Good post, Ezra. Libertarians are so ... ignorant of the real world that it is breathtaking. As if there is -- or could be -- a "Consumer Reports" for doctors.

Doctors go to school for years and years and years; patients are supposed to have the same level of knowledge to be able to weigh alternatives?

Good points!

It's also been a pet peeve of mine that libertarian economic analysis neglects invariably seems to neglect the costs of consumer research and education. Learning the ins and outs of different hip replacement strategies or heart disease treatments takes a huge investment in time and energy.

It's my impression that when you unpack "I want to be able to choose my own doctor", you find inside it "I don't want to be told that my current doctor is not inside the network, because I have no idea how to go about choosing a new one, and so the prospect frightens me"

Gore/Edwards 08:
I know it is easy pickings, but I always wondered how someone like McMegan could be so stupid. When ever I read her blog, I just shake my head. I am glad people like Ezra are around to set people like McMegan straight.

Ezra: Exactly Right
You've just stated what I've been saying for years to those who put up with my rants.
I'm a doctor (MD and PhD), and it's long ago struck me as absurd the notion that applying market forces and solutions to medicine will not work. Indeed, buying a Chevy and buying grandma's subspecialist heart care are utterly dissimilar activities. The psychology is utterly different. People "buying" health care (another term of acquisition is needed) are often irrational, and justifiably so.

From my POV, the greatest impediment to my patients' access to care is NOT their (lack of) informed thinking about the choices in front of them, but rather the vastly more difficult blockade put up by their insurance companies. Over and over, I will prescribe what I feel is the most appropriate, effective medicine - only to meet the obstruction that it is not covered on the insurance company's formulary - resulting in a tremendous time drain of faxes seeking an exception - which is of course inevitably denied. We then settle - often weeks later, on (an often inferior) related drug that the insurer will pay for. It's infuriating, a deliberate blockade to care (and the cost inherent) it's deviously effective and it must end.

It’s always funny to watch a band of clueless people berate others as clueless. Progressives’ inability to comprehend our current system, or common sense continually leaves you making foolish post like this.

Of the roughly 300+ million Americans how many have a hip replacement, heart attack, or need Chemo in a year? A very small percentage. There is a common ratio known by all those educated in our Healthcare System, the 80 20 rules. 80% of the plan participants will have 20% of the cost. That means 80% of the insured population has nothing more complex to decide then picking which drug to use, brand or generic, to take a day off and recover or go to work, or other decisions easily researched and understood by anyone with a HS education.

Our Healthcare system and Insurance handles the large stuff very well, we know how many people in a thousand will get cancer or have a heart attack. We can predict those and provide those individuals with the additional help they need. What has been skyrocketing cost is utilization and drugs. It’s the poor decisions of the casual every day user that is breaking the system not the large diagnosis your trying to scare us with.

Ezra and other clueless Progressives aren’t advocating reengineering our catastrophic claims system they want to destroy the whole thing. In all of their proposals they completely fail to address what is the underlying problem in the first place, people consuming care they don’t need. Picking a brand or generic antibiotic is very much like picking a TV. One with a liberal return policy at that. If the generic doesn’t work 30 days later you take it back and try a new one. It’s also a fact a large number of prescriptions could be avoided all together if people changed their diet, exercised, or took other action that would have no cost on the healthcare system. Are you claiming, Ezra, Americans are incapable of getting off the sofa and exercising or eating a healthier diet so we need government regulation?

Patient knowledge and cost sharing alone could cut a huge chuck out of our spending, look at any of the reports on wasted care.

Liberal Scientist would you care to even mention how much Pharma spends on marketing to Doctors? Aren’t their laws strictly forbidding certain common practices your ilk engaged in because it was found you prescribed medicine based on your gifts and not the patients needs? We evil claims payors use to leave the care decisions strictly to the patient and their provider and you went hog wild robbing the bank. Your right it is not any business of a patient what decisions they make with their provider, but if your asking a third party to pick up the bill then they have every right to question it. We could go back to people pay their own bills then request reimbursement, that system worked very well, but doctors hate it because then your justify your charges and pratices to the patients. It’s much easier to bill $200 for 15 minutes of your time with the patient never sees the bill. Our system today is a direct result of provider abuse in the late 80s. Take responsibility then propose a solution.

