Tuesday, December 30, 2008

Mandated Health Insurance Isn't a Capitalist Solution (Or a Solution At All for That Matter)

Everyone from my classmates to some of my family members has recently been talking to me about universal mandated health insurance as the solution to our healthcare woes. Apparently, we can solve our healthcare crisis by making everyone give money to insurance companies. The two things that I find most amazing about this argument are:

1)It is almost universally proposed by individuals with socialist leanings
2)The argument as to why it should work is usually that it is a capitalist or free market solution.

I think we need to get a couple of things straight. There is no such thing as a federal free market mandate. By being a federal mandate, it automatically ceases to be free market, which is essentially defined as being devoid of government interference. You cannot mold capitalism to your personal whims. Capitalism is why some people don't buy health insurance now. Forcing everyone to buy it is a strangely crossed socialism/fascism hybrid in which we force everyone to subsidize each other while simultaneously creating a profit for a private financer that is controlled by public regulatory bodies. This system cannot work effectively. I'll explain why:

As a precursor, let me point out a couple of universal points that are argued to achieve the mandated health coverage utopia:

1)People who can "afford to pay," are required to buy health insurance or face stiff tax penalties
2)People who cannot "afford to pay" are subsidized to some degree in the purchasing of insurance, with some groups inevitably being fully funded.
3)Insurance must cover pre-existing conditions
4)There is some control on insurance rates
5)Your insurance can't "drop" you
6)There is some continuing tie to employer funded insurance

Here's why these things don't work:

1)It doesn't address the overall cost at all
2)By forcing those who can "afford to pay" to also pay the taxes that subsidize those that can't "afford to pay" you are creating socialized medicine with two middle men. You have the government AND the insurance company. Far from being a free market solution, you get a government beauracracy and a company that largely generates profits by lobbying the government beauracracy and denying payment for things that the government gives it money to pay for.
3)If insurance covers pre-existing conditions, rates have to go up.
4)If rates are controlled, they cannot go up to cover pre-existing conditions. Companies will have to lobby for a rate hike that no one can afford, receive subsidies (a second knock against those who can "afford to pay") , or operate in the red.
5)By requiring insurance companies to keep patients for life, you require them to charge everyone more up front to deal with the inevitable risk factors that will appear later
6)You continue to rely on the employer based insurance model which is itself a relic of the New Deal Era as an attempt to avoid wage control policies.
7)The new system does NOTHING to address malpractice problems
8)The new system does NOTHING to ration expensive care
9)The new system becomes a hindrance to a new system, because it is now a mandate.

If people had to pay for their own care, there would be no medical cost crisis, because contrary to popular belief, the cost of medicine would over time come down to the price that people could pay. If you eliminate some of the malpractice incentives to over test, people will simply not want to pay for low yield testing. Insurance companies couldn't sell insurance unless it was cost effective. In a system without EMTALA, the cost effectiveness of the insurance system would be better assessed, as people would actually have an incentive to buy it.

Something doesn't become capitalism because a corporate entity is making a profit from it. Something is capitalism when it is the product of the natural adaptations of the free market based on the individual preferences of the people within the system.

I am actually going to take a stance here that most people will be shocked by. I believe in a two-tiered system. I believe in a locally funded county system that adapts to the local needs of its area and provides safety net care to prevent the spread of infection and control disease. I believe that the proper role of a lot of residency training is in these institutions as it was originally designed to be. I want the feds out of 99% of medicine beyond the prevention of nationwide disease epidemics and bioterrorism. I want the local governments out of the private medical system. A private system with a small safety net is better than than the hybrid mess we have created, and seem to want to perpetuate, any day of the week. That would be a true capitalist solution to healthcare. Entitlements at the public institution would be limited by budget considerations, and private healthcare would function like all capitalist systems, providing what it can based on the preferences of the people with the most cost effective solution that meets those demands outshining the others and taking market share.

Only in a dream.

Sunday, December 07, 2008

Duty Hours/Regulation/The IOM/The Cost/The Logic/AHHHHHHHH?

