From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: doctors of the nation - unite?
Date: 02 May 1997
Newsgroups: sci.med

In <dgs4.835.0E85D6CA@psu.edu> dgs4@psu.edu (Dennis Shea) writes:

>No, not a non sequitor.  You claim that managed care endangers
patients because managers have a financial incentive to undertreat.  I
claim that unmanaged care endangers patients because physicians have a
financial incentive to overtreat.  There is a total lack of evidence
that either leads to greater potential or actual harm to patients.<

    At last, the voice of reason!  Geez, why is it so rare?

    We need some bigtime randomized studies, and lots of outcomes
research to find out the truth.  That's not such a hard idea, now is
it?

   One of the greatest harms that democracy in general does (and
Federalization in particular) is that it stiffles what are otherwise
very useful social experiments.  Government "policy" is almost always
premature, because almost never does government *TEST* its proposed
social policies before universally implementing them (at the point of a
gun, needless to say).  States don't either, but at least if the Feds
butt out, you can compare state to state.


>As for me, I'd go teach economists.  Don't worry about me.
You DO create adverserial relationships with administrators when you
claim they have no interest in patients, when your holier than thou
attitude impairs your ability to understand the that doing EVERYTHING
for some patient sometimes not only endangers the welfare of other
patients, but also endangers the welfare of that same patient.<

   Sometimes.  Unfortunately not all the time.  In a world of limited
resources (which will always decribe the real world) it's useful to
have some super-organization to put a crimp on expensive treatments
which provide SMALL benefit.  What the best nature of that organization
is, remains to be determined.  One simple method of feedback involves
little organization at all: it's merely a rule requiring that there be
no such thing as a medical treatment with no deductable.  Deductables
enlist the patient (and family's) brains in the very complex question
of risk/benefit/cost in medical treatment.  And the more brains you
have working on a problem, the better you can solve it (parallel
processing).  That's the big lesson of a market economy vs command
economy, but one that we persist in trying to keep from applying in
many situations.


                                         Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: doctors of the nation - unite?
Date: 02 May 1997
Newsgroups: sci.med

In <dgs4.848.10D4C9FA@psu.edu> dgs4@psu.edu (Dennis Shea) writes:

>Third, let me suggest that the threat to patients in the past from
>unmanaged physicians may well have been as great as that of managed care.
>Yet, did we see physicians rise up in outrage over fellow physicians
>over-use of care which endangered patients? Did we see physicians call
>for stricter tort laws and tougher licensure standards to protect
>patients? Did we see daily letters to the editor warning patients about
>the threat to their health from other physicians?
>
>No. The outrage, the hue and cry came ONLY when physician income and
>autonomy was threatened by managed care.
>
>So, excuse me, if I am a bit cynical when collectively or individually
>physicians claim they are only interested in patients.


   Yep.  On the other hand, where is the *institution* more interested
in patients than doctors are?  It surely isn't the government-- if you
want to see how the governments runs a medical system, take a look at
the V.A.s.    If you want to choke on cynicism, take a look at all the
stuff on advanced directives now being pushed by MediCare.  These are
probably in the best interests of the patient, but it's rather strange
that they somehow didn't appear until MediCare needed a way to save
bigtime money.  Same with all the studies these days about how
withdrawal of food and water from dying and semi- or unconscious
patients isn't necessily always inhumane.  This is probably true, but
how come it took so long to figure out, if so?  When the government was
willing to pay for any medical treatment private hospitals want to dish
out, the issue of "compassionate dying" somehow never arose.  Hmmm.  We
doctors certainly didn't push it.


>Year, after year, after year, physicians, individually and collectively
>opposed any government efforts to contain the costs of health care. As
>they sowed, so they reap. They forced the private sector to develop its
>own solution. I don't shed tears for them.


    Me, either.  Except that the doctors who generated the problem are
not the only ones being punished by the attempted cures. I'm a bit
pissed that an earlier generation of doctors generated the problems and
retired, leaving yours truely and the younger physicians having to deal
with the government "solutions."

                                        Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: doctors of the nation - unite?
Date: 04 May 1997
Newsgroups: sci.med

In <dgs4.858.002BA7F3@psu.edu> dgs4@psu.edu (Dennis Shea) writes:

>In article <5kdpl3$hol@sjx-ixn4.ix.netcom.com>
>sbharris@ix.netcom.com(Steven B. Harris) writes:
>
>>    At last, the voice of reason!  Geez, why is it so rare?
>>
>>    We need some bigtime randomized studies, and lots of outcomes
>>research to find out the truth.  That's not such a hard idea, now is
>>it?
>>
>>   One of the greatest harms that democracy in general does (and
>>Federalization in particular) is that it stiffles what are otherwise
>>very useful social experiments.  Government "policy" is almost always
>>premature, because almost never does government *TEST* its proposed
>>social policies before universally implementing them (at the point of a
>>gun, needless to say).  States don't either, but at least if the Feds
>>butt out, you can compare state to state.
>
>I don't know if I'd lay this at democracy's door.  Bigtime randomized social
>experiments are enormously expensive and complicated.  You might check out
>Joseph Newhouse's book "Free for All" on the RAND Health Insurance Experiment.



    Well, look--- such experiments can't be that much more expensive
than simply deciding on social policy and implementing it.  Social
policy is, after all, just an experiment with one treatment group.  If
you have to do the experiment anyway, and have to monitor the results
anyway, adding one more group is not that big a deal.


>While deductibles are useful, there is not much evidence that they (or
>other cost-sharing devices) are any better at eliminating wasteful,
>rather than helpful treatments.


    There's lots of evidence in the case of ER visits.  I cannot
imagine why the same forces would not apply to every other medical
condition.

    I know my own patients give me Hell about stuff they have to pay
for deductibles on.   If nothing else, deductables eliminate the
patient who wants another test just to fix their anxieties.  Generally,
the doctor in that case has to order the MRI and be the foolish guy, or
else refuse and be the bad guy.  If the patient has foot some of the
bill, he's going to be asking how badly he needs this MRI.  And if the
answer is: "not that badly," he's going to HELP me do what needs to be
done anyway.  Which is to wait that back pain out for awhile to see if
it goes away all by itself....

    Deductables seem to save money on drugs, too.  My no-copay
dyspepsia love Prilosec, for instance, and demand it with the most
horrible of wailings that nothing else works.  My cash-pay patients buy
Zantac at the grocery store, and get by.*

                                        Steve Harris, M.D.


* Yes, they've all been treated for H. pylori.