Saturday, January 27, 2007

Law Suit or No Pay--Docs, Take Your Pick

Dr. Wes has thoughts on why doctors are dragging their heels about using information technology in healthcare:

"Intel’s Chairman Craig Barrett thinks I’ve been dragging my heels about using information technology in healthcare.

Hmmmm. Dragging my feet over something that represents hours of unpaid labor and exposure to litigation… What could I be thinking?"

Like Dr. Wes, I often have to wonder at some of the things people expect health service providers to do--often for free and with added exposure to liability. I often get requests for evaluations that carry very high liability risk such as violent risk assessments or child custody evaluations. The funny thing is, many times, the client, whoever that may be, balks at the idea that they cannot use their insurance for this type of forensic exam, or that if they have to pay out of pocket, the fee is not just a few bucks. Apparently, my time and exposure to liability means little--people think health service providers are a public commodity, to be used as cheap labor or thrown to the wolves if a patient is harmed in any way--either psychologically or medically because the doctor is overwhelmed with paperwork, patients and out-of-office monitoring. If out-of-office health technology is going to succeed, the liability issues and payment compensation for doctors needs to be worked out in a reasonable way.


Anonymous Anonymous said...

It looks different from here. After my wife filed for divorce, she put our kids in therapy. I requested the kids therapy records from the shrink. The shrink concealed from me that my soon-to-be ex-wife was planning to leave the U.S. with my children. This had huge legal, financial, and other effects. I was told by an attorney that I had no legal remedy against the shrink.


1:32 PM, January 27, 2007  
Anonymous Anonymous said...

Our local hospital has, as part of its management, a board of Doctors who review the handling of cases classifying the outcomes as Successful, Acceptable, or Poor. The idea of this is of course quality control, with the idea of creating more and more Successful outcomes and quickly identifying problems that may lead to Poor outcomes. Like any business, they want to improve their product.

The problem is that the quality control evaluations can become evidence in lawsuits from unsatisfied patients or their families. I used to think it would be cool to be a Doctor, but I don't think you could pay me enough to do the job now.

2:08 PM, January 27, 2007  
Blogger Purple Avenger said...

Any business where if you screw up some dies is going to be afflicted with high liability costs.

My GP recently decided to "go naked" and dropped the malpractice insurance because it was so high. He's very good, holding PhD's in chemistry and pharmacology, as well as the M.D. Possibly the the best in all of south Florida, so for him it was probably a relatively safe move.

If you're in an equipment intensive business you can mitigate by isolating the gear into a separate corp that leases the stuff back to you so your business doesn't actually own anything but a desk and a phone.

My consulting has been isolated in its own corp for almost 10 years now.

4:31 PM, January 27, 2007  
Anonymous Anonymous said...

Dear Doc,

I can appreciate your position, and certainly the sentiments of Dr. Wes. I believe most reasonable people would respond positively to an explanation of the economic details involved in your relatively specialized area of health care. Dr. Wes' issues might be better handled by working with technology vendors rather than insulting them.

But I strongly disagree with the assumption you've outlined describing what people think - at least with respect to conflating the terms "commodity" and "cheap labor"... something to be "thrown to the wolves". Those of us who may be earning less than you, but who also provide services (in other areas), certainly don't see ourselves as "cheap labor" simply because those services fall in the "commodity" category. Nor do our employers or clients.

Most health care services are, in point of fact, a commodity, just like any other service that can be had from multiple outlets at prices (which should be) controlled by the consumer's ability to get the best deal. This doesn't make health practitioners "cheap labor" any more than a $4800 DLP T.V. is transformed into "cheap junk" by the fact that it, too, is a commodity.

It's a side issue perhaps, but the health insurance industry has completely confounded the commodity price control mechanisms that might otherwise govern the the costs of health care services. In the process it has not only allowed the associated costs to increase at rates 2 to 3 times that of inflation, but has also created a good deal - likely most - of the paperwork and headaches that overwhelm professionals who have far more important things to do. Couple that with our litigious culture - which has created the wolves you describe - and I think we've identified the real culprits here. Those culprits are not patients' expectations or ignorance of liability issues, IMHO.

10:02 PM, January 27, 2007  
Anonymous Anonymous said...

"...people think health service providers are a public commodity, to be used as cheap labor or thrown to the wolves if a patient is harmed in any way...