Our need for coronary bypass surgery is not like our desire for a Viking stove top.

Although the two may nevertheless be linked, depending on what you cook on that Viking stove top.

Medicine is also the only marketplace in which the consumer neither makes the ultimate decision, nor, for the majority insured population, pays the bill.

The patient doesn't decide which hospital to be admitted to -- that depends on which hospital(s) the doctor is credentialed at and which hospital(s) the insurnace company contracts with. If the patient's perfect information were to lead them to another choice -- tough luck.

And perfect pricing information is of little concern to the patient if their insurance company is paying the bill.

Nate says: “Picking a brand or generic antibiotic is very much like picking a TV. One with a liberal return policy at that. If the generic doesn’t work 30 days later you take it back and try a new one.”

This is so breath-takingly stupid that I wonder if Nate really believes what he said or is just ignorant.

I take Vytorin, which retails about $3 a pill or about $90 per month. (I'm in generally excellent health, I eat a low-fat diet and exercise regularly, but genetics caught up with me at age 67, and I needed an operation for a partially blocked carotid artery. However, my mother lived to 89, so I'm planning my finances accordingly.)

Last month a study found that Vytorin appears to offer no more benefit than a generic alternative that retails for less than $1 per pill. A much larger trial will not be published until 2010.

So, would I do as Nate suggests and save myself and my insurer money by trying the generic (after all “If the generic doesn’t work 30 days later you take it back and try a new one”).

How would I know if it “worked” (leaving aside the “30 days” idiocy)? If I have a stroke? If nothing bad happens this year? Next year? What if the big study finds in 2010 that the smaller study was wrong and Vytorin is really superior to the generic? I suppose if I were still alive in 2010 after switching to the generic, Nate would take that as evidence for his notions for choosing health care. But do I really want to take that gamble to help out my insurance company and help reduce national expenditures for health care?

My family doctor is extremely highly regarded by his specialist peers, but I'm guessing he won't know how to advise me on whether to continue with Vytorin. After all, the academic researchers are a bit baffled by the results of the recent study.

So for me it really isn't like “picking a TV.”

Bob--while Nate's comments are, as you put it, breathtakingly stupid, it's probably not a good idea to wholly dismiss the idea of saving money. Or, actually, it's a breathtakingly stupid thing to do.

Excessive health care spending--including prescriptions for brand name drugs when generics would be statistically just as good and much more cost effective--really is an enormous problem. The fact that per capita spending on health care totals $7,000 or so does actually price a lot of people out of insurance. For every dollar an insurer--public, private, for-profit, non-profit, it doesn't matter--spends on an unnecessary or unnecessarily expensive treatment, it needs to get that dollar back from healthy people paying premiums (or taxes.) And since, depending on the estimates 20-30 percent of health care spending is unnecessary, you're talking about collecting a lot of extra money from a lot of people who can't afford it to fund treatments that may or may not be useful.

(Incidentally, I'm not commenting on your particular situation--but to simply dismiss cost effectiveness concerns out of hand is ridiculous.)

I know when I was in the emergency room with my roommate last year and we specifically asked how much a procedure would be - they wouldn't tell us and said not to worry about anything other than getting better. How are you supposed to be informed if you can't get the information? This stupid line of "if only patients were smarter" is a bunch of b.s. and shows that people really have no idea how the system works - every single insurance company or self-insuring companies works out different prices with different hospitals and doctors for every single procedure. The people that you get the care from DON'T know how much a procedure is being billed at because it differs depending on your type of insurance or lack thereof. Now if everyone knew that a hip replacement was $30K and we had a listing of how good each doctor, nurse, and technician working in a particular hospital are in regards to hip replacements - then we would be able to make a good decision as a patient - as long as we are able to postpone our care until our research is done and the replacement is not an emergency, but being properly educated about health care procedures and how much they cost is an impossibility based on the system we have today.

Bob,

I could go into a long explanation of why you’re wrong but I’ll keep it simple in a way everyone can understand. Vioxx, look at what the studies said and what doctors told their patients even after it was proven to be dangerous. How many of those patients do you think now wish, or the family if it killed them, that they stuck with the cheap alternative ibuprofen? If you knew the first thing about Health Care as a whole, there are very few exceptions to this, new drugs don’t perform any better then what we had 10 to 20 years ago. Most new drugs are worthless and seldom ever worth the added cost. Take away convenience, i.e. time release, compounded, gel coated, and there is no benefit.

