Wednesday, March 17, 2010

Health care needs to go to the dogs

My across the street neighbor has a two-year old chocolate lab, which turns out to have had serious knee problems in her back legs. (Actually, they are called hocks, but the right word only gets in the way here.)

To put things right resembled civil engineering more than surgery; the vet did everything but take them out and re-install them backwards.

Cost, both knees: $5200.

My daughter had knee surgery last summer, which involved relocating the lower anchor point of the patellar tendon about a half inch inboard on the tibia in order to keep the knee cap from occasionally dislocating. In the grand spectrum of knee surgery, non-trivial, but not particularly serious. Three days in the hospital post-op.

Cost, for one knee: $30,000.

I think I'm on firm ground suggesting that the skills and equipment required to do knee surgery on dogs and humans do not vary in any noteworthy particular.

But the cost does, by at least an order of magnitude.

Why?

73 Comments:

Blogger Bret said...

That's a rhetorical question, right?

March 17, 2010 10:31 PM  
Blogger Gaw said...

A friend is a professional economist who's looked into the economics of healthcare. He reckons that by far the biggest factor in making US healthcare the most expensive in the world is the salaries of those employed in the industry. US doctors are paid very significantly more than elsewhere. I suspect your experience provided a vivid illustration of this.

March 18, 2010 12:51 AM  
Blogger Mark Frank said...

For comparison with UK. My mother complete hip replacement including 5 days in private room in hospital and all associated costs e.g. pre-op and post-op consultation: just under £10,000 (this is private - it would of course have been taxpayer funded if she had used the NHS). At current exchange rates this is $15,000.

March 18, 2010 4:09 AM  
Blogger Susan's Husband said...

Margin of error. When operating on humans, the expected cost of failure is much higher than on a dog, and there is no limit to how much you can spend on those last little bits of uncertainty.

March 18, 2010 5:47 AM  
Blogger erp said...

Skipper, I hope your daughter's knee is serving her well now.

What do you say, is Gaw right, was the largest part of the knee surgery bill, the doctor's fees?

Health care costs are mostly salaries, but it's not the doctors who are getting the lion's share. Try the SEIU and malpractice insurance.

Around here only one hospital provides ob services because the costs are so prohibitive and a couple of the doctors we see regularly are thinking about early retirement. It's just too costly to maintain a private practice and be at the mercy of politicians who decide what portion of the pie you get.

As for the chocolate lab, I'm glad her owner is able and willing to put her right. We would have paid that and much much more to save our Husky/Shepherd mix who's been gone for five years now and not a day passes when we don't miss him.

March 18, 2010 6:35 AM  
Blogger Hey Skipper said...

Bret:

That's a rhetorical question, right?

Actually, no. Anatomically, dogs are as complex as humans. In terms of goods, services, and skills required, is there anything intrinsically different about human knee surgery that justifies an order of magnitude cost difference?

I really can’t think of anything off hand.

A couple weeks ago there was a health care story with a human interest angle — some guy had been stung by a wasp on his tongue. Fearing asphyxiation, he was taken to the nearest hospital, where they kept him overnight for observation and administered liquid benadryl to mitigate any allergic reaction.

The charge for the benadryl? $979.

The hospital stay, which really amounted to nothing more than occupying a bed overnight: $8000-ish.

There is simply no way he consumed $9000 worth of goods and services. And if I took my dog to the vet with the same problem, the charge would be nowhere near $9000.

______

Gaw:

In the US, docs in a hospital make about $200,000/yr. Malpractice insurance ranges widely, from around $4500/year in some midwest and western states to $40,000/yr in more litigious places. General surgeons and OB types pay $200,000/year in Florida. (mdsalaries.blogspot.com).

Presuming my daughter’s surgeon earns $400,000 per year, works 50 weeks/year, and has 30 billable hours per week, he makes $266/hour. Call that $300. Double that for the anesthesiologist, and add another $400 per hour for all other personnel, making the employment cost of the surgery $1000 per hour.

I’m sure that is more expensive than the UK, but it, taking employment costs alone, that seems like it is going to the dogs — three hour surgery for $3000.

____


Mark:

Clearly, the UK delivers health care at a lower cost; however, I don’t think the comparison is entirely fair. For instance, the rest of the world essentially free rides on the US medical industry, particularly with regard to pharmaceuticals.

Even so, I’ll bet a similar operation on a dog would be a lot less, even in the UK.

______

SH:

Perhaps. But what if, statistically speaking, surgical outcomes for dogs are as successful as for humans?

______

erp:

I think, depending upon the specialty, malpractice must have something to do with it.
At first glance, there would seem to be only two differences in surgical health care for dogs and humans: malpractice insurance payouts, and food while in the hospital.

Okay, make that one difference.

My wife has informed me that when Rusty the Alaskan Wilderness Adventure Dog goes to his reward (as if life as canus familiaris isn’t reward enough), there will not be another.

March 18, 2010 11:01 AM  
Blogger Harry Eagar said...

Medical costs are not paid out according to actual experience.

If your knee hospital also treats mental patients, then it loses money on those, so it has to make it up on items that it can be reimbursed for, like knees.

Doesn't make business sense, but there it is.

An old-timer at the paper here liked to tell the story about installation of a new press, a less than once-in-a-generation event at a newspaper.

About half a dozen millwrights were needed to install the machine, but they brought along about 15 apprentices, and the newspaper owner paid for all of that.

He asked why he should pay for so many apprentices.

"Because somebody you're going to want to replace this press."

