Wednesday, October 22, 2008

Food And Drugs

Two charts from our "less commonly publicized economic data" Dept.
  • Americans receiving food stamp assistance rose to a record 29.05 million persons in July 2008 (latest data available). That's 9% more than a year ago - and that's before the credit crisis started hitting in earnest.
  • People are starting to cut back on drugs - the prescription kind. According to a NY Times article, the number of filled prescriptions has dropped for the first time in at least a decade.

No more comments needed...Ok, just one: don't bet on permagrowth in the medical services sector, either - ageing baby boomer effects notwithstanding.


  1. The foodstamps comment is interesting, in that it is growing during a time of prosperity. Perhaps a policy reflection, more than anything else? I think the more precise way to look at it might be as a % of total population, rather than on a nominal basis.

  2. A little off your basic point but this article pushed one of my buttons…

    Hell, you are correct to point out healthcare spending will not “save our economy” from imminent recession, but you are incorrect if you don’t recognize that within healthcare spending there is a wonderful opportunity for our economy to find savings to rebuild our collective savings-we can easily find resources without having much of a negative impact on people.

    For while this article does a great job pointing to the personal heart wrenching rationing choices people are now faced with as the economy implodes, it does a terrible job pointing out that the patients who are rationing on these medicines are likely to feel very little negative consequences.

    For the key to understanding this article is you need to sort out “the emotional” from “the objective”. And if the patients in this article did not make the rationing choices for themselves, someone else would have to make them for these people (and you get back into that old theoretical question: “is a benign dictator the best form of government?”).

    For while the article did make the following quote:

    …“In some cases, the cutbacks might not hurt, according to Gerard F. Anderson, a health policy expert at Johns Hopkins Bloomberg School of Public Health. “A lot of people think there there’s probably over-prescribing in the United States”

    The author then glossed over this larger point and focused on the emotional side of the issues.

    Remember, a key to savings and spending is that it must be done productively and it is quite clear that US prescription rationing moved over into the realm of fantasy a long time ago.

    In medicine we talk about NNT or number needed to treat which is the number of people doctors need to give a particular medicine to in order that 1 person benefit from that medicine for the indication it is being used for.

    So to give you some kind of perspective: the NNT for aspirin vs. no treatment at all for someone having a heart attack is about 3 (meaning 3 patients much receive aspirin when having a heart attack for 1 to benefit).

    The NNT to get a patient to stop smoking using an intervention where nurses come and educate patients about the dangers of smoking when patients are hospitalized vs. not doing anything at all is somewhere between 225 to -75 (meaning 1 person is MORE likely to CONTINUE smoking if a nursing educator tries to help 225 people with therapy-counseling while the other 225 will not be effected at all by her counseling).

    I won’t even tell you the NNT for current drug and alcohol addiction treatment programs so bad are the numbers.

    Last time I checked, the NNTs for admission to a hospital for someone with "atypical chest pain" and a normal EKG are several thousand (if sudden cardiac death is the outcome one is trying to avoid).

    If we look at the NNTs for the medicines that this article mentions- the “gut wrenching” emotionally ‘tough choices’ they give: Lipitor (for cholesterol), a medicine for Alzheimer’s (brand not given) I think you will find the patients were a little wiser than they at first seem.

    NNT of Lipitor vs. nothing at all for that patient is something like 100

    NNT of Lipitor vs. Lovastatin (which is a generic cousin of Lipitor known under the brand name Mevacor) is 0 (meaning Lovastatin is just as good)

    Lovastatin costs $0.50/pill, Lipitor costs $2.60/pill.

    Guess which one you will get if you are a Kaiser patient or live in the united Kingdom?

    Again these are for pills with an NNT of 100 vs. nothing at all.

    I can’t find the NNT for Aricept (most common medication used to treat Alzheimer’s type dementia in the US) but I know the data is very clear it does not delay the loss of independence

    The NNH (number needed to harm) for Aricept is 8

    Medicine is full numbers like this (it is one of the main reasons healthcare is so expensive in the US but so cheap in England)

    Conclusion- If I were paying out of pocket and I were the patients presented in these articles, I can honestly say I too would also stop taking these medicines myself-- But if I were going to take a statin and was paying for it out of pocket, it would definitely be Lovastatin and NOT Lipitor.

    People just don’t think about this stuff because they get irrational when it comes to healthcare spending + they are usually spending someone else’s money.