Just you wait... When Hillary gets in in '08, your butt will belong to US. "Health Care Providers" will become the property of the citizens of the United States! That'll put an end to both your greed and your whining!!! Viva Slavery!!!!!!

11:51 PM, January 27, 2007  
Anonymous Anonymous said...

''The first thing we do, let's kill all the lawyers,'' - Dick the Butcher in ''Henry VI,'' Part II, act IV, Scene II, Line 73.

Some argue that Shakespeare was only referring corrupt, unethical lawyers. That may be, but there certainly seem to be a lot of them out there. And they cause a lot more harm than good, in my humble opinion.

11:52 PM, January 27, 2007  
Blogger Helen said...

goy 10:02:

I agree with some of your points, particularly the litigious nature of our culture. However, I do think that insurance and government sponsored healthcare does breed a sense of entitlement with people. They do not expect to pay for anything out of pocket, expect healthcare products like birth control, viagra, and other items to be covered under the plans which raises the cost. Take for example, psychotherapy, patients used to expect to pay the bill and did in earlier times. Now, everyone expects insurance to cover everything. The healthcare providers are paid less and less and we are expected to do more and more. As a psychologist, insurance will not pay for outpatient time or phone calls that eat up a good portion of my day, as do notes and paperwork. For those of us who take Medicare, psychologists are scheduled to get a 9% paycut--imagine if you were working a regular job and being asked to pay high fees for your office, and all of your expenses and then told your salary was being cut by 9%. Perhaps this is more of an issue for psychologists than for all medical practitioners so it may not be as relevant to Dr. Wes and/or the cardiologists etc. but it seems to be a growing concern. It also concerns me since a lot of docs no longer will take Medicare or other government insurance--and with good reason. They might go broke.

7:45 AM, January 28, 2007  
Anonymous Anonymous said...

Dear Doc,

Thanks for pointing out a glaring omission in my note: the entitlement mindset bred by comprehensive insurance plans (exacerbated by insane legislation of the sort recently approved by Mitt Romney). I've discussed this and related issues at length, fwiw, here and here. Health care premiums keep going up, providers claim their payments keep going down... makes one wonder where all the excess cash winds up, doesn't it. I've worked inside of large health insurance corporations. I don't have to wonder. That said - and this certainly isn't directed at you personally - I can't get too worked up over psychologists looking at a 9% pay cut from Medicare.

First off, Medicare is almost as broken as the private comprehensive health insurance system, so anyone who accepts it needs to also accept the ups and downs. It is the federal government, after all.

Second, there's also a type of entitlement mindset at work among many - if not most - health care professionals these days as well. And at first glance, it seems pretty natural that someone who spends (or borrows) hundreds of thousands for school, over 8-10 years, spends a few more years living on coffee, bagels and adrenalin to qualify for a good job or start/join a healthy practise should feel like they're deserving of some minimum compensation in return. Looking more closely, however, that's simply not the case. Health care services are a commodity that can't break the rules of economics any more than other commodity services - at least not without confounders like comprehensive health care insurance plans.

Finally, I can more than imagine "working a regular job and being asked... etc." That's exactly the scenario I've just lived through these past 7 years, as software engineering services saw the effects of commoditization and consulting rates and salaries were cut - in most cases by far more than a mere 9%. More like 30%. Not good for me personally, but in the larger picture it's been a good and necessary adjustment in the industry. I can hardly resent this change because services like these should be getting less, not more expensive. And I believe the same thing must happen in health care as a part of fixing the completely broken system now in place.

9:32 AM, January 28, 2007  
Anonymous Anonymous said...

I've thought about this quite a bit over the past 15 years. I used to be an HR exec in a Fortune 500 company and was at one time the president of a healthcare alliance (a consortium of large employers and agencies such as county government and school systems) working to keep costs down by negotiating with area hospitals and doctors. I've heard a lot from all sides (yes, even lawyers). I'm no expert and don't claim to be, but I have taken a more than cursory look at this whole topic. There is, obviously, no answer that will make everyone satisfied, as there are simply too many conflicting interests here. Someone's going to get "hurt". But here's what I'd do if I were king.

1) Get government out of the business of mandating insurance coverages of specific services, thus lowering premiums for healthcare coverage.

2) Set caps on damages in civil suits, thus lowering premiums for liability insurance for providers and thus, again, fees for service from these providers and thereby lowering healthcare coverage premiums. This, hopefully, would allow doctors to make decisions on tests and care based on the patient's actual condition and less on CYA considerations.

