Economics on the small scale

Tuesday, April 18, 2006

Medical Care In America

Let's compare and contrast:

From Dr Brewer:
It took me a while to conclude that a single-payer health system was the best approach. My fear had been that government would screw up medicine to the detriment of my patients and my practice. If done poorly, the result might be worse than what I'm dealing with now.
Doctors in private practice fear a loss of autonomy with a single-payer system. After being in the private practice of family medicine for 8 1/2 years, I see that autonomy is largely an illusion. Through Medicare and Medicaid, the government is already writing its own rules for 45% of the patients I see.

The rest are privately insured under 301 different insurance products (my staff and I counted). The companies set the fees and the contracts are largely non-negotiable by individual doctors.

The amount of time, staff costs and IT overhead associated with keeping track of all those plans eats up most of the money we make above Medicare rates. As it is now, I see patients and wait between 30 and 90 days to get paid.
There are powerful forces that oppose a single-payer system -- the health insurance industry for one. The insurance industry got its share of the Medicare drug benefit pie, as did the pharma industry. It would have been better and simpler for the government to design one plan with a standard drug fee schedule that everyone could understand, as the government does with care that doctors provide to Medicare patients. But that's not the way it happened.

Doctors have been supportive of the idea of universal access to care, but not necessarily a single-payer system. Some fear delays in obtaining necessary testing and surgeries. What I suspect they fear most is a loss of income and the fear of the unknown.

A single-payer system would admittedly lower fees for subspecialty care, such as radiology and cardiology. But if more doctors went into family medicine or obstetrics and fewer into subspecialties like plastic surgery, that shift might help correct the physician manpower imbalances that exist now. That wouldn't necessarily break my heart.

I suspect doctors would be more likely to support a single-payer system if national malpractice reform was part of the package -- which it should be.

I used to think a single-payer system would keep my income down and inject bureaucracy into my medical decision-making. But with the efficiency it could bring, it would at worst be an economic wash; more likely, the trimmed costs would more than make up for any foregone revenue. As for autonomy, I'm already struggling to maintain it amid the interference of insurers.

Melanie suggested a comparison with Costa Rica:
For a country not usually thought of as a fully developed nation, Costa Rica's lack of a standing army and its historical commitment to the social and educational welfare of its citizens have provided the foundation for a "highly developed medical system, internationally speaking" asserted plastic surgeon Dr. Arnoldo Fournier. He continued, "It's not the surgeons who have provided this, but the entire history of our country that gives us this advantage."

Dr. Logino Soto Pacheco, Chief of Surgery at Hospital Mexico, premier cardiac surgeon in Costa Rica and one of the foremost in the world, claims that Costa Rica is unique in its world position in health care. "I have studied every health care system in the Americas, and I can assure you that nowhere else can compare to what Costa Rica offers its citizens," he stated emphatically. Who would doubt these words from the man who assembled the Costa Rican surgical team which performed the first successful heart transplant in Latin America.

With a government-sponsored network of 29 hospitals and more than 250 clinics throughout the country, the Caja Costarricense de Seguro Social (CCSS) has primary responsibility for providing low cost health services to the Costa Rican populace. Though presently somewhat overburdened, like most of the Costa Rican infrastructure, this system has worked well for Costa Ricans for the past 50 or so years. Open not just to Ticos, the CCSS provides affordable medical service to any foreign resident or visitor. Foreigners living in Costa Rica can join the CCSS by paying a small monthly fee--based on their income-- or they can buy health insurance from the State monopoly Instituto de Seguro Nacional (INS) valid with over 200 affiliated doctors, hospitals, labs and pharmacies in the private sector.

Now, I don't really trust her link, so let's cross-compare using World Health Organization data

Costa RicaUSA

Total population: 4,173,000

GDP per capita (Intl $, 2002): 7,966

Life expectancy at birth m/f (years): 75.0/80.0

Healthy life expectancy at birth m/f (years, 2002): 65.2/69.3

Child mortality m/f (per 1000): 11/9

Adult mortality m/f (per 1000): 129/76

Total health expenditure per capita (Intl $, 2002): 743

Total health expenditure as % of GDP (2002): 9.3

Figures are for 2003 unless indicated. Source: The world health report 2005


Total population: 294,043,000

GDP per capita (Intl $, 2002): 36,056

Life expectancy at birth m/f (years): 75.0/80.0

Healthy life expectancy at birth m/f (years, 2002): 67.2/71.3

Child mortality m/f (per 1000): 9/7

Adult mortality m/f (per 1000): 139/82

Total health expenditure per capita (Intl $, 2002): 5,274

Total health expenditure as % of GDP (2002): 14.6

Figures are for 2003 unless indicated. Source: The world health report 2005

To summarize: a tropical country that is not typically considered fully developped has a health care system that's measurably nearly as good as the U.S.A's hodge-podge health-care, and they're doing to it using a third less GDP per capita.


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