    We still can't get away from intelligent choices.

    Sorry to go off topic.

  3. I have been on a campaign to let customers control the cost of medicine, not government.

    Not getting prescriptions, is customer initiated cost control. When you have free care, you are carefree about seeing the doctor -- appointments get made for painful pimples, aching adenoids, touchy toes, and assorted ailments.

    These appointments often crowd out more serious care which can get delayed in a rationed system.
    That happens because a lot of money is wasted providing for gating clinics to sort and ration care -- take two aspirin and call me in the morning.

    What is missing is caring care, which has been eliminated by the high cost of physician and nursing salaries. When I was a child, my parents paid a doctor to come to our home to administer antibiotic. The doctor's salary was in line with the salaries of those he was treating. My parents had neither health insurance, nor were they of means.

    Today physicians are rationed in the name of providing quality physicians, but quality care is missing because of the need tend more patients. Care tends to get randomized behind some large clinic and falls even lower in quality.

    Where many see the future in Canadian socialized medicine, I see the future of US medicine in the Mexican Social Security Hospitals and clinics. Lots of people hanging around, long lines and questionable care.

    More has to be done to make care lower cost in the US to bypass the grip of the huge insurance, pharmaceutical, medical supply, and heathcare industries. Making insurance mandatory and universal only increases costs and lowers quality. Cost controls get thrown out the window, just like we are seeing with $170,000 firefighter, and $140,000 police salaries. Government is unable to control costs in a meaningful manner when it comes to perceived essential services.

  4. print faster, some of what you are saying is true (like: "more needs to be made lower cost" i.e. medical productivity needs improving), while some is simple nonsense (like: "what is missing is caring care" or "Care tends to get randomized behind some large clinic and falls even lower in quality").

    First to 'debunk' you "good old days" myth: Physicians and nurses saw far more patients per hour 50 years ago than they do today (notice the recent trend in California to pass laws MANDATING ratios? Has a certain ring of 1970's Union labor controls doesn't it)- in fact, this reduction in MD productivity has been a primary drivers of increasing cost of care. Over 50% of a physician/nurses time today is spent on 'documentation'- done for a combination of reasons but primarily to 1. Justify reimbursement and 2. defend against medical malpractice claims.

    As for ultra high MD salaries causing our national escalating healthcare cost problem- again nonsense. MD salaries in proportion to the median income today are in no way above historic norms like they were in the 1970's and early 1980's. And while US physician AND nurse salaries are higher than the median salary in most other OECD countries, this is not necessarily the true if you adjusted for 1. higher American productivity and 2. national median GDP. (Canadian doctors make less than American doctors but god forbid they actually work as hard for that lower income- compare productivity and median national income between the groups and you will come up with a VERY different picture than you suggest).

    In fact, now that I think on it, relative to the income of their country's median citizen,
    physicians in countries like Austria, Holland, and sub-specialists in Australia make more relative to the national median income than their American counterparts.

    Further in the US there has been a tremendous negative pressure on physician incomes from physician mid-level extenders in recent years. Physician assistants (PAs) and nurse practitioners (NPs) and have had a tremendous negative impact on physician salaries (especially primary care physicians-internists, pediatricians and family physicians) as they see a larger and larger % of these "low acuity" patients. For those of you who make an appointment to see your doctor and end up seeing his/her PA/NP instead, you know what I am talking about.

    Where this has not been the case is ONLY due to local state laws preventing the use of physician extenders from practicing (has a certain air of familiarity to it? well intentioned government preventing competition in the marketplace).

    As for the loss of "higher quality relationship care" (what you call 'caring' care)- maybe. But having personally witnessed first hand thousands of patients drop one physician for another when their co-pay changed by as little as $10, it suggests that patients didn't value the relationship all that much.

    Care is more expensive (FYI- everywhere in the world FWIW) because:

    1. Technology allows us to do more for people but at much higher costs and with less gains in mortality

    2. A larger and larger % of the population is sick as (sadly) a larger and larger % of the population is older and therefore (again sadly) closer to death.

    Care is particular more expensive in America than anywhere else because we refuse to have a national dialogue on rationing.

    Make no mistake, the ONLY thing that will solve escalating health care costs in ANY country in the world as that country gets older is rationing. We do this worse than anyone else.