3) Use tax credits to reimburse for healthcare insurance premiums for basic coverage for evryone. You could pay for more extensive coverage if you wanted to.

4) Phase out Medicare over time (20 years, maybe), letting everyone know well ahead of time that they have to have insurance when they retire. This would entail not allowing companies to drop people as they get older or sicker.

5) Set up a better policing mechanism (not through the AMA) to get rid of bad docs. The docs I used to work with all knew who the bad ones were, but nothing ever seemed to get done about it.

Just some thoughts.

Mike Doughty

10:19 AM, January 28, 2007  
Anonymous Anonymous said...

Hmmm, sounds like I am about to fire Medicare!

In a divorce proceeding where I see the children the mom's attorney asked how he could get me to a hearing. "Subpoena me" I answered. He laughed and said something about doing it the rough way.

I have the lawyers subpoena me to keep my butt covered from the lawyer of the other party.


10:56 AM, January 28, 2007  
Anonymous Anonymous said...

flan has a great point. I could go on about similar experiences to his.
I've been to the doctor, gotten a diagnosis, and a prescription. Oops. Wrong. It happens. It has happened to me.
Now sicker,I return to the same doctor, get a different diagnosis, a different prescription, and that was the ticket.
I am out of pocket twice, having to pay my portion twice, missing time from work twice. Well, my time, too, is worth money. Thankfully, the situation was not life threatening. Is it fair I should have to pay twice? Shouldn't I be compensated (meaning, from my point of view, brought back level) for someone else's screw up?
In the company I am with, I make recommendations to customers regarding what they need to solve mechanical problems and /or improve processes at their large plants. Their downtime is in thousands, tens of thousands, to even six figure down time per hour. If I screw up, it can cost a possibly high profile customer a lot of money. People could be hurt, disfigured, killed. My company liable, my reputation severely damaged, me out of work. I certainly do not get paid for all the hours I put in to a project. I do not believe anyone truly does.

I know I am a bit sideways from what this post is about. But I believe fair and equitable is what I am whining about. For all. Got any cheese?

11:23 AM, January 28, 2007  
Blogger Helen said...


So what you are saying is that I should not accept Medicare since I do not agree with the terms or the pay? Fine, but don't complain that many of us have left the field due to the poor pay and terms. I am going that way, being an entrepenuer and heck, playing the stock market is more lucrative to me than the actual job that I trained 11 years in graduate school, three years of internships and years of clinical and forensic training for. But since, as you say, the rules of economics say that my time is not worth much, I understand that and am baling out as fast as possible. However, next time your kid or you is in legal trouble, etc. and needs a professional who can help, myself and my colleagues will be long gone.

12:35 PM, January 28, 2007  
Anonymous Anonymous said...


I feel your pain. As a real estate developer, I spend 95% of my time dealing with political processes, which can last for years with a large project. Most of my efforts fail repeatedly, requiring design revisions, modifications, being sent back down to sub-committees for further review, etc.

I spend 4% of my time convincing bankers and partners to carry me through the above refereced 50%.

1% of my time is spent actually building the products I can rent or sell.

THEN, there is another 100% of my time, which I spend fighting off "Construction Defect" lawsuits initiated by contingency fee lawyers who convince homeowners to join together and sue the developer.

But nobody cares about MY problems.

1:33 PM, January 28, 2007  
Anonymous Anonymous said...


I don't think it will be long before superstar blogger entrepreneurs such as yourself will be subject to all sorts of legal requirements, and the process servers will again be lining up on your doorstep.

There is no escape.

1:53 PM, January 28, 2007  
Anonymous Anonymous said...

Way to take it personal, Helen. Ok, then. Let's face it. Before plans were revised to cover psychological care, patients had to pay out of pocket. Which is to say, very few folks got psychological care. Which is to say, you wouldn't have had a business in the first place.

And anyway, let's dispense with this charade that you actually work and make a living anyway, shall we? You are supported by your husband. So none of this REALLY matters to you anyway.

1:59 PM, January 28, 2007  
Blogger knox said...

I think the blame lies with health insurance... people are simply used to going to the doctor for "free." This automatically makes them devalue the services they receive; yet the notion that docs have "deep pockets" remains.

There also exists a certain amount of resentment towards doctors, as they are perceived as rich and powerful. (There's certainly some bitterness/envy at Drs. peppered throughout these comments!)

