But it is of course just as important to point out very basic differences between those systems and ours in determining the applicability of foreign models. One of those differences is the role of doctors. As Atul Gawande points out in his seminal article on reigning in health care costs, "the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue." The culture of medical practice is extremely different in European welfare states, and one of the reasons is that doctors in this country are given every possible incentive to treat the practice of medicine as a business rather than as a profession.
Is that because American doctors are naturally rapacious capitalists? Of course not. The most obvious cause of these differing approaches is the enormous cost of medical education in the United States. In 2005, the average cost of a medical education in the US was estimated at $140,000 for public schools and $225,000 for private schools. That doesn't include the opportunity cost of being an intern, resident, fellow or specialist for several years at minimum wage. It is also on top of any loans taken out for the mandatory four years of undergraduate education. The cost of medical education in Europe, which in many cases begins right after high school, is far, far less. American doctors are thus under immediate and intense pressure to maximize revenue, either through entering high-pay specialties or by practicing medicine a la the doctors in McAllen, Texas. Relatively less-financially-burdened European doctors have a lot more professional flexibility as a result, allowing them to develop a more patient-centered culture. It seems to me that unless you can figure out a way of reducing the cost of medical education, driving down costs in either the public or private health care sector (which inevitably means lower payments to doctors) is a fool's errand. Why else would the American Medical Association be so consistently, implacably opposed to health care reform?
2 comments:
You're arguing that the medical education system in the United States is set up to provide incentives to become profiteering providers of care and not noble but humble healers.
That is probably true in a host of other professions where differences in the burden of training costs could lead to differences in outcome (see: lawyer, corporate), so this is a testable hypothesis.
I don't know if lawyers in more heavily socialized educational systems pursue more humble livelihoods or not, but my guess is that the incentives that matter in the medical system are the payments and not the loans. The third party payment system in the US is so screwed up it provides doctors with all the wrong incentives to provide the right care; my guess is this is a more significant source of profiteering in the medical industry than the loan burden.
Lawyers in European countries, have a significantly lower cost of education, and they also get paid far less than American lawyers. A corporate lawyer in the UK makes about half of what his American counterpart makes at the same firm doing the same work. I don't really know this cuts though.
My point was only that it has to be hard to convince doctors to accept making even less money than they already when their costs of education is so high. Obviously there are lots of other factors--for example, the crazy prohibitive costs of malpractice insurance thanks to a tort system that also doesn't exist anywhere else in the world--but the fundamental argument is that these differences matter a lot to health care reform.
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