    Every other country in the world rations except America (actually we do ration, only it is done covertly and therefore bizarrely).

    America sadly is just far less mature as a culture on this issue that (say) Europeans. I sense it has something to do with the fact that we as a culture do not really recognize the fundamental truth about death. The idea we might dies just seems to go against our national character.

    ... perhaps this is the same national character flaw that prevents us from discussing 'permagrowth'?

    Who knows?

  5. What I find so fascinating about this blog is that I understand what you are saying Hell, without having to resort to a dictionary, whereas almost everybody else is using technocratic jargonese that didn't even exist in the U.S. 30 years ago when I left.
    The commentors also seem to understand each other, whereas I, with a college education and beyond, have no idea of what they are saying.
    Maybe if people in the US tried speaking English, things would get better, without even having to dig into the hard core problems of food stamps and health care.
    And something else, REALLY REALLY basic : numbers will be the end of us. Statistics were invented in the nineteenth century ( a little earlier, I think) in order for governments to CONTROL THEIR POPULATIONS. Seems somehow understandable how all of this has gone so completely out of control, while the number of people employed in security in the western world has totally exploded in the past ten years even...

    For health care : take a look at Moliere's "Malade Imaginaire". It is still extremely timely, even after 400 years.
    And thai, that word "rationing" makes me VERY VERY UNEASY.
    It makes me think very nasty thoughts.
    No-one in France at least would agree with you on this issue, where doctors are much more devoted to their patients, in general, than in the U.S. where "pragmatic" ideology has led to some pretty seamy corner-cutting...
    My apologies in advance if I have understood you incorrectly, but the idea of rationing care (does that really mean what it sounds like i.e. choosing to "save" younger people vs. older people, like ?) really bothers me.
    It confirms for me what I thought this summer : that American society is not on its knees any more, it is quite simply groveling.

  6. Care is already being rationed. The number of doctors and allied professions is currently rationed.

    What I fear is the typical solution to misguided government regulation to provide 2 chickens in every pot ends up with government telling you whether you can eat chicken to deal with the resulting chicken shortages.

    To whit, everyone is bemoaning the results of the Fannie and Freddie failures (and resulting financial mess), calling for more regulation. What is not noticed is that Fannie and Freddie failed precisely because they were a government creation. Government is being called on to fix its own golem (Frankenstein to you movie goers).

    The result of more government meddling in health care will be a monster to take your breath away, just as more meddling in the mortgage and finance industries.

    As for less caring, I have some examples that I cannot cite that have very general application which were stunning to me and have affected my life. Leave it at that.

  7. Debra- I understand words can have unintended implications (especially on an international blog). I am not saying 'deny the elderly care' at all (far from it).

    Perhaps the term "there is better ways we can use (spend) the money" makes you more comfortable than the word rationing does- in the world of health care decision making, they are really the same thing since the implication is one cannot do both.

    As for the bizarre (not uniquely French view) that most other countries (especially France) are somehow more compassionate towards their brethren than are (say) Americans towards their brethren in regards to health care: this is a little like an American telling a Frenchman to use less oil. Just as markets can be irrational, so too can world public opinion.

    Make no mistake, your country rations health care (as health care professionals understand the word's meaning) far more than America does. And the most bizarre aspect of this incorrect notion is its accompanying (incorrect) view that somehow Europeans are more compassionate or moral because they do ration care whereas we do not.

    France: spent $3,159/person on health care in 2004 which was 51.8% as much per person as America spent per person. France spent 10.5% of its GDP on healthcare (which was $29,945/person in 2004) and of that 10.5% GDP: 78.4% of it came from public sources... i.e. approx. $2500/person was spent by the French collective on its fellow citizens- the other $600/person came from people's own private pockets.

    America: Spent $6,102 per person in 2004, spends 15.3% of its GDP ($39,772 per person in 2004) and of that 15.3% GDP: 44.7% came from public sources... i.e approx. $2700/person was spent by the American collective on its fellow citizens ($200 more than you are willing to spend in France)- the other $3375 came from people's own private pockets.

    By these numbers we are more compassionate towards each other than you are (on an absolute basis) and the difference on a % basis is Americans spend 6.8% as a collective while the french spend 8.3% as a collective- 1.5% GDP is a real number to be sure but hardly one to suggest massive differences in morality.