You can drive down the cost of individual surgeries by cherrypicking, setting up a clinic that does only that one kind, and rejects all the difficult and complicated versions of it. There's a famous clinic in Canada that does that with inguinal hernias.

Problem is, if you are the guy with the difficult case, you don't want a guy who only does easy ones. You want somebody who takes on all comers and operates every day.

A good part of health care delivery costs are involved in being ready for catastrophes that come along rarely.

In the rest of the world, when they come along, you die. Here, you might live.

Sort of like paying a lot of money to verify code.

March 18, 2010 11:50 AM  
Blogger Bret said...

Hey Skipper,

Since you're actually asking:
1. Longer, more costly training required for human healthcare professionals.
2. Much, much larger settlements for lawsuits for malpractice on humans.
3. "Prices" for human healthcare includes subsidies for those who can't pay.
4. Overwhelming amount of bureaucracy and paperwork required for humans.
5. Dogs don't complain much (so if there still in a bit of pain, no one knows or cares so the procedure doesn't have to be done as accurately).
6. Shorter life expectancy for dogs (so the bone work doesn't have to last nearly as long).
7. Dogs weigh less on average and their bones are smaller so easier to work with.
8. Dogs are less susceptible to infection than people.
9. Dogs are tougher (more resilient) than people.
10. Animal healthcare is largely private.

This is a bit like comparing apples to oranges, only in this case it's dogs to people. There's just no possible comparison.

March 18, 2010 11:57 AM  
Blogger Gaw said...

Canine versus human healthcare - this is what blogs are for.

I would rebut a few of Bret's points:

1. Vets over here train for longer than doctors (they have more to learn as they're dealing with more than one species).

5. I don't think doing something sloppily would save much money, if any.

6. I don't think there's a shortcut for fixing a knee (i.e. oh, don't bother sewing it right up - it's only got to last another year or two). Anyway, isn't this 5 repeated?

7. Or fiddlier. Children aren't easier to operate on than adults.

8. I'm not sure this is true.

9. Nor this. And a lack of awareness and intelligence might make a dog's recovery more difficult.

10. I thought human healthcare was private over there? Anyway, isn't this a repeat of 3?

That leaves 2-4. Can malpractice, subsidies and paperwork really account for the difference?

March 18, 2010 2:32 PM  
Blogger erp said...

Skipper, we feel the same way about our "big foot." He's irreplaceable.

Our mediocre lawyer from a mediocre Florida law school makes $300/hr. Cost us $150 for a short letter he sent for us which I dictated.

If your surgeon is part of Medicare, I doubt he makes $400,000 although I think a good doctor or surgeon is worth his/her weight in gold.

March 18, 2010 3:29 PM  
Blogger Bret said...

Rebutting Gaw's rebuts:

1. Not in the U.S. and Hey Skipper I believe was writing about the U.S.

5. Of course it would. You can trim the cartilage carefully or you can hack it off. There's a fair amount of variance with human surgeons as well. Some really rush through (according to a surgeon friend of mine).

6. The difference between 5 and 6 is that vets just need to make the dogs functional again. As long as Fido can fetch, nobody knows or cares if he is in agony while doing so.

7. Non-growing individuals of any species are easiest to operate on. Do you think it would be just as easy to do knee surgery on a mature elephant?

8. I've seen dogs eat stuff off of incredibly dirty floors that I'm sure would put many people in the hospital. This is perhaps not true of the species themselves, but we're comparing Americans who aren't very resilient to those sorts of things (we can hardly drink the water anywhere outside our borders) with dogs (who can drink the water anywhere).

9. The difference between 8 and 9 is that I'd bet I could drop a dog from a higher height and have it survive than a human.

10. This one I miswrote. What I meant was paid for directly by the person procuring the services as opposed to paid for by an insurance policy paid by an employer paid for partly by tax breaks. Though medicare is not private.

I stopped at 10. I could go on, but you get the point.

March 18, 2010 4:15 PM  
Blogger Hey Skipper said...

Harry:

You make a good point about some procedures bearing the freight of others — which could also be said of patients.

_____

Bret:

Gaw pretty much said what I was going to, but I’ll add a couple other quibbles.

1. Dog and human anatomy are of comparable complexity, so it isn’t clear why medical school should be longer.

If, indeed, it is. Vet school in the US is four years long, and is followed by internships and residencies. So, just like people docs, there is roughly 7 years training involved.

3. Dogs don’t complain, per se, but they have obvious signs when they are in pain. If there are women in the house, these signs will not be missed, or ignored. As long as Fido can fetch, nobody knows or cares if he is in agony while doing so. is just wrong.

I don’t see how this is an invalid comparison: dog and human knee surgery are essentially identical tasks. The cost differential needs explaining in ways that don’t involve the consumption of goods, services, and the opportunity cost of providing the skill.

And if it isn’t done right, Fido won’t be able to fetch.

Gaw also asked:

Can malpractice, subsidies and paperwork really account for the difference?

Depends. Malpractice insurance can be twice what the surgeon earns; insurance paperwork is largely deadweight.

But I think the bigger factors are these:

1. Veterinarians operate in a completely competitive market. That means they have to control costs (unlike a regional hospital). That also means that if they produce Fidos in agony, people will take their Fidos elsewhere.

2. All veterinary costs are out of pocket for the consumer. Compare to people medicine.

3. Because vet costs are out of pocket, and consumers are cost sensitive, sometimes people will simply decline the procedure. Fido may suffer; more likely, Fido will instead go to the great bark park in the sky. Consequently, there is less demand for healthcare than in a system that provides, say, “insurance” coverage for fertility treatments and viagra.