Only thing breath-takingly stupid is questioning me when you have so little knowledge of what we are debating. Of the thousands of drugs out there a small percent don’t have a safe generic equivalent.

In response to Nate, while it is true that the majority of drugs have perfectly good generic versions, most people don't have the time to parse drug reports. And the drug companies rely on this ignorance to keep their profits up.

More importantly, the flip side of the 80 20 rule is that 80% of our overall health care costs result from 20% of participants. If over-utilization is occuring in the other 80% of patients (and I imagine it is) it isn't effecting more than 20% of those total costs. That's not a very big dent. The problems come from those "large diagnosis" - the unusual, specialized and catastrophic stuff. Neither patient over-utilization nor solutions based on consumer empowerment are really relevant to those matters.

"Picking a brand or generic antibiotic is very much like picking a TV. One with a liberal return policy at that. If the generic doesn’t work 30 days later you take it back and try a new one."

I just hope my insurance covers the surgery I'll need to fix my jaw, which shattered from hitting the ground at high speed after reading the above quote.

See, lifestyle changes really do help - stop reading Nate, consume less healthcare!

Nate - I can only assume you have never had to make decision about treatment that was potentially life-saving (or -threatening).

My family physician prescribed the Vytorin because he was very concerned about my condition and wanted to effect the most aggressive reduction of arterial plaque to prevent stroke. Based on the medical literature a year ago(which I checked after he prescribed it), Vytorin was thought to be a more effective treatment than the generic alternatives. In fact, that's apparently why the recent report that Vytorin isn't more effective has caused some consternation among researchers.

As I said, I have discovered from visiting specialists that my family doc is very highly regarded for his knowledge and thoroughness. Very subjectively (but based on observing my mother's and wife's many family docs and specialists over the past 30 years), I'd guess that my doc is among the top 10% of family practitioners.

So, Nate, would I be wise or foolish to substitute my knowledge and judgment for the doc's in choosing the drug?

And to partially answer Brad's response, would I as an individual be wise or foolish to attempt to help our nation address its health care costs crisis by choosing a less-expensive generic, especially since I have excellent insurance coverage and can easily afford the co-pay? (I fully agree with Brad's point that as a nation we need to examine all ways to reduce costs.)

My questions answer themselves -- we laypersons are not well positioned to make informed judgments about treatment when even the experts are not always right, and while individuals can take steps to improve their own health, systemic change -- such as Ezra and others have been describing -- will be far more effective in improving the nation's health and bottom line.

Ezra has never proposed any specific changes that would make any meaningful improvement in our health or cost of the current system. He proposes generic solutions to broad issues. He attacks the boogeymen like a politician without substance. Name any proposed reform and how you would implement it and I'll show you they are worthless.

Name any proposed reform and how you would implement it and I'll show you they are worthless.

Wow, any reform implemented any way would be worthless? I believe this is the first time that I've ever read that the US healthcare. system is in fact completely perfect and there is absolutely no way to improve it at all. Nate, you are certainly a contrarian. Or, at least, you are clearly demonstrating that you've already chosen your conclusion and are willing to pick any argument necessary to support it

I posted a comment here that was rejected and lost.

Ezra is asking the wrong question. He's talking about patients shopping for providers, treatments and drugs, which is a straw man. The real question is, do consumers shop for insurers and policies when they have financial incentives to do so?

And, of course, the answer is, yes, consumers shop for HSAs, individual policies, and employers who offer the best health plans.

Under Medicare, Medicaid, VA health care and other socialized medicine schemes, consumers have little or no financial incentives to shop for insurers or policies, and they don't.

Jonathan Dursi,

you didn't read anything close to saying our system was perfect. What you read was Ezra has never proposed a reform that would accomplish anything meaningful and I challenged Bob to name one that would.

I have named a dozen reforms on this blog that would have meaningful reform and further provided actual details about how to implement them so they worked and what to watch out for.

If you care to have an actual discussion about reforming our system then get specific and lets do it. Other wise your just blowing hot air and advancing global warming.

Nate said "What you read was Ezra has never proposed a reform that would accomplish anything meaningful and I challenged Bob to name one that would."