    If you see a country groveling over this kind of difference, I don't even know where to begin. You may see a french physician denying you a treatment option because it is "too expensive" vs. any other way the money is spent WITH A KIND BEDSIDE MANNER as being a superior system (actually I do), but don't kid yourself.

    The differences between our health care systems are the way the money is spent and that is rationing plane and simple (again as any health care practitioner understand the word rationing, meaning we cannot do everything for everyone with the money we have so we need to chose the best options available to 'save the most quality adjusted life' (the way the British do it) as we can with the resources we have).

    print faster- I am sorry for you bad experience.

    I might suggest that regarding government vs. private sector, the issue is really more one of 'good use of money' vs. 'bad use of money' and in this regard it is quite clear that BOTH government and the private sector can spend money badly. I would suggest they BOTH can spend money quite well.

    Health care rationing is coming to America like they have it in France (not entirely a bad thing imo) whether we like it or not. If you are following any of the Democratic policy wonks you will see this is very clear. You might want to look closely at the integrity of the people they are choosing to lead this charge as these individuals decisions will mean literally life and death. Just like the same rationing boards in France in England and other countries also make similar life and death choices all the time (which many of their citizens seem completely oblivious to- Debra's comments as proof).

  8. Thai
    The notion that the amount of money spent is somehow a measure of compassion is anathema.

    There have been long ongoing discussions in the US about the money spent on education and what relation it has to quality of education. Bottom line there is either an inverse relation or at best none. Spending more money does not seem to improve education and may make it worse.

    Similar effects are seen in police and fire. We are now adding to medicine to the same overpaid model that these emergency services offer. Our cities are going bankrupt trying to maintain the horrendous police and fire salary structures. Adding medicine's gasoline to this fire will create an economic catastrophe.

    What medicine needs to do is step back from any government interference or action. I realize that this drastic, but look at medicine before government: doctors would get paid by some and not others. It was a compassionate profession that offered care to everyone whether they paid or not. They just upped the charges to the country club set. Today they up the charges to those insured.

    There is no reason that technology applied to medicine cannot achieve the same cost savings that the PC achieved in computers. If government steps in, there will be little if any technology improvements and there will be no cost savings.

    If you want to see what rationed care does, there are radiologists in Europe that make $150,000 euros per month, work three to four months a year under a national health system. Is this somehow a cost saving? The physicians have a hard time getting rid of their money.

  9. We may be talking past one another. My apologies if we are.

    As for amount = compassion

    I do think we judge each others' compassion by relating it to how deal the compassion is relative to one's resources: if someone truly only has 1 dollar and gives their last dollar to another suffering person- they are giving a lot. If someone has $1,000,000 and gives 1 dollar they are only giving a little (relative to their own resources).

    This is why Oseola McCarty will always be one of my true heroes.

    If you think I saying amount = results, I am not.

    I agree that amount often has little to do with results (isn't this in fact what got us into this financial mess in the first place?). I agree with you when you say amount does not equal results for BOTH education and health care spending (interestingly BOTH educational and health care spending shows 'fractal like' i.e. non-linear patterns, but I have said this too many times here and I am sure people are sick of me saying this).

    If you think I suggesting that rationing can only be done under a socialized system, again I am not.
    In fact I suspect that were US private health care entities allowed to ration like (say) NICE does in the UK, private insurers like Kaiser might do an even better job than (say) most European socialized delivery systems (the productivity of European health care workers can be truly stunning in their inefficiency, as you suggest with your extreme radiologist example (personally I doubt the validity of your statement but I know nothing about European radiologist compensation packages- though I do know a bit about American radiologist compensation packages and they are good but nowhere near that good).

    But make no mistake, no matter how much more productive US delivery systems are with the resources they use (we have hospitalization lengths of stays almost 40% less than some European and Asian countries- though interestingly we are exactly on par with France on this metric), still our delivery efficiency cannot make up for simply "doing nothing"- i.e. rationing- like many European countries get away with (especially the British). It is simply too much of a headwind to overcome.

    FYI- Do you know the British actually published studies comparing the treatment of acute heart attacks with hospitalization vs. simply sending the patient home with 2 aspirin (though to be fair this was a number of years ago). Google it yourself if you do not believe me.