Combine those factors with trial lawyers and doctors are opting out like crazy. I heard a few years ago that there weren't enough OB docs to deliver babies in Las Vegas because of the malpractice insurance there.

2:00 PM, January 28, 2007  
Blogger knox said...

Before plans were revised to cover psychological care, patients had to pay out of pocket. Which is to say, very few folks got psychological care. Which is to say, you wouldn't have had a business in the first place.

This is a pretty stupid statement. If the market worked that way, none of us would be typing on computers right now. They wouldn't exist "in the first place" because "very few folks" would be able to purchase them.


2:04 PM, January 28, 2007  
Anonymous Anonymous said...

Dear Doc,

No, that's not what I wrote at all. My position is that if you decide to accept Medicare, then you decide to accept Medicare - that is, with all its warts and with the possibility that compensation levels can, over time, go down as well as up.

The rules of commodity economics say that your services are worth what the market decides they're worth. That's all. And absent distortion mechanisms like the ones we have today in comprehensive health care insurance plans, that worth is determined by a combination of the perceived value of the services, demand for those services, the number of practitioners providing those services and the health care consumers' collective ability/willingness to pay. Given what you've listed as the personal investment required to do what you're doing, you may ultimately decide that the worth the market places on your services equates to "not much". But in response I would respectfully submit the following suggestions:

- "not much" is your subjective assessment, based on what you believe you're entitled to, not based on what the services are worth to the market,
- (more importantly) the actual worth of your services has never really been tested against a properly functioning health care services market, because
- the insurance system as it currently operates has not only utterly distorted the economics involved - to say nothing of the expectations of the consumer (per knoxwhirled's comments) - but has also created an almost parasitic "middleman" which presently absorbs an enormous amount of the actual value that flows through it, complicating payment processes, meddling in patient care and inflating overall costs while contributing virtually nothing in return.

As for bailing out of any career, well, I guess I'm inclined to agree with tomcal ("there is no escape"). :-)

Aside from that, I think the real question is whether one is looking for a career that's lucrative or one that's fulfilling. It's nice to have both, but unless one is a person who derives actual fulfillment solely from the act of accruing wealth (e.g., day-trading, etc., and I've met a few of these), then reality usually forces one to make a compromise. Unfortunately, after years spent developing a career in an area where you seem to have flourished, it sounds like our broken insurance system has created an environment that has finally led you to an "I don't need this s**t anymore" assessment.

I think you're right - there are many health care professionals who are coming to this same assessment. That's truly unfortunate, but it may be part of what's required to fix the system. I just feel forced to add that such an assessment appears to involve some confusion regarding the root of the real problem. Again, I don't think it's in patient expectations or their ignorance of liability issues, per se. IMHO, the root of the problem is so-called "comprehensive" health care insurance as it's currently structured. And I hope that's coming across: it's not my intent to criticize practitioners in your chosen field or your assessments regarding the relative worth of your services.

2:18 PM, January 28, 2007  
Anonymous Anonymous said...


"If the market worked that way, none of us would be typing on computers right now."

What do you mean if the market worked that way? How does the market work then, dear?

Are you telling me that, 35-40 years ago, when psychological care was generally not covered by insurance, that there were just as many psychological practitioners per capita as there are now? And that the same percentage of folks received psychological services as now?

Talk about a stupid statement.

2:35 PM, January 28, 2007  
Blogger knox said...

How does the market work then, dear?

Supply and demand. When a product or service is new to the scene, only a few are available and only the wealthy can afford it. Then slowly, demand grows as people become aware of the benefits. Producers work to make it more cheap and widely available. In the case of services, more people enter the field.

Do you really need this explained?

Computers certainly existed 35 years ago, but there weren't many. Now almost everyone has one. And they paid for it themselves. As far as I know, insurance providers and/or medicare didn't go around and place a computer in each home.

Here's another example: more and more people can afford Lasik surgery, even though most insurance doesn't cover it. The price has plummeted since it came out, and there are ads on the radio and everything else now. By your logic, the opposite would be occurring: doctors would have but a few patients, or their businesses wouldn't exist at all.

3:11 PM, January 28, 2007  
Anonymous Anonymous said...

Hi, tomcal

Although there are times we all need lawyers (to protect us from other lawyers, usually) I sure don't like 'em.