March 18, 2010 10:26 PM  
Blogger Peter Burnet said...

Skipper, your hyper-rationalism takes you to some very interesting places.

I'm looking forward to your post pondering the excessive amounts we spend feeding children compared to the much lower cost of a balanced, nutritious diet for Fido. I believe their digestive systems are comparable and equally complex. And how can we justify spending so much money taking the little terrorists to DisneyWorld when Fido's recreational and social needs, surely no less essential than Junior's, can be fully satisfied with an old stick and a daily run in the park?

March 19, 2010 2:27 AM  
Blogger Hey Skipper said...

Peter:

Skipper, your hyper-rationalism takes you to some very interesting places.

Come now. My "hyper rationalism" can't possibly lead anywhere, because it is descriptive, not prescriptive.

However, describing why one thing is much cheaper than another essentially identical thing means that it is, at least theoretically, possible to deliver health care at far less cost than we do now.

Since it is the cost problem that is at the crux of health care delivery, one would think at least understanding the difference might be handy.

And it might also stop us being surprised when the government starts making some very unpleasant choices because they didn't come to terms with the cost element from the outset.

March 19, 2010 9:08 AM  
Blogger Harry Eagar said...

First an anecdote about a vet procedure. Last year I wrote a story about a local vet who operated on a dog who had been dragged behind a truck for about a mile at maybe 40 mph.

He did the work alone, with one assistant, and spent around 6 hours on the initial surgery.

Contrast with what would be mobilized if you were dragged behind a truck for a mile.

Furthermore, his setup was really cheap, because it didn't have to be ready for, say, heart catheterizations.

One difference between veterinary medicine and people medicine is that vets don't attempt to cover nearly the ground that physicians and surgeons do.

I was amused, many years ago, when I went to my GP with Bell's palsy (which I had initially taken to the ER, where a nurse diagnosed it from 30 feet away).

Dr. Porter, was, I think, a good doctor and at the time nearly 80 years old. He told me I was the first patient with Bell's palsy he'd seen in over 50 years of practice (because almost all are treated in hospitals).

But he and his partner got into a shouting match about whether a newish treatment for Bell's was better than the standard treatment.

Here he was, 50 years of no business, but he was keeping up with a very wide range of contingencies.

Another version of the same parable:

Chiropractic is, per visit, usually cheaper than real medicine, although always a bad bargain. One obvious reason is that chiropractors don't support the huge infrastructure that real medicine does.

At a hearing about medical reimbursements years ago, a chiropractor was complaining about not being able to get payments from a state workers comp scheme because it enrolled only physicians who had access to 24-hour ERs, which, of course, chiropractors don't get.

They could, obviously, set up their own ERs, except that, as the chiropractor testifying said, people in a crisis don't go to chiropractors.

March 19, 2010 10:46 AM  
Blogger Hey Skipper said...

One difference between veterinary medicine and people medicine is that vets don't attempt to cover nearly the ground that physicians and surgeons do.

How much ground do surgeons cover?

The particular doc that worked on my daughter is an orthopedist (I may not have my medical terminology straight: he specializes in bones and joints).

March 20, 2010 10:43 AM  
Blogger David said...

Along with lots of other reasons people have suggested, it's pretty clear that prices have gone down and services have become better and more creative in medical areas not covered by insurance: ophthalmologists, laser eye surgery, plastic surgery, and, what the heck, vets.

March 20, 2010 3:22 PM  
Blogger Bret said...

I second David's point.

The main problem with government involvement and badly distorting the market (where those buying services are not the ones receiving the services), is that the trial-and-error evolution of the market is thwarted.

In the short term, it may not matter much. Doctors who spent huge amounts of money to become doctors are still going to be doctors, hospitals that have been built will remain hospitals, information technology won't change radically overnight, business processes won't suddenly become wildly less efficient. Indeed, in the short term, things may even be improved.

But after 20 or 50 years, stifled innovation catches up with you. Fewer people will become doctors, fewer hospitals will be built, less investment will produce fewer innovations, and mediocre business practices become entrenched. If productivity growth is reduced a mere 2% per year for 36 years, the productivity is half what it otherwise would've been. So this legislation is screwing our children and grand-children much, much more than it will hurt us, especially those of us who are older.

March 20, 2010 8:23 PM  
Blogger Mark Frank said...

The main problem with government involvement and badly distorting the market (where those buying services are not the ones receiving the services), is that the trial-and-error evolution of the market is thwarted.

I am confused about the proposed legislation. I thought it amounted to little more than making insurance mandatory for a large group of people - which extends the most common current method of paying for health services at the moment.

Or maybe you are not referring to the proposed legislation?

March 21, 2010 5:10 AM  
Blogger Susan's Husband said...

Who knows? Do you mean the legislation that passed the House, the legislation that passed the Senate, the sketch / proposal from the Obama White House, the proposed post-reconciliation legislation? Of these, has any person actual read the entire text?

But all of these do far more than just mandate insurance purchase.

March 21, 2010 7:15 AM  
Blogger Mark Frank said...

I was thinking of this one.

Is there something essential missing from this summary?

What are the key changes that will suppress innovation?

March 21, 2010 7:35 AM  
Blogger erp said...

We see a fair number of private doctors and they are having a heck of a time maintaining their offices. Most are in their 40's and 50's. Many have said, any more Medicare cuts and they will have to stop seeing Medicare patients, so we'll all be in trouble -- since a large percentage of their patients are geezers who have no option to buy private insurance and whose only other option is an HMO which limits who we see.