    When cardiac telemetry has an over NNT of over 1000 (it is in fact more expensive per year of life extended than cardiac transplantation), this can be a very hard cost hurdle to overcome. And when the medical malpractice liability for a national rationing policy for someone not placed on telemetry is solely born by one individual (in this case the physician), as opposed to simply being folded into the cost structure of the greater system (like the Scandinavians do), the asymmetric risk issues can be too much for most physicians to tolerate (whereas in Sweden the system simply writes the patient's family a check if they were unlucky enough to be wedded to one of the unlucky 1 in 1000).

    When you say "What medicine needs to do is step back from any government interference or action. I realize that this drastic, but look at medicine before government: doctors would get paid by some and not others"

    My response is: "What in a totally 'free market' system would make the doctors not just simply refuse to care for those who can't pay for their services?"

    I personally think some common set of controls and rules on the system needs to occur. And while a moral private entity could do just as good a job as a moral public entity, it is clear that large numbers of people in this country and abroad seem to only trust people-institutions they either voted for or witnessed being elected in some kind of open public contest.

    While I tend to see this reassurance as an illusion- I am happy to concede the issue if it is important to move off first base.

    As for your analogy with technology- I think it is a good one but that you are misapplying it. Remember that if you are always buying a 'bleeding edge' computer system, you will always be paying top dollar- it is only whgen you buy older systems that the price drops.

    US health care facilities almost always have latest generation CT scanners/MRI's etc... while in Canada it can be quite hard to even find an MRI. Europeans buy second and third generation equipment as a general rule (except for their central flagship facilities).

    ... Of course the real issue is whether an MRI scanner makes 'that much of a difference to the outcome' in the first place. I just saw an unfortunate gentleman Friday who had nearly 10 MRIs over the last 6 years (he had no insurance) and his back was still in tons of pain. The money was spent, it just didn't make any difference (poor guy).

    As for people having a hard time getting rid of their money (whether they are physicians or not)-- now if this were true we would not be in the mess we are in now would we?

    Our problem is not savings (and its alter ego investment), our problem is consumption.

    People love to consume

  10. Thai:

    It's too bad that we didn't really get to discuss this issue during our lunch. But let me interject a couple of points that I think need to be made:

    In regards to Lipitor vs. Lovastatin, how much compensation / incentive to doctors get for prescribing the cheaper Lovastatin vs. the more expensive Lipitor? Certainly drug companies spend money giving doctors "incentives" to prescribe their drugs for a reason.

    France: spent $3,159/person on health care in 2004 which was 51.8% as much per person as America spent per person. France spent 10.5% of its GDP on healthcare (which was $29,945/person in 2004) and of that 10.5% GDP: 78.4% of it came from public sources... i.e. approx. $2500/person was spent by the French collective on its fellow citizens- the other $600/person came from people's own private pockets.

    America: Spent $6,102 per person in 2004, spends 15.3% of its GDP ($39,772 per person in 2004) and of that 15.3% GDP: 44.7% came from public sources... i.e approx. $2700/person was spent by the American collective on its fellow citizens ($200 more than you are willing to spend in France)- the other $3375 came from people's own private pockets.

    As I read this statistics, I get the impression that state-funded health care gets much more efficient results than ones where the patients have to bear more of their own costs. The whole reasoning behind making Americans spend more of their own money for health care is that they will make more rational decisions regarding their health care; but this example above seems to contradict this argument.

  11. Okie- Bingo!

    Patient have absolutely no clue what is good care vs. bad care on any kind of absolute outcome sense- they tend to judge quality of care by things like "the doctor was nice to me" or "the room was clean" or "they spent a lot of time with me".

    And don't get me wrong, these are all nice things and to the extent they improve the trust-relationship between a physician and a patient, they can be very helpful. But I know a great many patients who love their nice doctor and yet knowing what I know I wouldn't send my family to these physicians.

    Maybe I am a little 'bottom line' but I really don't care whether my doctor is nice- I care whether my family lives longer and healthier as a result of the care.

    This is where I strongly agree with the Wonkonians (Democratic policy wonks).

    But I don't think the issue is so much 'state funded' vs. 'private funded' (FWIW, if I had to choose Kaiser over the Veteran's Administration, I would take Kaiser ANY day of the week). It is more the fact that:

    1. You get 80% of your result for 20% of the cost but the next 20% of results (which you never really reach) will cost you 80%.

    2. In the private system we have today, you have to be careful choosing a
    treatment option which is recommended to you when the cost of the treatment represents a large % of a recommending physician's income.

