Republicans are trying to cut health care spending. But hacking away at Medicaid, weakening coverage requirements and replacing Obamacare’s subsidies with a convoluted tax credit will not deal with the real crisis in American health care.
The Affordable Care Act was misnamed; it should have been called the Access to Unaffordable Care Act. In 2015 health care spending reached $3.2 trillion — $10,000 for every man, woman and child in America. While our health care system is the most expensive in the world by far, on many measures of performance it ranked last out of 11 developed countries, according to a 2014 Commonwealth Fund Report.
But deregulation will not fix it. To the extent that we can call it a market at all, health care is not self-correcting. Instead, it is a colossal network of unaccountable profit centers, the pricing of which has been controlled by medical specialists since the mid-20th century. Neither Republicans nor Democrats have been willing to address this.
Most Americans mistakenly believe that they must see specialists for almost every medical problem. What people don’t know is that specialists essentially determine the services that are covered by insurance, and the prices that may be charged for them.
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Physician specialty groups have created “societies” to provide education, establish clinical guidelines and handle public relations. These range from the Society of Surgical Oncology to the group that represents me and my ear, nose and throat colleagues, the American Academy of Otolaryngology-Head and Neck Surgery. They are also lobbyists, charged with maximizing the incomes of member doctors by influencing pricing decisions made by the Centers for Medicare and Medicaid Services. Those prices become the benchmarks for private health insurance companies, too.
There are so many specialty organizations because each develops authority over a niche market and vigorously guards its turf. Imagine building a house by allowing each workman to do his own thing. The plumber would put a sink in every room. The electrician would install chandeliers on every ceiling. The carpenter would panel every room in luxurious wood. That’s how health care works.
Though they would vigorously deny it, entrepreneurial doctors often treat each patient as an opportunity to make money. Research shows that physicians quickly adapt their treatment choices if the fees they get paid change. But the current payment incentives do more than drive up costs — they can kill people.
Sedated endoscopy, for example, which is used by gastroenterologists to treat conditions like acid reflux and to perform colonoscopies, carries significant risks of adverse effects, including mortality. Joan Rivers’s death from the procedure was not a one-in-a-million complication. Reported death rates vary considerably, but one rigorous study suggests that the death rate is 1 in 9,000. Since approximately 18 million sedated endoscopies are done each year in the United States, “routine endoscopies” may cause 2,000 deaths a year.
And yet, for acid reflux, there is a safer, cheaper and equally accurate procedure available called transnasal endoscopy; unfortunately, doctors rarely employ it, presumably because it doesn’t pay as well.
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