March 21, 2010 7:36 AM  
Blogger erp said...

Mr. Frank said: What are the key changes that will suppress innovation?

I thought that was obvious, the profit motive will be missing and even if there are altruistic genius's out there willing to do their all for the good of mankind, there will be many rules and regs and other hoops to jump that will deter all but the most avid from introducing new ways of doing things.

In addition, we have the best and smartest doctors because up ‘til now, they were very well paid and had a lot of status. When they’re merely another member of the SEIU, gone will be the glory and their pay will be regulated by bureaucrats anxious to pander to those who think, as does Obama, that doctors make too much money.

Overheard on the check-out line, I can’t wait to go to the doctor for freeeeeeeeeeeeeeee. Won’t she be surprised.

March 21, 2010 9:28 AM  
Blogger Mark Frank said...

I thought that was obvious, the profit motive will be missing

What is not obvious to me is why the profit motive should be removed. What is there in the bill that stops doctors making more money by innovating?

March 21, 2010 9:32 AM  
Blogger erp said...

Mark, why don't doctor's in the UK innovate? Same reason. Neither of us know what's in which bill right now, but we both know that the goal is a complete takeover of the way we receive health care and that means everything is in the hands of the bureaucrats/unions. Innovation isn't in of that crowd's vocabulary.

March 21, 2010 9:36 AM  
Blogger Gaw said...

Erp: The US has about three times the Nobel prizes for medicine as the UK, despite having about five times the population.

The UK is also home to some of the world's biggest drug companies: two of the world's top ten biggest are British versus the US's six (so again a disproportionately high number).

In both metrics, the UK is second to the US globally. By the way, Switzerland also has two representatives in the global top ten drug companies by size. The US is broadly heading for a Swiss model of healthcare - the Swiss aren't a bad model for many things.

March 21, 2010 9:50 AM  
Blogger Mark Frank said...

Mark, why don't doctor's in the UK innovate? Same reason. Neither of us know what's in which bill right now, but we both know that the goal is a complete takeover of the way we receive health care and that means everything is in the hands of the bureaucrats/unions. Innovation isn't in of that crowd's vocabulary.

erp - you make an awful lot of assumptions - based as far as I can see your ideology.

In addition to Gaw's comments - to give a couple of important examples, did you know that UK researchers were responsible for the first CAT scans (admittedly closely followed by the USA), and making the first practical ultrasound based on Austrian research?

You dismiss the proposed bill as suppressing the profit motive and therefore innovation despite being unable to identify anything in it that would suppress the profit motive. What you do know, of course, is the intention behind it. Even if you do know the intention - if the current legislation is acceptable why should that lead to that intention being fulfilled? Surely the Republicans are capable of preventing a future left wing health bill?

March 21, 2010 10:30 AM  
Blogger Bret said...

Mark Frank wrote: "Or maybe you are not referring to the proposed legislation?"

I was not specifically referring to the proposed legislation. I was referring to the already existing tax, regulatory, and market distortions already in existence since Hey Skipper was referring to dog versus human surgery right now.

It seems to me that health-care "reform" will make it much worse. You provided a link to health-care reform "at a Glance", but it sure is a short glance. For example, doesn't that plan also include elimination of refusal for pre-existing conditions? Wouldn't that further distort the market? In the bill being voted on today there's hundreds of things like that in the thousands of pages in the bill.

March 21, 2010 10:35 AM  
Blogger Harry Eagar said...

'Mark, why don't doctor's in the UK innovate?'

You could make a pretty good case that almost all the most important advances in medicine in the past 60 years were sponsored by the National Health.

That is, if you think genetios and immunology have been important.

March 21, 2010 11:34 AM  
Blogger erp said...

Gaw, to be fair, a lot of our Nobel prize winners in all categories are Americans who were born in the wrong country.

Our big businesses are leaving the U.S. because of we've gotten anti-business.

Pretty soon everyone will be going to Costa Rica. We might too if we were just a bit younger.

___

Mark, why yes, my "ideology" does play a part in my assumptions. Doesn't yours?

March 21, 2010 12:04 PM  
Blogger David said...

I wasn't thinking about research or the new "reform" legislation. I was thinking about delivery of health care.

Doctors and hospitals can't innovate because the government and the insurance companies over regulate the delivery of services, as well as medicine and medical devices. Innovative delivery can't be billed because there's no code for it, and you can't get a code unless you can demonstrate that it works. At the same time, there's no benefit to delivery of services at a lower charged price.

Because new HCR expands regulation, it's just going to make things worse.

March 21, 2010 2:02 PM  
Blogger Susan's Husband said...

"Is there something essential missing from this summary?"

The fact that the first 10 years have 10 years of taxes and only 5 years of benefits?

That requiring citizens to purchase a specific product is an unprecedented change in American law and custom?

That the costs are deflated by Medicare cuts which Congress intends to repeal (that is, not cut Medicare)?

The numerous boards, review, committees, etc. that will be set up?

The no pre-existing condition regulation?

That the business penalties are so small that any smart owners will immediately cancel any employee insurance?

Those are just from one pass. I am sure there is plenty more in the 2039 pages of legislation.

March 21, 2010 8:14 PM  
Blogger Mark Frank said...

The fact that the first 10 years have 10 years of taxes and only 5 years of benefits?

What does this mean? What kind of benefits stop after 5 years?

That requiring citizens to purchase a specific product is an unprecedented change in American law and custom?