Lawyers kind of remind me of G.E., only perverted. G.E. manufactures machinery and equipment that generates electricity. They also manufacture machinery, equipment and appliances that consume electricity. Fantastic! I am still searching for that same type idea. And, it is a fair trade. Look at the good electrical equipment has done for us all.

To me, lawyers not only make the laws, but they make money on the laws they make, which seem aimed and lining their pockets by draining mine. How in the hell can we possibly need thousands of new laws a year, collectively, at city, county, state and federal levels. Someone is breaking a law all the time, without even knowing it.

It's even easier to find a good woman than a good lawyer (humor alert!! see other threads on this site for further explanation).

4:06 PM, January 28, 2007  
Anonymous Anonymous said...


Someone is breaking a law all the time, without even knowing it.

Correction - EVERYONE is breaking MANY laws ALL the time, without even knowing it. I can think of five or six I am violating right now, so I am probably violating 20 or 30. The last violation began about 10 minutes ago - I installed a dimmer switch for the chandelier over our dining room table without getting a permit from the city building department; creating ongoing, intentional, and possibly negligent violations of a variety of ordinances.

4:45 PM, January 28, 2007  
Blogger Helen said...


Thanks for the explanation.

4:47 PM, January 28, 2007  
Anonymous Anonymous said...


(exacerbated by insane legislation of the sort recently approved by Mitt Romney)

Can you go into more detail about this?

4:59 PM, January 28, 2007  
Blogger DrWes said...

Goy -

In response to your earlier comment about me insulting Mr. Barrett:

Mr. Barrett threw down the glove in terms of insults when he suggested that the medical profession was "dragging our heels" regarding implementation of IT. Our institution prides itself on the adoption of the EMR, etc. Certainly there are benefits in the administration of medicine with IT (especially billing), but I feel it does little for the doctor-patient relationship. Gone are the days of looking in your patient's eyes to gauge their anguish and anxiety - instead we stare into a computer screen. Medical students do their "rounds" on line, rather than examining their patients, since it is more "efficient." I can't tell you how many times the early warning signs of congestive heart failure are missed by these neophytes because they routinely ignore their privilege to examine the patient. No computer will ever replace this in my view.

And don't get me started regarding the ridiculousness of seeing physicians flip through pages of blood pressure readings and glucose levels using “chronic disease management” software – I’d rather watch paint dry. Is this how we want to spend our days? None of us will stoop that low.

My comments regarding Mr. Barrett were a rant to expose the ridiculousness of an "economic" summit in Switzerland where Big Business needs to retreat to decide on unrealistic technology for health care problems they do not understand (except that it’s expensive) and one that exists here in the US. And by the way, I offered to go there if they wanted it...

6:26 PM, January 28, 2007  
Anonymous Anonymous said...

Anyone who thinks the medical profession is not already using leading edge technology should take their kid into a radiology lab and get one of the docs to give them a tour. It is absolutely amazing what they can do with imaging technology, and the radiologists seem to enjoy showing it off.

This month's National Geographic also shows it off pretty well.

Obviously Information Technology is being used in incredible ways wherever it is found to be productive in the medical field; and obviously Mr. Barrett is pushing a little too hard trying to sell a cure that has no disease.

7:56 PM, January 28, 2007  
Anonymous Anonymous said...

Look, knoxwhirled, I think just about everyone here (maybe even you, if you're circumspect) realizes that insurance coverage of psychological treatment has had an effect on the amount of patients seeking psychological care, i.e. the number of patients has been artificially increased. If we go back to insurance not covering these services (which sounds like what Helen wants), most folks will stop getting the care. They wont pay for it out of pocket. Why? Because the benefits of psychological care are not realizable, like the immediate and obvious gratification of a personal computer or high def TV.

She sounds pretty condescending about both patients AND insurance companies. Better recognize which side her bread is buttered on.

Oh, wait. Her bread is buttered by the husband. Nevermind.

8:11 PM, January 28, 2007  
Anonymous Anonymous said...

A forensic psychologist is any psychologist who offers an expert psychological opinion in a way that it impacts one of the adversarial arenas, typically the courts. Many people think of forensic psychologists as focussing on criminal matters. This is certainly not always the case.


A witch doctor often refers to exotic healers that believe that maladies are caused by magic and are therefore best cured by it, as opposed to science or developed medicine. The term witch doctor is generally used with negative connotations, as implying that the people whom the witch doctor serves are primitive and incredulous.

