Lecture Fifteen: Disease and Lifestyle

Hertzler's Hopes

1. Health care is available (to all) (in Kansas)
   • But public ignores, distrusts
2. Health insurance is becoming available
   • But big city palace hospitals are too costly
3. Medical advertising as quackery

Hertzler, the Doctor-Confessor, and the New Model Human

1. Not organic disease but social-existential
   • Rape
   • Fertility issues (too little or too much)
     1. Change in economic status of children
     2. Neglected and abused children
   • Unrequited love
   • Anger
   • Grief
   • Ageing
     1. "all right they have high or low blood pressure and there is not use making them miserable either mentally or physically by tring to do what just can't be done.  If they get pneumonia or a brain hemorrhage you know a kind Providence has not forgotten them" (303)
   • Dying
     1. "Nowadays the doctor more or less ignores the bedside of the dying"

What Has Changed?

1. "Nervousness...not a disease but a state and one must learn to live with one's self"
   • "Group practice is unsuited to the discovery of these intimate details"
2. Hertzler's day
   • Society imprisons, doctors liberate
3. Our day
   • Society liberates, doctors ...

New Medical Possibilities

1. Amputation: authenticity or perversion?
   • Apotemnophilia
   • Being stuck in the wrong body (anorexia precedent, sexual reassignment)
2. Depression
   • The conquest of invalidism or the legitimation of melancholia or the new hysteria
   • Female = pathological
     1. What produces a response cures a disease
3. Anger and Polio
   • From dependency to disability rights
4. New communities or out of control individualism?

The U.S. Health Care System

Costs and Efficiency

1. U.S.: ~15% of GNP, 1 of 6 $ in federal budget
2. Canada: ~10% of GNP (others: 6-10%)
3. U.S.: 5.5 doctor visits per year
4. Germany: 12 doctor visits per year
5. Japan IMR: 50% of U.S. IMR
6. Administrative staff : Bed
   • Germany, 1:7; U.S., 1:1
7. Administrative costs, public and private
   • Canada, 1.4%; U.S., 5.9%

WHO World Health Report, 2006

• Country	Health Care % of GDP	Health Care of Govt as % of Total Expenditure	Govt Expenditure on Health Care as % of Total Expenditure on Health Care
  Netherlands	9.8	62.4	12.4
  France	10.1	76.3	14.2
  United Kingdom	8	85.7	15.8
  Canada	9.9	69.7	16.7
  Sweden	9.4	85.2	13.6
  U.S.A.	15.2	44.6	18.5

(View the report online.)

Causes of High Health Care Costs

1. Need as supply
2. Over proceduring and information glut (X-ray, MRI, or both?; xs false positives
3. Industry lobbying: horrible Canadian drugs
4. Duplication of services (GPS, specialists, repeat services)
5. Death of optional
   • 90% of federal spending in last few months of life
   • 0.8% prevention
6. Setting limits: insurance, too little; profit too much

Varieties of Health Care Provision

1. HMO: free access or standard
2. Capitation systems
3. Indemnifaction insurance / major medical (Blue Cross / Blue Shield)
4. Medicare (2.1% of income)
5. Single payer?

General Problems

1. For-profit + capitation = underprovision of service
2. Precertification, service review
3. Indemnification + free access = overprovision of medical services
4. What is medical need?
5. If medical services are profit-making activities there will be incentive to use more of them - to create medical demand (flexible demand)
6. If medical services must be provided under a set fee (capitation) there will be incentive to use less of them (inflexible demand)
7. If medical services are charged at cost, there will be neither incentive nor disincentive to use services
8. The role of the gatekeeper (pcp)

The American Hospital

1. 40% over capacity
2. Hospital consolidation
3. Subsidy of charity care
4. Iatrogenic infection: nosocomial (resistant bacteria)
5. Mistakes with medication
6. The rise of the patient care technician
7. Institute of Medicine, NAS 7/2000: hospital error, 100,000 deaths per year

The Hill-Burton Act of 1946

1. Purpose: Expand supply of hospitals to underserved areas by offering partial federal funds and accelerated depreciation
   • Underserved areas can't meet matching funds expectations
   • Accelerated depreciation leads to incentive to expand, needed or not
   • More procedures to pay for more technology
   • Result: supply-driven medical industry: hospital occupancy, 60%

HMO Origins: What do HMOs have to do with health maintenance?

1. Against the threat of socialized medicine: a private sector solution
2. Health Maintenance Act of 1973
3. Paul Elwood, Jackson Hole Conferences
4. Collects fees: contracts with practitioners to provide all necessary services

Presumptions of HMOs

1. The Mayo model / First generation HMO
   • Coordination of primary care physicians to coordinate with specialists
   • Emphasis on prevention, vaccination, healthy behavior, screening
   • Use of primary (family) doctor, over the impersonal clinic
   • Reduce cost through share facilities

The Fate of HMOs

1. Away from the Mayo Clinic model
2. Non-profit to profit
3. Control of doctors to control by insurance providers
4. Away from prevention
5. Gatekeepers as naysayers - bonuses for cherry-picking and cheapness
6. Pre-certification / prescription restriction / service review
7. Lack of concern with follow-up care
8. Better deals for bigger customers/providers

Improvements of HMOs?

1. Right to specialists
2. Right to information about finances
3. Independent review of complaints
4. Emergency room access
5. HMOs as regulated utilities
6. End of for-profit? Minnesota, Connecticut

Who Should Decide?

1. Individual: Everyone should get all they ask?
2. Provider: Buy anything you can afford?
3. Insurance Companies: We can get healthy people better bargains
4. Society: Medicine is an element of equality