Don't you require car insurance?


That the costs are deflated by Medicare cuts which Congress intends to repeal (that is, not cut Medicare)?

How much?


The numerous boards, review, committees, etc. that will be set up?

Of course it will need organising - it is a question of how well it is done.


The no pre-existing condition regulation?


This is the most interesting. It ties in with Bret's comment about distorting the market. How far do you want to take this? Is it distorting the market to prevent insurance companies asking for genetic tests? Soon it will be possible to make very specific predictions about a kid's chances of getting cancer in their 30s and 40s. What do you about the child that is born with cystic fibrosis to poor parents? Distort the market by offering state assistance or rely on charity?

That the business penalties are so small that any smart owners will immediately cancel any employee insurance?

Well campaign to increase the penalties rather than just use it as a political opportunity.

March 21, 2010 11:36 PM  
Blogger Susan's Husband said...

The benefits don't start for at least 4 years, possibly 6.

Only car owners who drive cares on public roads are required to buy car insurance. I know many people who own neither.

The Medicare cuts are between $300B and $500B, a very substantial fraction of the overall costs.

Why will it need organizing? As for how well it will be done, wouldn't that count as something important that wasn't in the article?

As for distorting the market, the pre-existing condition regulations destroy the market, because it will no longer be insurance. Why not require car insurance companies (your example) to not check the car for pre-existing conditions so you can buy car insurance after an accident?

As for the penalties, I campaigned to prevent this entire travesty. Why should I therefore campaign to make it worse? Besides, your question was "what important facts were left out of the summary". That is what I answered.

March 22, 2010 7:15 AM  
Blogger erp said...

Just as Obama himself is the Chimera, so his insurance scam will be a monster that changes to suit him.

March 22, 2010 8:02 AM  
Blogger Susan's Husband said...

Here's another important issue left out of that summary.

March 22, 2010 8:18 AM  
Blogger Harry Eagar said...

Excellent arguments for single-payer, David and SH.

The worst thing about the changes is that they were cobbled together to answer (mostly misinformed) political requirments, not medical requirements.

It's a set-up to fail, but the present system is failing, too. A lot of people are in denial.

March 22, 2010 11:03 AM  
Blogger Hey Skipper said...

David said: it's pretty clear that prices have gone down and services have become better and more creative in medical areas not covered by insurance: ophthalmologists, laser eye surgery, plastic surgery, and, what the heck, vets.

Yes. The reason this is so is that consumers in these areas are price sensitive, and have many opportunities to compare performance.

Bret said: The main problem with government involvement and badly distorting the market (where those buying services are not the ones receiving the services), is that the trial-and-error evolution of the market is thwarted.

The other type of government involvement is through the judicial lottery. Excluding vets for the moment, none of the areas David mentioned is particularly diagnostically dependent, so any tortious claims are focussed almost exclusively upon procedural error measured against very specific outcomes.

Add vets into the mix. They pretty much cover the same range of health failures in animals that MDs do in humans. The difference is the complete (or close as darnnit) absence of exposure to tort claims.

Consequently, the cost of defensive medicine in each area is essentially nil.

Knocking out malpractice insurance and defensive medicine costs is bound to leave a marks in both cost and innovation.


Mark Frank said: I am confused about the proposed legislation. I thought it amounted to little more than making insurance mandatory for a large group of people - which extends the most common current method of paying for health services at the moment.

At the risk of repeating SH ...

The penalty for not buying coverage is derisory, so this bill increases moral hazard by also eliminating pre-existing conditions.

Progressives have, with MSM connivance, long derided the insurance industry's treatment of "pre-existing" conditions. They might as well get all wound up about insurance companies refusing the purchase of fire insurance after the house has burned down.

erp said: We see a fair number of private doctors and they are having a heck of a time maintaining their offices. Most are in their 40's and 50's. Many have said, any more Medicare cuts and they will have to stop seeing Medicare patients, so we'll all be in trouble.

The practice where my wife works, and this is common throughout Anchorage, will no longer accept Medicare patients.

Of course, the cure for this is to force them to do so.


Gaw said: The US has about three times the Nobel prizes for medicine as the UK, despite having about five times the population.

Interesting. I didn't know that.

Given, as Mark Frank says, that the first CAT scans were in the UK, and ultrasound in Austria, where did their implementation become widespread first? My guess is the US, which drove down cost, then the rest of the world.

Regarding drug companies, I would be interested to know where those based in the UK and Switzerland get most of their profits.

If it is the US (my guess; I don't know), then, pharmaceutically speaking, the rest of the world is free-riding.


SH said: Here's another important issue left out of that summary.

So, I wonder how long it will be until a state gives the Federal Gov't the single digit salute on this?

Progressives have great intentions, but have problems with unintended consequences.

Harry: to be fair, of course, you would have to acknowledge all the arguments against single-payer.

Of which there are many.

The central problem with Obamacare is that it failed, utterly, to acknowledge that cost is the root problem with our health care system.

So, absent progressive hubris, the proper way to attack the problem is through cost first (by understanding why human knees cost so much more than dog knees).

Because solving the cost problem makes the provision problem far easier.

March 22, 2010 11:14 AM  
Blogger Mark Frank said...

I am still not sure what solution the right wing have for the child of poor parents with cystic fibrosis.

March 22, 2010 11:37 AM  
Blogger erp said...

Mark, please stop being contentious and do some googling of all the agencies and charities that do good works and stop believing what you read in the media.

We're in deep mourning right now.

