More on Why Seeing a Doctor is so Damn $$$

Washington Post columnist Robert Samuelson writes to the point today about the key issue behind uncontrollable and unsustainable health care costs. I used to think this problem was too complex and multi-factorial to really boil down to a single evil cause. But my attitude about that is changing. It is multifactorial and complex, but I think the primary driving force for health care costs in the US is, simply put, over consumption of health care resources. It's not rocket science.

We have gone far beyond a reasonable saturation point of return on investment on health care dollars. Best evidence tells us that if you have a healthy colon and no risk factors for colon cancer that after the age of 50 you are fine with 1 colonoscopy every 10 years. But our system behaves by ignoring medical evidence and fiscal sense and gives colonoscopies whenever there is the slightess excuse for one. Hey, it can't hurt to be extra careful, right? Peace of mind for the patient and piece of paycheck for the doctor. Over using CT scans or getting hi-tech arthoscopic knee surgery for 80-year old granpa is a of win-win situation for patients and doctors, and that is precisely why, as Samuelson points out, there is little incentive to change the system. Samuelson writes:

We have a health-care system that reflects our national values. It's highly individualistic, entrepreneurial and suspicious of centralized supervision. In practice, Medicare and private insurers impose few effective controls on doctors' and patients' choices. That's the way most Americans want it. Patients understandably desire the most advanced surgeries, diagnostic tests and drugs. Doctors want the freedom to prescribe.

Without thinking too long, here are 4 reasons I can think of why our system has tolerated, even begetted, this dysfunctional and destructive over-use of health care.

1. There is no central oversight to spending, this is, a federal budget that will say no those unreasonable CT scans and knee replacements when they are not indicated by best medical evidence.
   
2. Direct personal financial consequences of over-utilization by patients is minimized by comprehensive health insurance policies; patients paying high premiums are even feeling entitled to over-use so they feel they are getting their money's worth.
   
3. There is a simulacrum of a free-market for patient choice; it is not common practice for patients to shop around for low-cost, high-quality care because costs are opaque and quality data is hard to get, and sometimes patients just don't have a choice period (taken by ambulance to the ER).
   
4. Providers are incentivized by profits that are driven by volume (number of tests/procedures ordered, patients seen) rather than quality of care or health outcomes.

My recommendation to Obama would be to approach the health care problem like education. They are very similar. Tax everyone a modest amount so that there will be health care for everyone, regardless of ability to pay. Getting seen by a doctor is a public benefit, just like education. These two things - producing smart kids and then keeping them healthy - are at the heart of any long-term investment in progress. But like private education, allow people - on their own dime - the right to go to a doctor other than the one provided by the government.