    I am not worried about someone recommending to me a treatment that only pays me a small % of their income (they have a conflict but the pull is not as strong). But if the % incentive becomes large to them, the conflicts of interest simply becomes too great.

    Example: Right now it is the interventional cardiologists who determines if someone needs a cardiac cath- or they get around it by being partners with the non-interventional cardiologist who makes the recommendation to operate and then split income at a partnership level.

    But the truth is smoking cessation AND Lovastatin might be a much cheaper option than angioplasty with equivalent results- both might be 20% better but a lot more expensive (and sadly a lot of people do not stop smoking). See my point...?

    We spend a ton because we chose to intervene a lot and we have a system that allows a financial conflict of interest in whether the procedure should be done or not.

    (but understand any system has this conflict of interest- just like it was int the government's interest to play with CPI numbers, so too if they really felt responsible for paying for everything they would have an incentive to 'fudge' numbers somewhere).

    And on top of all of this the data is so complex and studies are changing recommendations so often, no single doctor can ever stay current. So we rely on 'our experts' tell us their models suggest. And 'yes', there is opportunity for corruption at every level in the system (and believe me, it all does get corrupted periodically, and then it gets fixed).

    So I have come to trust the New England Journal of Medicine (knowing it may periodically lead me astray)

    I trust most of the faculty at Hopkins, UCLA, Stanford, Duke, UCLA, Brigham and Harvard (again knowing the same corruption is just a fact of the system and periodically needs cleaning, etc...)

    One can't be a total nihilist ;-)

    FYI- I have never heard of drug companies paying docs to use Lipitor over Lovastatin. The way they get patients on the drug is they stop by a physician's office and hand the physician ton's of free samples. When a patient is started on a statin for the first time by their doctor, the doctor then says "let me give you a bunch of free samples to start you off'. Doctor looks like a 'good guy', patient leaves the office with a handful of "free goodies" happy as a clam. But of course once the patient has been started on the drug, the drug is rarely changed to a cheaper generic (docs and patients just continue with "what they know works" under the idea "why mess with a good thing"?)

    Since generic manufacturers can afford this and keep costs low, the physician is never given free samples of generics to start their patient on.

    This is the way most drug companies get doctors and patients to use their drugs. Clever hunh?

    Of course, we use this trick to get the uninsured free medicines all the time so it can work both ways (but as a general rule I am not in favor of this system- seem to me better to just say that government will pass a law paying for certain generic medications for anyone with a valid US ID and a prescription).

    Also, the Wal-Mart prescription drug program is truly stunning in how cheap generics now becoming. It does makes the 'too expensive' argument more and more bogus for more and more people.

  12. Thai,

    FYI, I was at a doctor friend's house in the early 90's and saw a gift catalog (large-screen TVs, Caribbean vacations, home gyms, plus less expensive items) on his coffee table but their were no prices on any of the items, only points. I asked him how the points were earned and he told me by writing prescriptions from the sponsoring company, I forget which one. So, yes, it does happen.

  13. And on top of all of this the data is so complex and studies are changing recommendations so often, no single doctor can ever stay current.

    As I have said: society advances through specialization. Medicine, like law, is increasingly becoming specialized. We have fewer doctors who are general practitioners (the same thing is happening in the legal system). Now, that may be due to the fact that GPs don't make near as much money as specialists; but it may be partially due to this fact that you have spelled out above.

  14. Jesus, thai, somewhere in the middle of your post I just stopped reading because it made me SO SO SO ANGRY.
    You haven't read ANY of my previous posts, have you ?
    Or did you even understand what I said about the numbers being the end of us ?
    Must I spell all of it out for you?
    That means, numbers, like percentage points, numbers followed by dollar signs, or preceded by pound signs or in whatever form you want to throw them on paper.
    And your presumption in telling me about the quality of French medical care and throwing "compassion" at me backed up by statistics and more... NUMBERS really infuriates me.
    I have lived in France for over thirty years now.
    I have seen our medical care deteriorate significantly over that time, although nobody over here has yet had the crassness to suggest that women be denied adequate prenatal care (an important INVESTMENT for any society...) as the financial associate of my accountant suggested to me.
    And also, to the best of my knowledge, no French hospital has yet refused to treat emergency patients who arrive without health insurance.
    I HATE EUPHEMISMS TOO, by the way.
    So, I will continue to maintain : the country is groveling these days.
    Even more so if you can blithely throw out such comments in public without feeling ashamed of yourself.