March 22, 2010 11:41 AM  
Blogger Susan's Husband said...

Charity would be one. But as many have noted, hard cases make bad law. I think it's telling about the mental state of MALists that they think anecdotes are the ultimate argument and that only utopian claims are valid policy arguments.

P.S. I also need to note that Mr. Frank is more knowledgeable than House Speaker Nancy Pelosi who said "“But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy". That is, according to her, none of "us" (such as Mr. Frank) actually know what's in the bill and can't find out until it is law. Yay.

March 22, 2010 11:45 AM  
Blogger Hey Skipper said...

Mark Frank:

I am still not sure what solution the right wing have for the child of poor parents with cystic fibrosis.

That takes as given that Obamacare will, in fact, produce results superior to what could happen in its absence (tort reform, health savings accounts, treating employer provided health coverage as wages, more exposure of consumers to cost, eliminating state line barriers on health insurance, etc).

----

This hydra-headed legislative monster puts the cart ahead of the horse, fails to take on board moral hazard, puts Medicare on a track for total failure, and (I predict) will lead to either blowing CBO cost estimates out of the water, or forcing MDs into servitude.

When Medicare was passed, its estimate for the cost circa 1990 was off by an order of magnitude.

When waxing ecstatic over the CBO estimates for Obamacare, I don't recall the MSM once acknowledging that.

March 22, 2010 1:59 PM  
Blogger erp said...

Mark, please accept my apology for my less than courteous reply above.

I plead temporary insanity as a reaction to the disgraceful behavior of my public servants in congress taking bribes from my public servants in the executive branch.

March 22, 2010 2:05 PM  
Blogger Mark Frank said...

erp - no problem - I have been subjected to much less courteous comments than that!

Hey Skipper


That takes as given that Obamacare will, in fact, produce results superior to what could happen in its absence (tort reform, health savings accounts, treating employer provided health coverage as wages, more exposure of consumers to cost, eliminating state line barriers on health insurance, etc).


How does the alternative help the child of poor parents with cystic fibrosis (1 in 3000 births) or Down's syndrome (1 in 1000 births) etc?

This problem is only going to get worse. E.g. soon it will possible to predict at birth the chances getting cancer as a young adult. Do you "distort the market" by preventing insurance companies using this information? Or do you tell the poor ones to go ask a charity for help?

March 22, 2010 2:42 PM  
Blogger Harry Eagar said...

I will cheerfully acknowledge all the problems with single-payer.

As I see it, the alternatives were single-payer or some version of sauve qui peut. Between those two, I prefer single-payer. It is a defect of democracy that it prefers Rube Goldberg apparatuses to engineered solutions, but there you go.

A high school friend of mine went to work for Glaxo when it first expanded to the US. Their sales went from $0.00 to $2,000,000,000.00 in 24 months and now he lives in a mansion on the beach.

But the products they sold were formulated in the UK.

Peter Medawar said the National Health was the finest thing his generation accomplished. Not to argue from authority, but he was a man whose opinion was worth listening to, and as hardheaded as any man of the 20th c.

March 22, 2010 2:46 PM  
Blogger erp said...

Mark, are you not aware of Medicaid? It is tax payer funded health care program for the indigent and here's a link to some free help and treatment sites for those suffering from cystic fibrosis.

Foundations and other charities are supported by individuals and corporations. Why is creating a monster bureaucracy and public sector union paradise funded by individual and corporate tax payers preferable?

March 22, 2010 3:25 PM  
Blogger erp said...

Then those horror stories about NHS we keep hearing about are grossly exaggerated?

March 22, 2010 3:30 PM  
Blogger Mark Frank said...

Mark, are you not aware of Medicaid? It is tax payer funded health care program for the indigent

Of course I am - I thought that was the kind of thing you disapproved of?

and here's a link to some free help and treatment sites for those suffering from cystic fibrosis.

To quote from that very site:

"People living with cystic fibrosis face a lifelong challenge of paying for medications, nutrition supplements, respiratory equipment, physician services, and various other medical expenses. Even with health insurance to cover some of the costs, the expenses of treatment can be devastating to any family's budget. If you find the cost of treatment is giving your wallet a squeeze, there are places you can turn to for help."

Followed by a list of charities and other organisations you can apply to. And you want to cut down on the bureaucracy!

Foundations and other charities are supported by individuals and corporations. Why is creating a monster bureaucracy and public sector union paradise funded by individual and corporate tax payers preferable?

I am not sure how this odd hybrid is going to work out for you - but one of the things that people who use the NHS emphasise is the lack of bureaucracy from the patient's point of view. Just register with a GP and that's pretty much it. Having talked to my US relatives I know that battling with insurance companies can be a nightmare.

Then those horror stories about NHS we keep hearing about are grossly exaggerated?

Absolutely. Of course there are individual horror stories, as there are in the USA, and the press, especially the British press, love to leap on anything that goes wrong. It is far from perfect and I am sure there are better systems. If you are in hospital the food will be dire and you probably be in a six or eight bed ward. But you can always pay for the luxuries - after all it costs less than the half the US system. Basically it works and it can be very good.

Let me give you an example. A few weeks ago I acquired a deep vein thrombosis. I decided something was wrong on the Sunday evening, saw my GP at 9:00 AM on Monday morning (a 10 minute walk in our 600 household village), he immediately took a blood sample and sent it to the nearest hospital (7 miles) while I went to work, he called me at 4:00 to say it was almost certainly a thrombosis, I was on injections (again delivered locally) by 5:00. Went to the hospital for an ultrasound to confirm the extent on the Thursday. No waiting at any point. No forms. Potentially dangerous situation speedily dealt with.

