Consumer-centered selection mechanisms in medical care

Posted: 17th February 2012 by Khannea Suntzu in Uncategorized
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Infect Teh Interwebs

There is this premise that you can not challenge the notion of free market selection mechanisms in medical care. It is regarded as unacceptable to to do. The competitive element of market is widely regarded sacrosanct, to the point that any intervention the government is regarded as deeply undesirable. Even when the medical-industrial complex clearly exhibits major deficiencies any suggestion that we could let big government come in, recalibrate wrongs, corruption, excess and injustice, is met with hostility and ridicule by the market, by right wing anti-statist ideologues.

By Khannea Suntzu

So, what’s wrong with the medical profession?
There are numerous things not working as they should.

Physician Corruption and the Lure Of Big Pharma Bribes
I have clearly experienced a negative trend in interpersonal skills in physicians. This is evidently the result of a conveyor belt attitude in the medical profession – training any physician, specialist or general practitioner, is extremely expensive. The consequence is that this extreme expense is spread out over as many clients as possible. This breeds alienation on both sides.

An Increase of Patient Agitation
There is increases stress in the world. More people are unhappy about the economy and over-all increasing competition. This hasn’t become a nicer world in the last decades and the trend in (at least my) society is towards people becoming more unpleasant. There have been incidents of aggression towards medical personnel in the Netherlands, and I am sure this is happening everywhere. I can see this have its consequences with medical workers as well. But there is a flipside to this.

A Factory Mindset and The Deconstruction of Empathy
Due to ever increasing budget cuts medical workers have become overall cold and uncaring. I am personally not happy about medical service providers and I know many people are noticing the same trend. The mix of increased work load, budget cuts, an ever more demanding job, less societal appreciation, more problematic cases in society (among which many people with severe psychiatric issues for which medical aid workers get the first impact). The general trend is for aid workers to regard clients and patients and family members as an endless stream of cattle. You get this attitude of “you patch them up, and send them on their way” with medical staff. Also – if a highly qualified specialist acts like an asshole there is no corrective mechanism. Complaining about unpleasant treatment won’t do much good as only a torrent of visible complaint and incidents will cause a hospital to dismiss a specialist. Rather complaining patients will be marginalized, ridiculed and in extreme cases asked to leave. In essence there is no compelling reason to look at the attitude, behaviour, courtesy of a medical worker, and as a result there rarely is a corrective mechanism to correct worsening behaviour.
There are excesses. I had a lengthy conversation with a former nurse and a dear friend on this topic years ago, and while he might be cynical (and the quote anecdotal), he qualified a worsening trend of sheer contempt with medical staff for “the losers out there”. Nurses and physicians are highly trained and disciplined individuals and they regard normal people as decidedly less – unless their patients make a high income, are highly educated or have “equally” responsible jobs. In some cases physicians don’t care much “if they lose one”, because next few minutes “someone more deserving” else might need their undivided attention. One could conclude that a percentage of medical workers is predisposed towards a “social darwinist” mindset, and some of them might not make a full effort in what they regard as some of their less “deserving” patients. A good example are drug users, heavy smokers, alcoholics, people with suicidal urges and obese people. Some medical staff rather not help these people at all and discuss these feelings with their colleagues openly.

Intellectual Property Rights as a Coercive Mechanism
Another negative aspect of the medical profession and associated industries is the already extreme and ever increasing cost of medical care. There are no mechanisms in place to decrease these costs. Governments as a result are forced to cut collective resources for medical care and play a game of chicken with the insurers, hospitals, pharmaceutical industries. One minister in my country openly admitted that “in deciding how to spend government money, in some cases money is saved keeping critical care from patients who are already likely to die”. In other words – a policy maker intentionally withholds treatments at a policy level, because the range of treatments is too expensive, and it pertains to a small selection patients who (1) aren’t well represented in the electoral process, (2) aren’t very appealing in the media or (3) “the money won’t cure them anyhow”. This is just one aspect of the aforementioned game of chicken.
On the other end are pharmaceutical companies that often have to play the same converse budget game with big government, getting medicines developed, approved and tested. The process of developing any treatment can cost tens of millions of euro or dollars, and generally a lot more in the US for reasons of pervasive litigation. Also pharma realizes quiet well that these costs cause their products to become subject to piracy. This is inescapable – as big pharma (as well as big agri-business, especially Monsanto) literally begs policymakers to come up with the most invasive intellectual property rights protection schemes you end up with decidedly dubious attempts at repressive international law. ACTA is but one example. These organizations hide themselves behind a façade of being humanitarian workers, while in the real world of facts this legal process is all about investors, shareholders and making money.
The enormous amounts of money involved in the rainbow coalitions of corporations who have a stake in defending their products is not just toxic to patient lives, it is toxic to the whole Hippocratic ideal of medical care workers. The entire style of looking at this becomes one of literal statistics, triage, cost-effectiveness calculations. The patient becomes a bookkeeping factor on the side of the government clinical ethics councils, who decide on considerations of electoral shifts, lost worker hours and tax revenues. Essentially the patient becomes not a person to provide human care and dignity for – the patient becomes a pawn in a complex macro-financial game of chess. Or as earlier mentioned, a pawn in a complex game of chicken, where government play the pity vote of large numbers of dying patients (and potentially very angry patients) in a decidedly cold-hearted and ruthless manner against the big pharmaceutical industries. We can only bear witness of the results.