So it appears that the IOM has released its recommendations to congress regarding duty hour restrictions for medical residents at programs receiving federal funding (AKA every program). I'd like to take a minute to go over some of these recommendations, discuss the potential impact, and then explain why this is a bad idea. I do not have a comprehensive list. All of my information is second hand, as the report itself is rather expensive to access. If I write anything inaccurate, or anyone else finds something in the report worth mentioning, please let me know.

1. Maintain 80-hour workweek. There is no recommendation in the report as some program directors feared limiting resident work hours to 56 hours a week. The cap is however limited to 80 hours a week, which would eliminate averaging. I guess the big change here is that a congressional mandate would be accompanied by stiffer penalties than the RRC can possibly impose. It would also make some efforts to balance rotations a bit more complex, as the strict 80 hour max is currently not the norm at many surgical programs that have residents cover >80 hours some weeks and make up for it during others.

2. Maintain 30 hour shift max. There is no change here, except for the fact that they now want to require a 5-hour mandatory sleep break within the shift if it supercedes 16-hours. This would be the first required nap at any adult job in the history of working in the United States. It also makes it virtually impossible to cover a night call with only one resident.

3. 1-full Day off per week with NO AVERAGING. For those that suddenly found that weekends could exist again as part of the 80 hour work-week, no more. There are no more golden weekends under this report without extra days off (Something hard to give in a system in which there are multiple residents required for each call and residents can't alternate going above and below 80 hours each week. Whereas now some programs have residents alternate weekend call, this system will soon be a thing of the past if the recommendations are implemented.

4. Call no more often than q3. There will be no more q2 call even for a small stretch. This means that you cannot alternate q2 call to cover vacations. You also cannot do a Friday-Sunday call to give another resident a weekend off.

5. No more than 4 night shifts in a row. Of all the recommendations, this really makes the least sense. The obvious adaptation to all of the above call requirements is to establish a night float. This would only be possible under the recommendations by having people switch onto and off of the night float every few days, making establishing a circadian rhythm impossible.

6. Interns can't be the only MD in-house. This is really ridiculous, as many hospitals currently have no physician in house. In other words, it is legal to have the intern go home, leaving no one in-house, but it would be illegal for him to stay alone. It also makes the call schedule even harder, as junior call interns couldn't cover a potential nap break for the senior residents in a junior-senior joint call system to adapt to the required nap under the new recommendations.

There are some more, but they're escaping me at the moment. Feel free to post them.

Why are we here?

For those of us in the trenches, this really makes no sense on so many levels. I am going to be the resident who should theoretically be receiving the benefit of these work-hour restrictions. By continuing to have 80 hours weeks with a bunch of crazy rules implemented on top of them, compliance costs will go through the roof, AND it will do nothing to solve resident fatigue. There is no evidence base for any of these changes. Why would we even consider implementing these changes as a requirement for every program with no reason to believe that they will work? Again, this smells an awful lot like what happens when we start to dismantle the free market.

Medical licensing is a hot-button issue to bring up in some groups, so I will not go all the way back to that point in terms of market intervention. If we assume that the government should require some minimal level of proficiency in order to practice medicine, then we have to question how that level should be obtained. In other professions with similar requirements, the usual course of action is to have a some degree of professional schooling as a primary requirement. This is the case in every profession from law to architecture. After these different types of schooling, there is usually a state sponsored exam. The bar exam might be an example of this. There is some variability between states and professions, but the concept is the same. This is also true in medicine with the USMLEs, which every state has now simply adopted as its state licensing exam.

After this, certain professions require different things. Most people agree that hanging a shingle immediately after school is complex. In law, this is legal but relatively rare. Most people will go work for a firm, where they will get real world experience. The firm can be a solo attorney or a Devil's Advocate styled enterprise. Nevertheless, it is not formalized. The formal background is found in the schooling itself, and everything thereafter is variable, creating a vibrant heterogenous market. Pay ranges are wide, with some new associates demanding >$100k/year and some receiving $25k. People migrate towards positions that meet their needs for work, pay, hours, training, environment, location, etc... Everyone is a potential employer and a potential trainer.