  15. I also hasten to comment that any equivalency between money spent per capita and quality of health care is exceedingly naïve.
    French health care, until it started following the thorny path of the American model, was rated number one by OMS, regardless of the dollar/euro amount spent.
    You should be asking different questions, like, how is it that Americans manage to spend so much money while getting such lousy care ?
    Now, that's an interesting point.

  16. Debra, I understand you don't like numbers-- but since most airplanes I know of would fall out of the sky if they didn't operate on numbers or I would kill patients if I did not pay attention to the number when I pushed a drug in their vein, I am not sure what your point is?

    You have not been in the US for 30 years and you spout that as your supposed examples of how you view the US health care system?

    I see something like 30% of patients with no insurance, I care for uninsured pregnant women literally ever day I work (large numbers of them don't speak English) and you tell me from France how our system works?

    This is not a fantasy blog.

  17. Sorry I spouted off too quickly...
    Good health care and consumerism are not compatible.
    Consumerism leads to pill-popping and doctor popping, and hospital popping too.
    I think that that sums things up pretty well without having to go into the details.
    And, specialisation is an ideological prejudice.
    Even 50 years ago, a clinical exam would have sufficed, without all the expensive rigamorale, if doctors are adequately trained to perform clinical exams, and cutthroat lawyers are not out there waiting to get their claws into patients to urge them to sue.
    Who wants to live to be really old in our society ?
    Not me.
    That's why I'm not eating bio.
    I think I should push over within a reasonable lapse of time to make way for the others.
    But that's my decision : NOT MY DOCTOR's and NOT MY GOVERNMENT'S either.
    Sorry for spouting off ,thai.
    My apologies. But I really was mad...

  18. Debra said "I also hasten to comment that any equivalency between money spent per capita and quality of health care is exceedingly naïve"

    You are not reading my comments or you would have read that I said the same thing.

    I am responding to the idea that we are less compassionate because of our system- this is definitely not true.

    I am suggesting the America needs to ration like French do (the word Triage is French and it is 100s of years old).

    Rationing has been around since the beginning of time.

  19. Thai, please read Theodore Roszak's Where the Wasteland Ends.
    He is much more intelligent than I about just why all the numbers are there when they didn't necessarily have to be.
    As the daughter, wife, and mother of doctors on both sides of the continent (I see that you are a doctor...) I maintain that western medicine is excessively violent and intrusive.
    A consequence of the nature of our entire society, thai.
    And, I like fantasy.
    I think we all should read a lot more fantasy.
    It would help cure our sick souls. : )

  20. Have you ever seen a child with Leukemia cured with modern technology that only a specialist understands? I have. The improvements in pediatric cancers have been truly awe inspiring over the last 30 years.

    So while I don't necessarily disagree with people who have a 'low tech' vision of the world- I care for a large Amish community at one of the hospitals I work in, they are clearly lovely people, are doing fine, and exemplify how technology is not more than a tool to improve one's life- still I for one would not chose their world as my own where I have a vote.

  21. @Okie- Personally I think its the money.

    Primary care physician incomes have been hurt more by physician extender competition (PAs and NPs) than any other group of doctors and this trend is likely to continue for years unless 1. the government gets involved (I hope the don't) or 2. my crystal ball is broken.

    Low acuity visits for things like high blood pressure, diabetes, migraines or asthma really are not that complicated and do not require someone with 7 years of training after college to manage. (Systems are still working out what the appropriate ratios of supervising physician to mid-level provider should be: 1-1, 1-2, 1-3, 1-4, etc... no one really knows as it all depends on the acuity mix of patients, etc...)

    Notice we are even seeing mid-levels staff urgent care centers today (witness Minute Clinic's success in places like CVS and Wal-Mart and Target, etc... (has been less successful than initially hoped as mid-level salaries have exploded so fast their incomes are now approaching those of physician's making the business model less successful right now- but this will change with time).

    Oh and Okie, remember specialization increases one's risk as well (a variant of this idea is being played out in the ongoing conversation between yoyomo and Dink as they plan their 'return to nature' agrarian compounds when society collapses). Sub specialization increases attachment to the collective because the sub specialists need the collective to even exist.