8:33 PM, January 28, 2007  
Blogger knox said...

Why? Because the benefits of psychological care are not realizable, like the immediate and obvious gratification of a personal computer or high def TV.

This is unconvincing. There are tons of goods and services that people pay for every day that have absolutely no instant gratification. Insurance, in fact, is a great example. Many of us willingly pay for homeowners, short- and long-term disability, and auto insurance knowing there's a good chance we'll never recoup the money we put into it.

And here's a tip: when you are always making comments like this:

Oh, wait. Her bread is buttered by the husband. Nevermind.

It makes you sound lonely, pathetic and bitter, unattractive, and wishing you had a partner yourself.

8:52 PM, January 28, 2007  
Anonymous Anonymous said...

I see your husband is having genocidal reveries again, Dr. Did you take him off the red pills for a while, or what?

9:40 PM, January 28, 2007  
Blogger David Foster said...

Information technology can do a lot of good for healthcare, but it is not a panacea. It's important that these systems be well-designed and reliable and function as servants rather than masters of the people they support.

In general, the IT industry could use just a tad more humility. There are a lot of really bad information systems running in American business (and government) today, and the fault is with the designers at least as often as with the users.

10:37 PM, January 28, 2007  
Anonymous Anonymous said...


Thanks for your concern. Got one. He's a lawyer too. A real one. And let me tell you, he's freaking hot.

12:16 AM, January 29, 2007  
Anonymous Anonymous said...

Anon 12:16

I thought you were a man. This means you are gay?

3:06 AM, January 29, 2007  
Anonymous Anonymous said...


No, no-- certainly not a man. But if I were one, I probably would be gay. You know, because I am TOTALLY buying the post below.

7:46 AM, January 29, 2007  
Blogger knox said...

Got one. He's a lawyer too. A real one. And let me tell you, he's freaking hot.

This is what's called "overselling."

10:42 AM, January 29, 2007  
Anonymous Anonymous said...

"This is what's called 'overselling'."

This is what's called "jealousy".

11:38 AM, January 29, 2007  
Blogger DADvocate said...

anon. may be female, may be male. One things for sure, if he/she had an EEG his/her brainwaves may very likely be like those in DrHelen's recent post, "a pattern characteristic of stupor and delirium."

Although, I think anon. hit the nail on the head with the "jealousy" bit. A little bit of projection, perhaps?

1:51 PM, January 29, 2007  
Anonymous Anonymous said...

tomcal said...
''The first thing we do, let's kill all the lawyers,'' - Dick the Butcher in ''Henry VI,'' Part II, act IV, Scene II, Line 73.

Some argue that Shakespeare was only referring corrupt, unethical lawyers. That may be, but there certainly seem to be a lot of them out there. And they cause a lot more harm than good, in my humble opinion.

11:52 PM

tomcal, if you'd read the play, you'd know that this quote, famously misused by many, such as yourself, as an indictment against lawyers, has really quite the opposite meaning. In the play, some nefarious ones are planning a "coup", for lack of a better word, a new regime which will destroy the peoples' liberty. They are planning how to accomplish this. Thus, "First thing . . . let's kill all the lawyers" is Step One on the path of converting liberty to tyranny.

Shakespeare knew this.

Feel better now?

3:28 PM, January 29, 2007  
Anonymous Anonymous said...

anon: "Can you go into more detail about this?"

Heh. You're kidding right? Please click the links I provided. More detail there than anyone's likely interested in reading (except thenewguy, who although he never finished the long post, provided some great comments that added perspective). :-)

4:26 PM, January 29, 2007  
Anonymous Anonymous said...


I admit that the line in question is of some controversy, whether it is a lawyer joke or an affirmation of society's need for a legal system with lawyers to maintain order. I am not a Shakespearean scholar, but it seems to me that if you read the lines before and after the famous quote that Jack and Dick, although scoundrels, were on a rant about the utopian society they would create after they had overthrown the King. This impossibly perfect world would include, as stated by Jack:

"There shall be in England seven half-penny loaves sold for a penny; the three-hoop'd pot shall have ten hoops; and I will make it felony to drink small beer; all the realm shall be in common; and in Cheapside shall my palfrey go to grass; and when I am king,as king I will be,....there shall be no money; all shall eat and drink on my score; and I will apparel them all in one livery, that they may agree like brothers...."