Here's one that I think would improve patient care dramatically and probably reduce costs.

I'm working from memory because the the Prospect's archives don't have Ezra's articles on the VA as a potential example of how to do things better.

But I recall Ezra pointed to the VA's digitized medical record system -- so a vet's records are available at any center he or she happens to visit -- as a potentially potent improvement for a national health care system. A related advantage is having prescriptions digitized so that handwriting doesn't result in errors.

I regularly ask vets about their experience with the VA health care (I'm a vet but I've never needed to use the VA because I have had few health problems and excellent insurance).

The responses are mixed, but the problems cited -- mostly long waits for routine care -- are inevitably caused by inadequate funding. I've never heard a vet complain that their records weren't available when visiting a new doc.

Incidentally, my family doc uses software that consolidates all my medical data (for example, reports from labs and specialists) and he gives me a print after each visit which covers everything we've discussed and all of his observations and recommendations for future treatment, plus all the lab and specialists results.

Now that's patient education!

So, Nate, doesn't that help?

Bob,

That is a great start to a discussion but it's not reform. What you mentioned is a result. Ezra and Progressives are great at suggesting results but the devil is in how you achieve them. Digital Medical records, UHC, Lower HC as % of GDP are all generic goals, what all the reform proposals to date lack are plans to get there. It's in these shadows that government is the most dangerous. Using your digital medical records as an example, because I agree that is a result we need to achieve, you have the following questions;

1. Private or Public control. The easiest solution if Congress mandated Digital Medical Records(DMR) would be for the Federal Government to control them. This would scare the crap out of a lot of people and likely have no opt out provision. A more amendable approach would be for private companies, like is already happening, to control DMRs. But then this raises the issue of common standards, access, portability, and cost. Who will pay to maintain these records? Well off people might see the advantages and potential health benefits but those that are living pay check to paycheck aren't going to pay $10 let alone $100. There will also be a large population of Tin Hats that refuse to be part of any DMRs, possibly creating an underground health system for people looking to duck the tracking.

2. Privacy would be of a concern, if you’re a criminal and get shot or stabbed while killing someone if you know the government can quickly scan the central database for everyone treated for that within 100 miles it will effect your actions. Privacy in general will be a great concern. If you’re the First Man and catch something from banging interns do you want your antibiotic treatments saved in your DMR? No you want some pills on the sly and no record it every happened, short of a stained dress not many more obvious ways to get caught. Would courts allow contents to be subpoenaed? What about in cases of rape? We aren’t far from being able to sequence DNA for every person quickly, will that identifier be part of your record?

3. Cost - it will cost billions to implement such a system, I personally think it will pay for itself many times over but who pays up front. My business, TPA claims payor, gets hit with mandates like this every year, we had to pay for EDI for example. Providers will cry poverty though and expect someone else to foot the bill, even though it will surely save them money and pay for itself in a matter of years.

4. Mandatory or not, as I mentioned above will people be forced to have DMR or not? If not then you haven't simplified the system your now running a paper system and digital. If you do require it then you have a whole set of other concerns.

This is a quick and non thought out response but I think it illustrates the point anyone can say we need DRMs but that is meaningless if you don't have the proposal to achieve it. In that manner of reasoning I say every reform I have seen Ezra mention is intellectually cowardly. He's selling promises and propaganda with no effort or intention on delivering them. Typical politics, standing on stage promising to make everyone’s life better with no sacrifice. He’ll tell you what ever you want to hear even though none of it can be delivered like they claim.

Take the discussion you and I just started, go back and forth 50 times include a score of other people and we might have a “reform” proposal in a couple months. And that is just for one minor aspect of it, but that is exactly what is required to actually achieve something that will work. If your just trying to win an election then you say DMR for all and count the votes. Are you interested in HC reform for the votes or to really improve our system? I want to fix our system and make it the best in the world, that will never happen with Progressives pimping the issue every 12 years trying to win elections.

Nate - You've provided a serious response so I owe you a reply in kind. Please do not take the brevity of my reply as a brush off.

It's just that you've described a stage of the process toward a more rational and efficient system that goes way beyond either my experience or the type of discussion we have here on Ezra's blog.

I would be very surprised if there were not highly detailed (and probably highly contentious) discussions of the sort you ask for among health and privacy policy wonks.

