Single-payer advocates are painfully learning about the basic conservatism of
A key unasked question in today's constricted debate is whether any new law will strengthen or weaken physicians, a group that has saved so many lives while running up a bill that many believe is unaffordable. So we see nothing that matches the audacity of the century-old Flexner report that successfully put physicians in the driver's seat. While this boost for academic medicine elevated the role of science, it also (as Paul Starr reports in Social Transformation of American Medicine) marginalized other players who tended to offer cheaper alternatives. Doubtless this raised the level of care, but it also forced out many low-cost providers who had been useful.
A review of that decision would be an appropriate issue in today's debate about constraining costs. But no one has raised the question. In fact, while the ratio between physicians and patients keeps shrinking, there are persistent threats of a doctor shortage - this despite evidence indicating unsurprisingly that a larger doctor supply leads to bigger total bills.
Instead, today's debate dances around some crucial facts, one of which is that, unsurprisingly, a minority of sick people run up most medical bills. The shorthand is that the 20% of people with chronic diseases are responsible for 80% of the charges. That suggests a focus on the sick 20% that would reduce the number of people joining this expensive group and becoming very efficient at treating those who do - a not illogical course when four or five diseases have become virtual money pits.
What would a system look like that essentially reserved doctors for people who were already certifiably sick--beyond the obvious result of cutting costs which would be good news for patients, but bad news for doctors? Rather than worrying about Americans who lack easy access to physicians, it would focus on making access more difficult, reserving medical expertise to those who clearly had medical problems.
We're not talking about
Contrary to myth, one reason for rising demand is that people are more impatient, reflected by the fact that the average emergency room complaint is becoming less severe. Unfortunately, we've yet to reach a point where we authorize the triage nurse to say: "Despite your discomfort level, your problem will place you at the tail of the queue and it may be eight hours before a doctor will see you. You might be more comfortable going home, taking an aspirin and trying to sleep it away. If that doesn't work, you can always come back."
Why don't triage nurses say that?
Their cousins who work in pediatricians offices often do, fielding calls from worried parents, telling some to come in immediately, scheduling others for later and telling a not insignificant number of callers that their child has an ailment that seems to be going around that typically disappears within 36 hours, a polite version of "take two aspirin and call tomorrow morning if it still hurts."
One step in this direction has been the creation of walk-in clinics by drugstore chains and big box retailers like Wal-Mart. They are generally staffed by nurses or others who are less educated and expensive than physicians, but adequately trained to deal with common problems.
Nor surprisingly, the reaction of the physician community has been wary at best, echoing the obstacle course faced in years past by independent midwives. The deregulation that whipped through telecommunications, financial and travel planning has yet to seriously challenge the medical establishment.
When we discuss our suboptimal legal system, someone's always quick to say, semi-facetiously, "first, let's kill all the lawyers." But when medicine's the topic, we take a very different approach that successfully constricts the debate.
Maybe doctors are just smarter than lawyers.