Sharply Decreasing Societal Affluence versus Sharply Increasing Medical Needs
One can not close their eyes for geopolitical trends. There are a few distinctive trends that cause global society to become less affluent. This is an irreversible process, and the result is starting to have effects of attrition. All the world is being fed an increasing diet of austerity and the results can be deadly, especially for the vulnerable.
At the same time people grow older, and big pharma has for some reason or another, to expend an ever increasing sum of collective societal resources in to treatments. Clearly the consumer (the patient) of medical care has no choice and will get these treatments one way or another, and generally she or he has only one alternative. Clearly there is no incentive, other than the aforementioned mechanism of government “austerity blackmail”, to reduce costs of a treatment, especially in countries where the clients (or their insurers) can still afford to cough up the pricetag. This creates a global sellers market for medical care. The suppliers can ask whatever they want, hiding behind the figleaf of “extraordinary medical costs” and “inflation” and “high wages”. These excuses are mostly bunk – treatments are more routine than ever, hospitalization lasts shorter, exactly the same treatments cost a fraction in other countries. The end result will favor the segment of society which can afford to pay out of pocket, and it will hurt or prematurely kill those who can’t. If a medical insurer won’t pay for a fully functional treatment abroad, the results can be lethal. Nevertheless in such a constipated market of ageing and more demanding clients versus every more monolithical and aloof medical service providers there will be increased black market treatment piracy (with all the accompanying risks). Patients will deflect to black market surgeons if the alternative is death. The downside is the development of a most hideous black market where debtors will do anything to repay their bills, and the development of gruesome black market expertise that will no doubt be uses in other ways. Government and big pharma should so whatever it can, outside fascist legal frameworks that only worsen this problem, and that basicly means – provider cheaper service soon. Black markets never work, they create career criminals, they are hard to get rid of once they exist, and provide a slew of highly undesirable horrible side effects.

Underhanded dealing between Big Pharma
If the development of a major medical treatment costs a massive investment in research, development, testing and certification, then it makes sense to conclude that pharmaceutical companies will try and increase their profit margin by closing deals. It will be hard to prove, but I’ll bet my money that there exists a wide range of back room secret cartel agreements between big pharmaceutical investors, dividing up the markets, or going as far as underhandedly making deals with medical insurers. There is too much money to be made, so the corruption is nigh inescapable. If a company has to compete with another on a complex treatment regimen, why not close a deal where the other company “forfeits” the market in exchange for another? In the pharmaceutical multi billion dollar markets this would be hard to prove but inescapable.

Alternatives
So how can we do something about this? My guess is that the traditional free market mechanism of introducing (or even forcing in) a competitive element won’t ever work, or at best only peace meal. Worse, we’ll see a sharply declining ability of society to pay for ever more inflated costs of care, and we will also see escalating societal disparity. The latter will cause critical treatments to be wholly inaccessible to the poor. This will cause extreme stress in the long run. Worst case scenario is in the emerging field of life extension. Life extension treatments are right now not regarded as “a medical treatment”, since ageing itself is not regarded as a “affliction”. The well-known life extension activist Aubrey de Grey doesn’t call himself that for the simple reason there isn’t any chance he’ll get research grants for “life extension”. If Aubrey would claim to be working for longevity (or even rejuvenation) he would fail. Hence he must work on “general robustness” treatments.
But these treatments will have effects sooner rather than later. And even the slightest level of treatment will have dire consequences for pensions, clearly. Just a provable or merely “plausible” generic medical treatment for some diffuse set of geriatric conditions that would (might!) increase the average lifespan of recipients by a few months will literally go pension funds to go bankrupt. As a consequence I can already predict pension funds are investing money to make sure Aubrey de Grey (and the general field of bio-gerontology) doesn’t succeed “too quickly”. The pension funds (and most of our macro-economic model of retirement) is out of business is, gods forbid, by 2025 the medical field does in fact come up with a treatment which makes people live a decade longer, statistically.

Remind you all, this seems to be inescapable at this stage. The combined fields of organ printing, general research of longecity, as well as the potential of nanomedicine is certain to yield major paradigm shifts in the whole medical field. The simple calculation is that the biggest cost generator at the current stage is old age – people who are close to death generate by far the most medical care bills. Make sure that (most) people do not end up in the venerable stage and society (taxpayers, insurers) will save a large amount of money. There are arguments to conclude that, if life extension treatments are affordable enough, they might literally provide a cheaper alternative to the grossly expensive part of medical care at “end of life” scenario’s.

But we do not have a guarantee that these life extension scenario’s will come to fruition. Or if they do, many social conservatives at least think them a mix of “highly undesirable” or “impossible”, so the last work hasn’t been said about them.

How can we create selection funnels?
I have little faith in leveraging market mechanisms in the health care field. For me I am starting to increasingly associate free market competition with various forms of attrition, and that’s what we don’t want in medical care. But we do need a means to reduce the absurd costs explosion. I don’t see any means, other than a very pervasive change of the entire system.

Breeding on Empathy
Consumers might collectively want to become more empowered. The only way to stand up to what I term “bullies” is to resist them. A bully never stops being a bully, a loan-shark never stops being a loan-shark, a predator never stops being a predator. Not unless you stand up to them. What we are now faced with is that the medical-industrial complex has become somewhat of an indiscriminate bully. People need the medical care, and have no choice, and the bully charges what it wants, and quite often doesn’t treat the patient all that well while providing care.
The way to change this is to let the care=provider know when they are acting ruthless and condescending (or worse). If enough people become disenchanted with the heredetary authority of the white coats, the white coats in turn might turn back in to human beings again.

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