I know it's an absolutely necessary discussion at some point, but it's not one that I'm willing or able to enter into now.

But I fully agree with you that someone needs to be thinking about your questions now because we will all soon need to consider them.

Bob,

Remember Nate is an insurance provider. His evidence and his calling us all idiots is based purely on his own self-survival. I would take it all with a large grain of salt (sodium-free, or course!).

The insurance companies always squawk about how many people they enroll and how that 'huge' number gives them leverage for paying less to providers and passing that savings on to you. For my own self-survival, the best insurance for me would be one that included every person in this country, insurance that was provided without attachment to my current job, and one that will negotiate costs based on the leverage of the 300 million people in that pool. The problem with this plan is that it likely leaves Nate looking for a job. I imagine Nate has made out quite well in his years in the insurance game and likely will retire with all sorts of nice benefits, while if I lose my job I'll be lucky to afford to self-insure if I don't find a new job quickly that covers me.

Hi Bob,

I actually appreciate you reply, I think it's one more people need to think on. Are you certain some where along the line someone does know the answer to these questions? Most people don't know how laws are written or enacted. Healthcare and insurance in particular has had terrible problems with the way legislation happens.

Congress doesn’t pass specific laws, there more like outcomes. For example HIPAA and COBRA where passed years ago. We are still getting “interpretations”, opinion letters and revenue rulings defining the law. Do you have any idea how hard it is to comply with a law that isn’t written yet. This is why the claims that government run plans are more efficient are a joke. DOL, IRA, and Congressional staff interrupt the law as written then write guidance. Using DMRs for an example Congress would pass a general law saying everyone will use DRMs then leave it up to staff to determine how it is implemented and achieved. Your not relying on people with experience in the field or even the consensus of public debate, bureaucrats literally write the law. Are you comfortable with some nameless bureaucrat with no accountability defining the future of our healthcare system?

I experienced a specific example of this around 10 years ago. We had the majority of community hospitals in NV as clients. They where isolated, small town only hospital for 100+ miles facilities. They where often one of the largest employers and always struggling financially. They wanted to ban together and self fund their benefits so they could eliminate the insurance company and save money. The state already sponsored a similar plan doing the same thing, a few of these where trying to pull out of that plan because cost had gotten so high. Every time the state plan changed TPAs it was a disaster and they didn’t get claims paid for half a year. The insurance commissioner for political reasons wouldn’t allow them to do it. So we got together the representatives from these small counties and had a special law passed specifically to allow then to pool together and self fund. The insurance commissioner took this law which clearly authorized them to do this, used their oversight powers to interrupt reserve requirements in a fashion that made it impractical to self fund and killed the idea. That’s the power non elected officials have to shape things. These people are neither educated enough nor trustworthy enough to trust with these decisions.

Any reform passed must be done transparently. Precise and defined reforms should be debated in public and only enacted with consensus of the majority. This is too important of a decision to trust blindly to the powers that be. If someone is going to claim DMRs will save lives and reduce cost then they need to explain how we get there. What will happen is Congress will enact the law the common public wants but it won’t delivered what was promised, it never does. That’s part of the reason Congress avoids the details, it insulates them from accountability.

Ricky,

Not much assistance I can provide to someone that refused to learn. I have told you before my job is to put insurance companies as you know them out of business so your entire analysis is off base.

Take a couple minutes and think about this, SS disability is a single payor almost universal system and it is a nightmare. They deny the majority of their claims, it takes years to get claims settled, cost are out of hand and service is terrible. Millions of people need to hire an attorney just to navigate the system. UHC like you yearn for has no accountability, none of the goals you claim would result would ever be achieved.

I think it's a shame that the "you can't expect people to shop around for healthcare during a heart attack" argument is continually propagated. Libertarians have never argued that patients should comparison shop for emergency care. They do argue that market forces should be allowed to increase consumer input into how care is distributed and which services are offered under the given insurance plans. i.e. I don't comparison shop when I'm dying of thirst on a hot day, but I do benefit from the market forces that have driven the cost of bottled water down, and, if allowed to, I will generally plan ahead in ways that allow me to efficiently hydrate. Same thing with health insurance. Consumers need more info and more control to force the insurance companies and hospitals to improve quality and transparency, not to make on-the-spot decisions, as Ezra claims.