    @Yoyomo- I sense things have changed a lot in the last 15 years (when I was first coming out of residency)... I am sure this stuff is out there but I can honestly say I have never seen anything other than the occasional free pizza at a department meeting or drug company sponsored meal at a nice restaurant in all my life (and you have to listen to an expert talk for 1 hour so they are not much fun)... And I obviously can't comment where it exists and I haven't seen it but I honestly do not think it is nearly as big an issue today as people make it out. My group has something like 80 physicians and mid-level providers in it. People love to gossip, especially about stuff like this, if it was happening I have a hard time imagining the rumors wouldn't filter my way. It is not looked well upon.

  22. Thai, in France, where the French LOVE to import every bad American idea and muliply its badness by 300 percent (yuk, the number, but I cheated, no sign...) psychiatry has been totally taken over by the pharmaceutical companies who offer lots of expensive goodies, and even host "parties" to plug their newest old inventions (doctored because the new molecules are simple variants on the old ones, free market ideology oblige...)
    The patient is lost, when he is not floating around in a chemical straitjacket.

  23. Debra, what exactly do you read me saying?

    Where has anything I have said suggest I espouse 'pill popping'? (though I might suggest you comment contains a certain cognitive dissonance in its simultaneous rejection of medical consumerism while espousing patient autonomy in matters of mortality- not that I differ with you on this latter point in any way).

    The meme "better living through chemistry" has been around since the dawn of civilization. Witness its predecessors continuing existence in Asia with trade in ivory powder and exotic animal parts as aphrodisiacs, virility enhancers, etc... (heck, the entire water system of America's Mid Atlantic and South East has been polluted just recently with Snakehead fish for this very reason).

    And to the somewhat amusing notion that the flaws of one country (say France) originate in the cultural exports of another (say America): nonsense. We are always our own worst enemies.

    And America bashing doesn't do it for me either. Again I tend to view most peoples as fairly similar in regards to their wants, desires and actions (though I might agree with those with a kind of Dostoevskian view of the world where each nationality has its own unique cultural illusions).

    Americans, for all our foibles and flaws (and I realize there are many), are really not such bad folk... though you might get Greenie to agree with you if you are singling out residents of the Bay Area. FWIW I like the Bay Area.

    I read a link from Google describing 'Theodore Roszak's Where the Wasteland Ends' (in truth as much as I will realistically ever read). To the extent the link accurately describes your view of the book and philosophy, I don't really think our views are that far off (except for the fact that I don't really buy rejecting technology/numbers/science as any more valid than mindless embracing them). Science and numbers can be very practical?

    What is making you so mad?

  24. Hello, Thai,

    I'm not mad.
    At the beginning, yes, but not now.
    Yes, I already figured out that we have many of the same opinions, so why should we get worked up about it ?
    But, I repeat what I said about fantasy.
    I think that I liked getting worked up because it led me to a few verbal fireworks which I congratulate myself on, because I find them rather original, and amusing. A question of style.

    Why not ? It feels good. I don't think that I went so far as to insult you, which would be very offensive. I certainly hope not, and if so, ask your forgiveness.

    But... I still don't like numbers very much. And you didn't answer my point about western medecine being violent and intrusive, a point that I feel very deeply every since I saw my two month old in intensive care, and realized that all that the white coats were doing for her, they were also doing TO her, and that I couldn't explain to a two month old just exactly why torture was good...
    Please don't tell me that I'm being emotional about this. When YOUR two month old is in intensive care, we'll see how you react.

    Actually, I appreciate your comments, Thai. I think that you have a great sense of professional responsibility. Much much more than my accountant's assistant.

    You should read more of the Roszak book.

  25. And Thai, I am not amused by your amusement at my statement that French and American cultures are very interdependant.
    This is truth.
    You seem to be forgetting the very important truth that the United States is the ultimate Enlightenment experiment, and that Enlightenment thought originated in France.
    Why do you think that there is such a love/hate relationship between the two countries ?
    You must know that the founding fathers learned their ABC's at the knees of Enlightenment thinkers in France.

  26. Modern medicine can definitely be very violent- the truth is not all violence is bad.

    FWIW, my oldest was rushed to the NICU the moment he was born (neither I nor my wife ever got to hold him)- I think I can understand what you went thru.

    Sometimes life just is what it is.

  27. EVERn thai ?
    That's really awful.
    My condolences.