Don’t allow hospital and healthcare systems to operate as “non-profits.” There is incentive to continually spend more so there’s no profit to show. It is a disincentive to efficiency.
Pay doctors based on outcomes rather than production. There is a huge amount of unnecessary testing and surgery done in this country.
Reimburse tuition for doctors that choose lower paying specialties.
Cap drug prices. New biologics are ridiculously expensive.
And yes, reduce physician pay. The average is double the next closest country, Germany.
Those are all highly controversial, because it means giving up some of the pie, but it can’t continue as it is. Anyone who can’t get by, let alone thrive on Medicare reimbursement, has built up an ill-conceived overhead structure (fancy buildings, giant staff, multiple houses, etc.).
My husband is on a biologic. It’s been miraculous. His quality of life is so improved and we are so lucky that he’s able to be on these drugs.
Since we are still on private pay insurance, the drug companies do help with our expenses.
There are programs for physicians to practice and get debt relief. They have to go to parts of the country that are underserved but they exist. There is also federal debt relief available.
But every physician in training that I’ve known, wants to be a specialist. Because it’s more competitive and challenging. It pays more, yes. But young physicians I know, want to be challenged and excited about what they practice.
Wouldn’t more general specialties like the primary care ones and emergency medicine be more challenging because a patient could come in with anything, possibly leading to challenging puzzles to solve in diagnosis?
Of course, “competitive” may be an attractor due to the selection effect of constant competition along the pre-med path and in medical school. Medical students presumably thrived and won in the pre-med competition, so they may be self-selected in favor of competitive situations.
To solve that you’d also need to reform liability insurance and limit people’s ability to sue.
All your suggestions seem entirely logical but unfortunately impossible to achieve political consensus on. I can imagine the campaign ads already:
Your representative voted to mandate “for profit” healthcare, while limiting your right to compensation for doctors’ mistakes and introducing “death panels” to restrict access to new lifesaving drugs.
If it was easy, it would have been done by now. Putting our heads in the sand because it’s politically difficult won’t make it go away though. You asked for solutions. I gave some.
I asked how to get from here to there. I think your solutions are interesting, but how could we get agreement to implement major changes in the healthcare system? There’s not an acute crisis that puts it on the front pages (unlike the mess in the UK right now and even there not much seems likely to change). Just a gradual deterioration. That’s not something that persuades lawmakers to act.
This would require significant legal reforms, which are unlikely to happen, for many reasons.
Some of the specialties pay more because they are procedure based. I don’t think all procedures are seen as challenging, but they do have high reimbursement rates.
It is a misconception that this is done as defensive medicine. There are many surgeries still being done that are no longer supported by the literature.
The over testing piece is absolutely based in legal risk (but I have no idea how much this costs per year).
Do you have non-cosmetic surgery examples? (because cosmetic surgeries aren’t typically covered by insurance). Any idea what percent of total health care spend these non-data supported surgeries represent?
That’s a great example…but the surgery does get some people back to activity relatively faster. I’m happy to report my meniscus tear last year healed within 6 weeks with rest and PT!!
ETA: my orthopod is a conservative cutter, although the more surgeries he does, the more money he makes. The hospital also makes more money the more surgeries their docs perform. (Obviously but just making a point how many areas healthcare touches, and someone suggested above that more hospitals should be for profit. If that happens, they will do what they need to to fill the beds)
If the US ever does get universal, “free” health care, I imagine it would be modeled after Canada. Canada is the country most like the US. But as Canadians have come to realize (but would never admit to an American) is that their system is broken too. Part of it is money. Highly taxed Canadians are unable or unwilling to put more money into health care. The other part is government control. Quebec centralized health care administration a decade ago. Like any government bureaucracy it makes decisions at a snail’s pace. Hanes: Quebec is locked in a vicious cycle of health-care system failure | Montreal Gazette
Something is going to have to change at some point. Many people I know who were against single payer 10 years ago (I live in a UMC community where most people get their coverage from their employer) are starting to move on the idea. We are paying more and more and getting less and less - finding a doctor who takes new patients is challenging as is finding one that will spend more than 5 minutes with you. Unless you are on death’s door the wait for an appointment stretches for months which really underscores that, in many ways, we already face the same issues you see in countries with single payer - we just pay much, much more for it.
Not testing per se, but sometimes the US tends to prefer a more expensive option generally, probably because it means more revenue for providers. For example, the primary screening methods for colorectal cancer in rich countries:
Most: FIT every 1-2 years, colonoscopy if blood found.
Germany, Austria: colonoscopy every several years and FIT in other years.
US: colonoscopy every 10 years or FIT every year – colonoscopy appears to be the majority recommendation and use.
The US preference for colonoscopy as primary is significantly more expensive than in other rich countries (besides Germany and Austria) but only slightly more effective.
One of my patients is a physician that transitioned to working for an insurance company mid-career. He’s become an expert on costs in healthcare and reform. I asked him that question several years ago. He said that tort reform and the resultant change in defensive medicine would save about 1/2% per year.
By far the biggest piece of the puzzle…we simply charge too much. Why? To support offices and hospitals that are built like Ritz-Carleton hotels and to pay physician and executive salaries that are dramatically out of line with the rest of the developed world.
As for unnecessary surgeries, two come quickly to mind.
The first was already mentioned, meniscus surgery. This has to be caveated. Acute tears do benefit. Degenerative tears don’t when compared to sham surgery and the same PT. The end result is the same as conservative treatment and the time course is the same as conservative treatment. People who have had it and said it “worked,” almost certainly would have had the same outcome without it.
MRI for low back pain is another example. Yet another is elective C-section.
That’s not the only reason though. Particularly wrt colon cancer testing, patients have a say in what testing they want to do…and colonoscopy is more accurate than ColoGuard or FIT (greater than ‘slightly’ more). So, when a patient has to do that only every 10 years, it’s an easy choice for some to go with the more accurate test (assuming they have the choice).
I am not sure this is true? I don’t have time to do a deep dive on cost comparisons between a colonscopy every 10 years in the US vs. what is happening in Germany/Austria (which seems like more colonoscopies in each 10 year period, so more expensive than US) vs. how often a FIT test finds blood, requiring a colonoscopy.