In medicine of course, we have a formalized residency requirement. Without belaboring the entire history of residency training, some of the following things are true:
1. Every physician who wants a license has to complete somewhere between 1-3 years of formal residency depending on the state.
2. Every physician who wants to specialize must for the most part fit his interests into a series of predefined specialties that require anywhere from 3-10 years of formal training depending on the specialty
3. The government funds almost all of these positions through Medicare
4. Residents receive a surprisingly similar percentage of this money at most programs, with almost all salaries falling between $40k and $60k depending on location, specialty, and post-graduate year.

This set-up is why we are currently dealing with the IOM report. The government funds these positions, which gives them excessive amounts of power in regulating them. Work hour restrictions get tricky on a constitutional level when the government isn't funding things. When they are, it's very simple. They can simply take the money away.

It is also very clear that different people want different things from their post-graduate training. Some people like to work hard and often. Others have different priorities. Different people have different tolerances for stress, labor, sleep-deprivation, etc... Yet every program is regulated to be similar.

As an attorney looking for a niche, let's say tax law, there are a million different ways to fall into the niche. You could get a masters in tax law, you could go work for a big tax firm. You could work for the tax division of a big firm. You could enter a small firm looking to expand into tax law and become the specialist by doing the job. You could hang a shingle. It's all possible. In many ways, the only difference between one of the big firm jobs and a medical residency is that the big firm usually pays better up front with less remote guarantee. However, all of these entities are possible. They are regulated by their ability to get people willing to work in the way that they require, and they are limited by the ability to provide for their clients. A few botched cases, and a big firm doesn't remain as big.

In residency, the only way to change things is to lobby congress. You can't quit easily. You can't find a different training model for your specialty. You can't just go out and work with someone who performs your specialty until you start to feel proficient. One might say that this isn't so bad. I mean, at least we'll set a floor on quality. Close reflection (and the recent IOM report) show what the problem is.

There is no natural adaptation. Residencies functioned until the original RRC changes in nearly the same manner in which they worked 50 years before, with the only major changes being the progressive addition of more years in order to be qualified to do the same thing. The 80-hour work week was the first real new step in 50 years. Normal markets, including those in training programs adapt slowly over time. These changes were abrupt, and rather than being based on mutual preferences, they were imposed from the outside. There was an extremely hetergenous response. Many couldn't or wouldn't adapt at first. Many residents loved it. Many hated it. Many ignored the rules. Many programs made them ignore the rules. Some of the biggest programs in the country went on probation.

Eventually, people mostly adapted to the new rules, but there is no evidence that they've done anything to improve outcomes. Many residents are happy with the changes, but some are certainly not. One must question the decision to force people to work less who want to be more productive. The new restrictions are not based on anything. There is no logic, no evidence, and no real objective standard behind them. However, we are a federally regulated and funded enterprise. Arbitrary rules and compliance are the lot in life of such an entity.

Medicine has evolved over so many years within the system of federal funding and control, that it is hard to see how it would work without it. This doesn't however, mean that it couldn't, Residency would probably have to continue to exist in some form. No one is ready to be a surgeon at the end of medical school, but the rules would have to be different. That may not be so bad. We might eliminate some the conflicts that we have now, where a PA straight out of school can bill as a first-assist on an operation where a chief resident with over 1000 cases cannot. We might change the system in which it costs more money to hire a secretary to do scut work than an intern. Many programs are dedicated to training, but the natural evolution of a training system would slowly lead to a proper balance between training, service, and the reimbursement that is proper to achieve those balances. Service could be exchanged for teaching, and resident reimbursement could be based on what they actually produce. Some could forego residency, though hospital credentialing for all but the most simple practice would require some demonstrated competency, setting a natural floor on the system.

That was probably a long incoherent ramble. Whatever the case, I am scared. As a new trainee, I know that the system is flawed, but it does produce competent physicians in large part. If implemented, these new rules will hit hard. Because we've let ourselves become beggars at the foot of congress, we are essentially powerless to stop them.