March 22, 2010 11:41 PM  
Blogger erp said...

Mark, I didn't say I approved of Medicaid, only that it exists. The link I sent was just one I picked out sending you on to more info. I'm sure that having a family member with cystic fibrosis is a life long struggle in every way.

I'm glad you've acclimated to and enjoy your health care delivery system and as we humans are adaptable creatures, we will adapt too and in a short time few of us will remember how it was when we were independent and could spend our resources how we saw fit and not the way scummy left wing politicians/bureaucrats/SEIU find more profitable.

March 23, 2010 5:46 AM  
Blogger Susan's Husband said...

And it's such a great deal that the Congressional staff who drafted it exempted themselves from its requirements. In all seriousness, what more would you need to know to realize this is bad legislation?

March 23, 2010 8:04 AM  
Blogger erp said...

If Republicans would put us in charge of their campaigns, the dems wouldn't have a chance.

The ads write themselves.

March 23, 2010 8:42 AM  
Blogger Hey Skipper said...

Mark Frank:

That's good news about your quick recovery.

How does the alternative help the child of poor parents with cystic fibrosis (1 in 3000 births) or Down's syndrome (1 in 1000 births) etc?

If costs come down -- which is to say, by making health care go towards the dogs -- then the affordability problem is consequently eased.

Now, I completely agree that, due to nothing more feckless than having been unlucky in life, there is no conceivable degree of cost reduction that will make required health care affordable for some people.

But by having done things both obvious and easy to reduce cost in the first place, the access problem is much easier to solve in the second.

March 23, 2010 8:57 AM  
Blogger Harry Eagar said...

It doesn't sound to me as if Mark had to do much 'adapting' to the National Health. It sounds like it works like a dream.

Another plug for the NH, an AP story tucked away in Tuesday's paper: LONDON -- Nobel Prize winning pharmacologist James Black, whose breakthrough beta-blocker drugs help treat millions of heart patients and save thousands of lives, has died at age 85.'

Another proof that socialized medicine squelches innovation and retards patient care, I suppose.

David sez: 'Innovative delivery can't be billed because there's no code for it, and you can't get a code unless you can demonstrate that it works. '

A management problem that could be solved without legislation. One would suppose that the for-profit sector would already have solved it, if the profit motive works the way you guys say it works.

March 24, 2010 2:05 PM  
Blogger Susan's Husband said...

Why is that a plug for the NHS, since almost all of the research leading up to the discovery happened before the NHS existed?

I also like the "could be solved" rhetoric -- just like Communism, it could work, it just doesn't happen to do so in real life.

I will also note that it's easy to look good if you don't count the cost, until the money runs out.

March 24, 2010 7:57 PM  
Blogger Harry Eagar said...

The market as we have let it develop doesn't want it solved. I'm not arguing that the current system makes any sense, although I am arguing that there is enough money allocated already to fund a NHS for America.

Some people would have to find other work.

Your argument about research puzzles me. Socialist Austria developed advanced weaving and steelmaking techniques when America did not. It's true, those were built upon work done outside Austria and long ago. So what?

If the argument is that socialism stifles innovation, experience shows that it doesn't.

March 25, 2010 12:46 PM  
Blogger Bret said...

Harry Eagar wrote: "If the argument is that socialism stifles innovation, experience shows that it doesn't."

Socialism certainly increases innovation in torture and oppression, no doubt about that.

However, looking at USSR, China (under Mao especially), Cuba, Viet Nam, Cambodia, etc., I didn't see much in the way of economic innovation.

March 25, 2010 1:57 PM  
Blogger Susan's Husband said...

I don't think we spend enough money to fund an NHS here, given how much of the UK budget it consumes.

Experience shows that socialism stifles innovations. Why you think a few anecdotal counter-examples falsifies that claim escapes me.

March 25, 2010 8:43 PM  
Blogger Harry Eagar said...

Quaint how you put Cambodia in there.

March 25, 2010 9:39 PM  
Blogger Harry Eagar said...

There was no simple graph I could find quickly, but a little math and wandering around suggests that the NHS must cost around $200 billion/yr or about 25% of the $900 billion government revenue; or, more relevantly, a great deal less than 10% of national income.

Compare to health care of about 16-17% of national income in the US.

And since NHS spends less than half a much per capita than US overall spending, that sounds about right.

I am not seeing NHS as a bankbreaking venture in these numbers.

March 25, 2010 9:54 PM  
Blogger Mark Frank said...

Harry

Wikipedia has most of the figures. They are slightly out of date. Projected UK expenditure on the NHS (which is pretty much all of health expenditure) for 2010 is £110 billion = $165 billion. This is £1,980 (= $2,930) per capita. US expenditure was $7,290 per capita in 2007 - it must be higher for 2010.


It is interesting to compare this to the cost of medicare alone: $600 billion in 2008, about $2,000 per capita if my maths serves me right.

The federal government is already spending over three times the absolute cost of the NHS and over two thirds of the cost per capita on medicare alone.

I don't for one moment think that the NHS is the best healthcare system in the world and it has almost nothing in common with the Obama plan. But I do despair a little when it is held up as an example of how not to do things.

March 26, 2010 12:33 AM  
Blogger erp said...

Mark, what do you think is the best health care system in the world?

March 26, 2010 8:36 AM  
Blogger Mark Frank said...

Mark, what do you think is the best health care system in the world?

