DownWithTyranny!: What Do Doctors Know About Health?

Tuesday night we looked at some of the issues around organic food and healthy eating. It sparked quite a few responses but this one from a woman in Missouri was the most galvanizing and I want to share it with you.

Vegetarianism has been a huge part of my life for the past several years and I plan on raising my daughter based on the principles involved. Today I was shocked at the government, and special interest groups involvement in trying to prevent informed eaters from keeping this restricted diet. My daughter is about to start preschool (daycare), and I informed them she was vegetarian, and did not drink cow's milk. They insisted upon a doctors note stipulating that I was depriving her of these "essential resources." My physician wrote a note, and that should have been the end of it (which was ridiculous to begin with) but I was told it had to be worded a certain way due to USDA regulations on children in schools' food! I put 2 and 2 together quickly, and asked them if that was because they had a vested interest in keeping my child on dairy products to make money. I was given a noncommittal nod from the instructor. So despite the fact that we have moral reasons for maintaining this diet, there are also numerous health concerns with the hormones/steroids found in most dairy products, & meat. Choosing not to give my child these should be an educated choice I make, however the USDA has said I do not have that right. Fortunately, I convinced the doctor she would be getting adequate protein, and iron. Even if you do not agree with my stance on being vegetarian, or refraining from cow's milk, you should realize how absurd government interference (backed by the funds of private companies) in choosing what my child eats truly is! This is outrageous!

She included a note from her cousin, a kindergarten teacher in the same district who voiced the same concerns about collusion from the USDA and the dairy industry. "We get in trouble if we don't have a doctor's note as then we are taking away their nutrition and the school district gets money for every kid that gets milk. So, yes your school will loose money if her daughter doesn't get the milk. The USDA gives the school money for each child and we have to give it to them."

Last week I had dinner with one of the country's best known raw vegan chefs and one of the most prominent young surgeons in the country. We were all grooving on the food and I asked the surgeon how many courses doctors are required to take on nutrition during medical school. He laughed. "There was a three hour lecture," he said. "That's it."

Ezra Klein at the Washington Post knows a lot about health-- or at least health costs. It's his beat. Last week he looked at a question that perplexes U.S. policy makers and consumers alike, Why an MRI costs $1,080 in America and $280 in France. In fact, health care costs more in America-- and doesn't get better results than in other industrialized countries.

In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978. If we had the per-person costs of any of those countries, America’s deficits would vanish. Workers would have much more money in their pockets. Our economy would grow more quickly, as our exports would be more competitive.

There are many possible explanations for why Americans pay so much more. It could be that we’re sicker. Or that we go to the doctor more frequently. But health researchers have largely discarded these theories. As Gerard Anderson, Uwe Reinhardt, Peter Hussey and Varduhi Petrosyan put it in the title of their influential 2003 study on international health-care costs, “it’s the prices, stupid.”

...“The United States spends more on health care than any of the other OECD countries spend, without providing more services than the other countries do,” they concluded. “This suggests that the difference in spending is mostly attributable to higher prices of goods and services.”

On Friday, the International Federation of Health Plans-- a global insurance trade association that includes more than 100 insurers in 25 countries-- released more direct evidence. It surveyed its members on the prices paid for 23 medical services and products in different countries, asking after everything from a routine doctor’s visit to a dose of Lipitor to coronary bypass surgery. And in 22 of 23 cases, Americans are paying higher prices than residents of other developed countries. Usually, we’re paying quite a bit more. The exception is cataract surgery, which appears to be costlier in Switzerland, though cheaper everywhere else.

...“Other countries negotiate very aggressively with the providers and set rates that are much lower than we do,” Anderson says. They do this in one of two ways. In countries such as Canada and Britain, prices are set by the government. In others, such as Germany and Japan, they’re set by providers and insurers sitting in a room and coming to an agreement, with the government stepping in to set prices if they fail.

In America, Medicare and Medicaid negotiate prices on behalf of their tens of millions of members and, not coincidentally, purchase care at a substantial markdown from the commercial average. But outside that, it’s a free-for-all. Providers largely charge what they can get away with, often offering different prices to different insurers, and an even higher price to the uninsured.

Health care is an unusual product in that it is difficult, and sometimes impossible, for the customer to say “no.” In certain cases, the customer is passed out, or otherwise incapable of making decisions about her care, and the decisions are made by providers whose mandate is, correctly, to save lives rather than money.

In other cases, there is more time for loved ones to consider costs, but little emotional space to do so-- no one wants to think there was something more they could have done to save their parent or child. It is not like buying a television, where you can easily comparison shop and walk out of the store, and even forgo the purchase if it’s too expensive. And imagine what you would pay for a television if the salesmen at Best Buy knew that you couldn’t leave without making a purchase.

“In my view, health is a business in the United States in quite a different way than it is elsewhere,” says Tom Sackville, who served in Margaret Thatcher’s government and now directs the IFHP. “It’s very much something people make money out of. There isn’t too much embarrassment about that compared to Europe and elsewhere.”

The result is that, unlike in other countries, sellers of health-care services in America have considerable power to set prices, and so they set them quite high. Two of the five most profitable industries in the United States-- the pharmaceuticals industry and the medical device industry-- sell health care. With margins of almost 20 percent, they beat out even the financial sector for sheer profitability.

...But as simple an explanation as “the prices are higher” is, it is a devilishly difficult problem to fix. Those prices, for one thing, mean profits for a large number of powerful-- and popular-- industries. For another, centralized bargaining cuts across the grain of America’s skepticism of government solutions. In the Medicare Prescription Drug Benefit, for instance, Congress expressly barred Medicare from negotiating the prices of drugs that it was paying for.

The 2010 health-reform law does little to directly address prices. It includes provisions forcing hospitals to publish their prices, which would bring more transparency to this issue, and it gives lawmakers more tools and more information they could use to address prices at some future date. The hope is that by gathering more data to find out which treatments truly work, the federal government will eventually be able to set prices based on the value of treatments, which would be easier than simply setting lower prices across-the-board. But this is, for the most part, a fight the bill ducked, which is part of the reason that even its most committed defenders don’t think we’ll be paying anything like what they’re paying in other countries anytime soon.

“There is so much inefficiency in our system, that there’s a lot of low-hanging fruit we can deal with before we get into regulating people’s prices.” says Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University. “Maybe, after we’ve cut waste for 10 years, we’ll be ready to have a discussion over prices.”