Then, to add the final touch of perfection to this brave new world, where the best of everything will be available to everyone, for free, Dick chimes in and says basically:

"And the best part of all is that there won't be any lawyers!"

I think it is a lawyer joke.

4:19 AM, January 30, 2007  
Anonymous Anonymous said...

If it weren't for lawyers, black people would still be riding in the back of the bus.

10:58 AM, January 30, 2007  
Anonymous Anonymous said...

TheNewGuy - Hey - my recollection is that we worked through all that. :-)

In any case "poking" - when done gently - can often lead to new and interesting lines of thought. My thought process on comp. health plans - which I think directly addresses a BIG part of the issue Dr. Helen is discussing here - is still at a very high-level stage. I need all the input people are willing to contribute. And I appreciate(d) yours!

11:11 AM, January 30, 2007  
Anonymous Anonymous said...

I think the black people were going to stop riding in the back of the bus with or without lawyers. Lawyers just meant they didn't have to do it the hard way.

And what were the lawyers doing for the hundred years preceding the back of the bus thing?

If it's of any interest, last year I went to an ENT specialist for some tinnitus problems. He came into the exam room with a little Sony VAIO, started up a program, and proceeded to ask me a list of questions presented to him by the software. He clicked on the answers as he went, and when he was done he hit Enter and pronounced that he didn't know what was wrong with me.

So there's at least one dr. who's not afraid of information technology.

11:13 AM, January 30, 2007  
Anonymous Anonymous said...

"the fault is with the designers at least as often as with the users. "

I have to take exceeption to the above for not going nearly far enough. TO quote a friend of mine who does UI design for a living: "There is no such thing as a stupid user, there are only bad designs."

Well, I suppose there are a few people so dim they could make anything fail. But if your customer base doesn't have at least a 95% success rate in figuring out your product with what they consider a reasonable amount of effort (seeing as how they've already go a job, which your product is supposed to make easier, not harder) then there's something wrong with your product.

2:14 PM, January 30, 2007  
Anonymous Anonymous said...

The problem is the product, system, model, etc. is often no smarter (with some exceptions) and often much much dumber than those designing it. Make the wrong assumptions, assign the wrong probabilities, assume the wrong distributions, etc. and nothing else matters.

If you have a GIGO system or model it isn't going to matter if you have supercomputers analyzing the data. Garbage In = Garbage Out.

12:12 AM, January 31, 2007  
Anonymous Anonymous said...

I have to take exception with the assumption, underlying several of the postings here, that medical services is viewed as a commodity item by most of its consumers. Think about that statement for a minute. Take gasoline: These days, the bulk of gasoline consumers consider it a commodity (this hasn't always been true, BTW). When shopping for gasoline, what do you do? Well, if you're like most folk, you typically just shop for the lowest price in your area. Brand loyality plays no part. Quality of the product plays no part; we assume they are all essentially the same (and given how the spot market moves different brands around these days, we're probably right). The only other things that might make any difference are location and convenience of payment method. But for most gasoline consumers, price is *the* determining factor.

Now let's take medical services. Back in the '90s, there were lots of health-care plans trying to do this very thing, that is, commoditize health care services. But there's a problem with that. When you are looking for health care, are you willing to go to just any doctor that the plan has determined has the lowest price for the services you need? Very few people are. I know I'm not. I want to be able to choose a doctor. And, having had good experiences with a particular doctor, I now have brand loyalty. If someone wants me to stop seeing that doctor, they have to give me a darn good reason, and the price being a little higher than that of a doctor who I consider to be of inferior or unknown skills is not an acceptable reason to me. Not all doctors are providing the same level or quality of service. It's not a commodity to me.

So my opinion is that any health care plan that starts by treating medical services as a commodity, that is, the only determining factor is price, is doomed to fail. That's why insurance companies are having little success in holding plan costs down despite their numerous efforts to negotiate/strong-arm doctors into lowering prices. To make a knowledgable market decision, the buyer must have information on both the pricing and the quality of the services being offered. And yes, this would imply some kind of public rating system for doctors. I'll admit that I'm not sure how such a thing would work. But without that information, the market cannot act rationally.

2:10 PM, January 31, 2007  
Anonymous Anonymous said...

cousin dave - IMHO, the glaring flaw in your otherwise thoughtful post is this: you've overlooked the fact that having "the health care plan" stand between the consumer and the commodity good or service is exactly what confounds the commodity economics involved. This is the intellectual box from within which we've been trying - and failing miserably - to solve this problem for decades. And it is at the heart of the idiocy in the law recently passed in MA that requires the employer and taxpayer to purchase insurance - or face increased taxation (i.e., fines).

