Monday, August 7, 2017

Failure of the Profit Motive in Driving Good Medical Care (Part 1)

An article of faith among every Republican is the profit motive is the best possible driver of human behavior. From Ayn Rand to Paul Ryan to Mitch McConnell, every deep red Tea Party Republican believes what Ronald Reagan preached, the "9 most scary words in the English language are, 'I'm from the government and I'm here to help."

It's a catchy and absolute simple minded concept, but it's dead wrong when it comes to medical care.

As Alexandre Yersin once observed, when asked why he did not practice medicine--and he was a fabulous physician who discovered the cause and first treatment for bubonic plague--he said, "I simply could never bring myself to say to a patient, 'your money or your life.'"

Examples of this come up daily in every doctor's office, but I'll start with a first installment which occurred at a bar.

I was telling a guy who worked for a major health insurance company about this patient whose father, brother, sister and paternal aunt had all died of colon cancer before the age of 50.  I advised him to have a colonscopy but the insurance company rejected this because he was only 46 years old.  The company official explained the company does not approve or pay for colonoscopy before the age of 50. When I asked why they said the rate of colon cancer deaths does not skyrocket until age 50. The curve of deaths rises abruptly only after that age.
"But this guy does not want to be on the DEATH curve," I pointed out. He wants to get to that polyp with the cancer in the tip of the polyp before the cancer has worked its way down to the wall of the bowel, invaded the lymphatic vessels and blood vessels there and metastasized."
"I don't know of any company which would approve that," my beer drinking insurance guy told me.
"But, tell me," I persisted. "The colonoscopy costs, I don't know, say $2000--overpriced but that's another story--but even at that price it's a lot cheaper than the partial colectomy and the chemotherapy and the radiation therapy you'll be paying for when the disease is finally discovered 5 years from now."
"Ah, that's the rub," my beer guzzler pointed out. "The average customer stays with us 3 years. Then his employer buys his coverage from some other company. By the time that guy arrives with his widely metastatic disease on the doorstep, he'll be some other insurance company's problem."
Insurance Companies Have to Pay Rent, Too

Now this insurance guy is not really a monster. He is doing his job, which is not to save this patient but to protect the profit of the share holders of the insurance company. And if he can spare the cost of the colonoscopy this year, his books look good. That's his mission.

That's the profit motive, pure and simple.

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