, here’s a better idea. Why don’t conservatives do opposition research on the journalists endlessly running stories about Bristol Palin and Joe the Plumber? Have they ever been arrested? Whom do they own property with? Have they ever been paid to do a speech for someone and then run a favorable news story about him? Certainly Keith Olbermann’s personal life is just as newsworthy as Joe the Plumber’s, and the details of Maureen Dowd’s life are just as noteworthy as those of Bristol Palin — are they not?

Sure, start writing about Keith Olbermann and Maureen Dowd’s sex lives. Anyone think that will get anyone who has abandoned the Republicans to give them another chance?

Republican Congressman Sees Communism In Bowl Championship Series

I’ve often mocked conservatives who stretch the meaning of socialism to include Barack Obama or the Democratic Party. It is so hard to parody them because they get more and more absurd on their own. Now Republican Congressman Joe Barton of Texas is comparing the Bowl Championship Series to communism.

The BCS is a poor way to pick a champion. It isn’t even a real series as the earlier games in the so-called series don’t lead to teams advancing to the national championship game, but it has nothing to do with communism. The manner in which the college national champion is decided is also not something which Congress should be concerned with. This is a private matter, even if handled badly. There’s a stronger case to be made to compare politicians who want to meddle in a private matter such as this to communists than to compare the BCS to communism.

Besides, how could Republicans call the BCS communism when that notorious (to them) socialist Muslim Barack Obama opposes the BCS system and supports a playoff?