prevention is much cheaper than cure
Ay, there's the rub. That's the acorn the pigs in our for-profit system will never sniff out.
How do you build a system that rewards wellness? In a perfect world, nobody would ever set foot in a hospital and we wouldn't need doctors. Who gets rich off that? Bally's, perhaps. But things like nutrition, exercise, etc. are only now creeping into the picture under the guise of "behavioral health."
The cardiothoracic surgeon who performs the triple bypass gets the glory and is hugely compensated. But a much better outcome is obtained by the health coach who convinces a patient to stop smoking. We rewarded the wrong person.
Where is the medical home? Nowhere. Why? Because it's damn near impossible to create a medical home when the average worker changes jobs and health insurance companies every couple years.
(Why do I get new bite-wings every time I go to the dentist? Because it's always a new dentist and I'm a new patient and they'll get reimbursed for the x-rays. We'll just hope those x-rays don't give me cancer later on...)
The inefficiencies stemming from not having a single payer are the reason our costs are so out of whack. It also negatively impacts patient care. Prevention sure is cheaper than cure, but our patchwork, piecemeal system has a very hard time addressing health issues proactively. Especially for the 1/5th of Americans without insurance.
I don't buy for a second that doctors earning less will doom the system. Airline pilots have seen their pay deteriorate over the past few decades and air travel is safer now than ever. Cuban doctors make a pittance by our standards, yet their system delivers a 20% lower infant mortality rate (!) and only about a half-year less life expectancy.
I'm not saying anything new. Berwick pointed out all these problems when he wrote Seeking Systemness seventeen years ago. www.ncbi.nlm.nih.gov Since then, things have gotten seventeen years worse. Patients are not participants in a cohesive health care system. They experience a series of loosely related encounters overseen by myriad billing providers and mysterious funding instrumentalities. In the event of something as commonplace as a motor vehicle accident, the patient practically needs a lawyer to successfully navigate the byzantine bureaucracy we've enacted. And look what happens if the accident isn't covered by health insurance or auto insurance, they have no choice but to sue or go bankrupt, or both. Single payer would achieve the goals of "tort reform" with the added bonus of insuring everyone.
Our system is a sham. Something like a swine flu pandemic could break our system completely -- people get sick, lose their jobs, can't afford COBRA... with nowhere to go they flood the ER. To cover the costs, insurers raise premiums; employers can no longer absorb the rising cost, especially in a declining economy, leading to more layoffs and more uninsured.
Employer-provided healthcare is bleeding our employers to death; it damn near put GM out of business. A public option is the only way out.
