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Neither YAY or NAY -- but FACEPALM

Government policy has already made it customary and relatively cheaper (if not easier) to have medical insurance cover and pay for every medical service. So insurance dominates the finance and provision of even the routine medical services market -- e.g. seeing a doctor for an earache and obtaining medicine.

The consumer situation in medical care has become radically different from other types of transactions; under a regime of medical insurance, there is little to no incentive for people to care about or respond to price, outside of copayments and coinsurance; there isn't even a simple and widely accepted way to talk about price of most medical services; bills are written to get insurance companies to pay up, not to provide a clear record of the services performed, and at what prices.

The situation is so different from other transactions based on people paying their own way, that some people without insurance are actually scared just to go see a doctor, and rightly so. This is a terrible madness. And while at first glance, it looks like a subsidized insurance mandated appears to solve the problem, I think in the future, it will further empower Congress, not the people. The consumer will become ever more reliant on other people to make decisions about what care he can access.

Medical insurance was already heavily regulated. It will now be further subsidized by taxation and even higher premiums for others. This will increase "access", as some people will now get insurance (and medical services) who otherwise wouldn't, but at a real cost to others.

But while this policy will increase the quantity of medical services that will be provided, it will increase prices. While some people will now use insurance to get necessary services, many more will get even more unnecessary services. What is necessary? We are already at the point that insurers and regulators determine this more than a consumer advised by a doctor. Is it not plainly obvious that fewer and fewer people will have personal financial incentives to keep cost down?

The only way to lower cost is to simply let almost all people pay for the vast majority of their own routine medical services, like almost all pay for their own food. Of course, the entire medical culture would have to shift towards a framework of clarity in price and competition in quality.

I yearn for a future where people can find out the price of an MRI just as easily as the price of an iPad.

Regardless of the lawsuit implications, I am not so sure of the benefits of EMRs.

I would be all in favor of a private and complete electronic medical history for each person, but the EMRs I have seen are neither private nor complete, and tend to reinforce formulaic medical practice, as opposed to discovery, discussion, and intelligent understanding.

Broadly, my concerns with EMRs:

First, GIGO. I was enthusiastic about Kaiser-Permanente's electronic medical records until I saw garbage being put into the system by well intentioned folks. This translated into outputs that incommensurable over time.

Second, ownership. I should own my EMR, because I own myself and manage my own care.

Third, format. My preferred EMR would have a wiki template, because I should be able to add my observations to my EMR, and anyone who sees it will know how to access the most relevant information. I would keep mine up to date with a current status report up on top.

Fourth, interpretation. This is fundamental. Regardless of data quality, ownership or format, new doctors (say the harried folks in the ER) will not know how to interpret and use the data from all the other doctors. In fact, I've seen this first hand. It is very hard to practice medicine wisely in the short-run. Doctors disagree with one another on observation and diagnosis of the simplest things. Even when there's agreement, notes are always incomplete and cryptic, many times providing negative information.

If you were to look at my KP medical records, you will have almost no idea of interventions or medications or lifestyle changes that I've ever taken, or why all my basic measurements improved drastically over a one year period.

We should be looking at how patients, doctors, bureaucrats, politicans, and insurance companies use EMRs in the real world. This cannot be a pretty picture. Personally, I now focus far more on the meaning of test measurement, how doctors know what they say they do ( when and why they started believing it as well as causes of justified variance in opinion), and far less the alleged expert opinion that I should just trust.

Access to Healthcare

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It turns out that "access to healthcare" is actually an incredibly complex sociological concept:

Facilitating access is concerned with helping people to command appropriate health care resources in order to preserve or improve their health. Access is a complex concept and at least four aspects require evaluation. If services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may 'have access' to services. The extent to which a population 'gains access' also depends on financial, organisational and social or cultural barriers that limit the utilisation of services. Thus access measured in terms of utilisation is dependent on the affordability, physical accessibility and acceptability of services and not merely adequacy of supply. Services available must be relevant and effective if the population is to 'gain access to satisfactory health outcomes'. The availability of services, and barriers to access, have to be considered in the context of the differing perspectives, health needs and material and cultural settings of diverse groups in society. Equity of access may be measured in terms of the availability, utilisation or outcomes of services. Both horizontal and vertical dimensions of equity require consideration.

And here I thought "access to healthcare" meant you could get whatever medical services you want, and somebody else would pay for them.

Completely Backwards

Various surveys have found that 20 million to 50 million family members in the United States provide care that has traditionally been performed by nurses and social workers.

-- Jane E. Brody, NYT, "When Families Take Care of Their Own", 11/10/2008 (emphasis added)

That has it completely backwards.

In the past century or so, nurses and social workers are have been providing care that has, for thousands of years, been performed by family members. Modern capitalist economies in democratically run countries have produced a wildly different outcome than traditional societies. The extraordinary wealth required to have other people look after your family members was once had only by the elite. How strange to see the modern specialization and division of labor in healthcare called "traditional".

Family caregivers are, in effect, home-based representatives of the patient’s medical team. They provide medical services, make assessments of the patient’s well-being and determine when to call the doctor or bring the patient to the emergency room. Yet they often lack 24-hour access to professional advice and clear instructions about when and whom to call for help.

The medical establishment-centered view of care seems to overestimate the relative value of the judgments of medical professionals. Yet, I think analysis should be done to assess the relative cost and quality of care provided by "home-based representatives" versus "professionals".

Still, something doesn't sit right with me about this. Aha! Wait a minute. All these people being cared for at home by family members have suddenly become "patients"! That's pretty slick, Ms. Brody!

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