Thursday, August 28, 2008

Incompatible with the profit motive

Both presidential candidates are pushing preventative care to save health care money. A recent paper in the New England Journal of Medicine by Peter Neumann and Joshua Cohen and others at the Tufts Medical Center says not so fast. Yes, something simple as routine blood pressure checking does indeed save money because the test is so cheap and the consequences can be so expensive. But a test such as prostate cancer screening is more expensive and the number of men who actually have prostate cancer is much smaller and there is a very high expense of dealing with a false positive. Childhood immunization? Sorry, that program is so successful we can't get anymore savings through it. Smoking cessation programs? Well, no. People live longer those expensive medical bills just come later in life. Which means in some cases it may be cheaper let a person get sick and to treat the sickness than to keep them healthy. And if you look only at the bottom line it is perhaps cheaper to let a sick person die.

Keep in mind the above discussion is only about money. It is not about longevity and not about quality of life. For example, a smoking cessation program boosts both of those goals. We as a society (and even a species) place a high value on both longevity and quality of life, neither of which can be expressed in dollars.

Which brings me to an idea that has been rolling around in my head for several weeks now: Health care is incompatible with the profit motive.

If a doctor runs a fee-based system, he may get some bucks off you by administering some preventative tests, but his/her money comes when you are sick. The sicker you are, the more cumbersome the treatment, the longer it takes for you to regain your health, the more money the doctor makes. While we're at it, he/she will likely throw in a few extra tests just to be sure. Now, an ethical doctor understands the value of longevity and quality of life and will forego income to see you healthy. One that isn't so ethical faces the prospect that if you don't get healthy fast enough you will turn to another doctor.

If you add medical insurance into the mix it gets worse. The faceless bureaucracy is concerned only with the money and doesn't care so much for longevity and quality of life. They don't see your rosy glow when you return to health. To them your premium may be an asset, but you are a liability, a cost they would like to eliminate or control. While offering some preventative care may reduce that cost, the easiest way to control cost is to not treat you -- don't let you buy insurance from them, deny the claim, cancel coverage, let you stay sick, or (as noted in the study mentioned above) let you die. Even if they treat you it may not be to a complete return to health, but only get you well enough so that you stop bothering them. What keeps that from happening is the possibility that you might hear of their abysmal record and take your premium elsewhere -- if you can. While HMOs (health maintenance organizations) were developed a couple decades back with the idea that if they work to keep you healthy they will spend less on care, actual day-to-day expenses show that not to be the case (or they would still be doing it). Even if you are able to get great care out of the system your own cost and the cost to society goes up because the insurer will insist on that profit.

Republicans claim we should rely on the market for optimal solutions to problems. There are some sectors of our society where we measure success in terms other than profit, such as health and quality of life, and searching for the best solution through the profit motive won't get us what our society values. Health is only the biggest sector where this is true.

The best solution to health care, and probably even the cheapest, is one that gets rid of the need for profit. We have such a system in place, good enough that other countries copy it. It's called Medicare. And we should expand it to include everyone.

Health care is not the only place where the profit motive gets in the way, leading us to solutions that don't match what society values. Here is one example.

There seems to be a push into privatizing all kinds of things, such as highways or toll roads. However, a privately owned toll road can work against what is best for society. The road's owners will fight against competition, such as additional roads that might reduce congestion on their own road (so what if traffic is backed up as long as all those people paid?) or such as mass transit, which would alleviate air pollution.

What other sectors of society should not be run with a profit motive? I'm sure there are more.

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