The interposition of the comprehensive health care insurance company, and the fact that it CAN be strong-armed (and TNG knows I don't think this is the entire issue), is the source of the problem. The market cannot act rationally if its buying decisions are being made by someone else whose interests are not the consumers' interests. This is happening on two levels. It happens at the health care insurance company level, which "negotiates" with providers but has no real incentive to lower costs (after all, higher cash flow for ins. companies means higher profits!). It also occurs at the level of employer, which is most often the entity that is deciding on which plan to offer - the company's interests in choosing a plan aren't necessarily the same as the employees'. In the current system, the consumer never gets a chance to exercise any choice at all!!

That said, people choose between commodities - even gasoline - based on factors other than, or in addition to price all the time. I know I do. Commodity vendors are always doing things to woo consumers. Ideally this kind of arrangement should be MOST true of health care services. In a properly functioning system, it shouldn't MATTER which practitioner or product one uses since they should all be doing as good a job, or be as high of quality as possible. It'll never be that perfect world, but I think a properly functioning market - where decisions are made and costs are handled directly between the provider and consumer - will help.

Try this over a phased plan spanning 5-7 years. Eliminate comprehensive health care insurance plans entirely, and return 95% of the premiums back to the consumer. Every employee gets a huge "raise" and/or each direct policy member gets a "refund". Allow them to decide which providers and products to use - just as we did in the 50s! Keep 5% at the State level to cover the costs of those who can't afford to pay anything for health care so PCPs, etc., don't go broke treating people they're legally (and morally) obligated not to turn away. The medical industry will have to cowboy up and get efficient real quick since the consumer's ability/willingness to pay - not negotiation with an insurance company - is going to determine whether or not they stay in business. Likewise, the consumer is going to have to cowboy up and abandon the entitlement mindset that pushes them to run to the ER every time they get the flu, or try to get a nose job covered as "medically necessary" to protect their self-esteem. Finally, the costs of much, if not most of health care is going to have to come back in line with other quotidian expenses. It's risen at rates exceeding inflation for far too long.

In the meantime, catastrophic plans, administered at the municipal level (instead of the employer level) could take advantage of enormous economies of scale (a township!?) and ensure that no one goes broke paying for bypass surgery. Most towns already offer a health plan to city employees. Convert that to catastrophic and let anyone in the township enroll if they feel the need. Add the premium as an extension to property taxes, since there's already a mechanism in place for collecting that revenue. Renters in the township get billed (the only significant expense being added to the town's costs).

Would this be a painful transition? Shhyeah! Would insurance company lobbyists fight it tooth-and-nail every step of the way? Of course! But would we prefer to be spending 20% of our GDP on health care alone not so far down the road?? Not me!! We should be using what we've learned about how medical costs have skyrocketed since the inception of so-called "comprehensive" health insurance. And I think this kind of plan would do that.

7:14 PM, January 31, 2007  
Anonymous Anonymous said...

Dear Dr. Wes,

I apologize for not responding sooner to this. I plead temporary blindness. Honest. :-)

"Mr. Barrett threw down the glove in terms of insults when he suggested that the medical profession was "dragging our heels" regarding implementation of IT."

I'm well aware of that. Mr. Barrett apparently has too much free time during 2057's timeslot, and I found his comments insulting also.

And I can't tell you how many times I've seen missed opportunities to solve a problem or resolve an issue because one side tossed a road flare and the other side insisted on picking it up and throwing it back. As you did. I know why you did and I am in complete agreement with you on the points regarding how the medical community has adopted appropriate technology at an appropriate rate. I've worked on software for some of it, so I do have some familiarity here. My intent, however - and it may have been intentionally terse - was simply to point out that 'responding in kind' might not be the way to resolve that particular issue. That's all.

"My comments regarding Mr. Barrett were a rant to expose the ridiculousness of an "economic" summit in Switzerland where Big Business needs to retreat to decide on unrealistic technology for health care problems they do not understand..."

And this, of course, leads to my point. How else will they ever understand those problems if the response to their inappropriate commentary (engendered, IMHO, by defensiveness born of their ignorance) is just more inappropriate commentary?

7:39 PM, January 31, 2007  
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