I don't know. I only know a bit about a few systems and of course it depends on what you want from a health system. On the face of it the mandatory insurance systems of France, Germany and particularly Japan seem to do very well - although of course all systems have problems.

March 26, 2010 10:35 AM  
Blogger erp said...

Mark, I've been in an ER in Paris. My husband got food poisoning and I assure you, it wasn't funny at the time

From my standpoint, it was third world -- looked like something in a documentary about the old Soviet Union.

March 26, 2010 11:35 AM  
Blogger Mark Frank said...

erp

I am sorry you had a bad experience in France. I have never had to use their health service - although it has a good reputation.

Three points:

Anecdotes are not evidence - and that includes mine. You have to base it on statistics and proper surveys.

A lot of your experience of a health system depends on how well you know it. We had our first child in Atlanta when I was on assignment and our second in London. We still bear the mental scars of our treatment in Atlanta (and there was no shortage of money - IBM was paying). Our baby became very ill indeed when there was nothing wrong with him initially. But it was largely down to us not understanding the system. Our second child got jaundice and it was dealt with promptly and efficiently because we knew how to use the system.

It is in the nature of the US system that some will get outstanding care and some much worse. The average appears to be no better, and maybe worse, than other industrial countries but if you are used to outstanding care then other countries, where services are more uniform, may seem inferior. Although I would not expect that to apply in the case of food poisoning.

March 26, 2010 12:29 PM  
Blogger Harry Eagar said...

Measured by outcomes, the US system is not nearly as good as any other top 10 or top 20 economic state.

Skipper would say that's because poor blacks drag down the averages, but that's still an outcome.

I wouldn't say you could reason back from outcomes to causes, but still, outcomes are outcomes.

March 27, 2010 11:39 AM  
Blogger Hey Skipper said...

Harry:

If the argument is that socialism stifles innovation, experience shows that it doesn't.

Stifle is not a synonym for throttle to death.

Experience does show that socialism retards innovation: the British car industry is a perfect example. (Even if it does suggest that stifle is nearly synonymous with kill dead as plank.

Mark Frank seems on the money for budget numbers, although further down the Wikipedia page there is an assertion that the true spent amount will exceed budget by £7bn in 2010.

I also agree with Mark that the NHS is effective in its own way. It does stifle innovation (IMHO), but for people on the lower end of the income scale, there can be no doubting the sense of security it offers.

Mark said: … although of course all systems have problems.

He has put his thumb squarely on what has annoyed me most about this Obamacare schlamozzle. Health care is the Super Bowl of moral hazard and demand outstripping supply.

Care will be rationed, the only question is how.

In a previous life, ca 1991, my Grandmother visited me while I lived in England, about 20 miles north of Oxford.

She slipped on the gravel driveway, and broke her wrist.

On the up side: we didn't have to raise our blood pressure even the tiniest fraction worrying about how to pay for it.

Down side: three hour wait in an empty emergency room before she was seen. From what I have read, waiting times are down across the board since then, but at no small amount of cost.

Skipper would say that's because poor blacks drag down the averages, but that's still an outcome.

There is no doubt that comparing like against like, US lifespan is identical (or close as darnnit) to other countries.

If you think that the most perfectest health care system imaginable in this universe or any other would change the lifespan for blacks, then it is a gross statistics foul to lump the social pathologies that particularly effect them as somehow related to health care.

March 27, 2010 6:31 PM  
Blogger Hey Skipper said...

Last para should read:

"Unless you think ..."

March 28, 2010 10:18 AM  
Blogger Harry Eagar said...

Well, even if the outcomes are nearly the same, if one costs half as much, that one's preferred, right?

I could eliminate a lot of US spending with the stroke of a pen: Do away with helicopter ambulances.

We didn't have them a few decades ago, and most Americans still believed (incorrectly) that our health delivery system was the best in the world.

Now we have them, and although an occasional life will be saved thereby, probably 999 of 1,000 flights it makes no difference.

March 28, 2010 10:51 AM  
Blogger erp said...

If one out of a thousand, or ten thousand helicopter flights saves a life, it's an acceptable cost. We're a very rich country and can afford it.

What we can't afford are all the parasites, bureaucrats and union thugs leeching on our body politic. Get rid of them and we're talking big money that saves no lives, not even one in ten gazillion.

March 28, 2010 12:12 PM  
Blogger Harry Eagar said...

erp, you, David and Guy are making better arguments for a comprehensive universal system than I ever could.

A comprehensive, universal health system would unquestionably save many, many lives, and, as you say, we can afford it.

March 29, 2010 6:08 PM  
Blogger Hey Skipper said...

Well, even if the outcomes are nearly the same, if one costs half as much, that one's preferred, right?

This stands right next to the lump of labor fallacy.

The Hep-B vaccine has put a real dent in liver cancer.

Depress innovation now, and the bill comes in the future.

March 29, 2010 9:06 PM  
Blogger erp said...

Harry, I and, I believe, lots of others, question that national health care would save lives, so apparently, it's not unquestionable. What is unquestionable is that Obama’s insurance scam won't save lives in the sense of people's health, it will only save lives in the sense of making the lives of the federal establishment even more cushy.

I'm against socialized medicine, not because it's too expensive, but because, it spends my money on bureaucrats and unions, not on delivering medical care, research, etc.

March 30, 2010 6:04 AM  
Blogger Harry Eagar said...

Skipper, can you really be saying that in a free market, shoppers would pay twice as much to get the same stuff?

March 30, 2010 10:41 AM  

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