Covert Rationing Even Wrecks Socialism

Posted on December 11, 2007
Filed Under Wonkonian Rationing |

Last week, John Goodman wrote a provocative piece about what he’s termed the “nonprice rationing” of healthcare. By nonprice (or nonmarket) rationing, Goodman means the kind of rationing you get when the government, rather than market forces, control the healthcare system - specifically, he’s addressing a system of socialism. He offers five principles of such nonmarket rationing, which I paraphrase here:

1) Any excellence that may exist is not systematic, but instead occurs spontaneously and randomly.
2) Access to this random excellence is not random; the rich and connected are the ones who get it.
3) The skills that allow people to succeed in a market system are the same skills that allow them to succeed in a nonmarket system (i.e., one’s wits will determine one’s access to excellence).
4) Doctors rationing at the bedside will make value judgments about their patients; youthful and highly productive (and presumably influential - DrRich) patients will get an unequal share.
5) People at the bottom of the income ladder will almost always do better in a market system.

To sumarize: Despite the inevitable efforts of the government to homogenize healthcare under socialism, pockets of excellence will still randomly appear. The rich, the connected, and the quick-witted will find those pockets of excellence. So: the same people who are getting decent healthcare today will continue to get better than average healthcare under a government system, and the peons will suffer even more than they do today under a more market-based system (where they at least have a shot).

Goodman also says:

I am probably one of the few people you interact with who has a real interest in understanding nonprice rationing of health care. In fact, I may be the only such person. . . .In fact, I don’t believe anyone has developed a real theory about it.

Readers, please do not think too badly of Dr.Goodman just because he has not yet heard of DrRich or his Grand Unification Theory of Healthcare (GUTH), the theory that explains everything. Dr. Goodman’s a busy man, and DrRich is, well, obscure.

Does the GUTH account for Goodman’s “nonmarket rationing?” Indeed it does. Does it reach the same conclusions as Goodman? Well almost, but not quite.

The difference? Goodman’s formulation could be applied to almost any aspect of a classic socialist system, where virtually all goods and services are controlled (i.e., rationed) centrally. The same five principles (with the possible exception of principle 4, which seems to refer specifically to physicians) would hold under a socialist economy whether you’re talking about healthcare, cigarettes, plumbers, or wheat.

Under a socialist system, there will always be shortages of everything; but on the other hand there also will always be special caches of the rationed item, which somehow will be made more-or-less available to the rich, the connected, or the quick-witted. (The Cuba segment of Michael Moore’s Sicko, for instance, nicely displays the special cache of healthcare excellence that Cuba makes available to the fortunate few, such as American filmmakers bent on embarrassing the Bush administration). This inherent aspect of socialism is merely a concession to reality. Perfect socialism, requiring as it does a fundamental change in human nature, cannot exist. So special caches (whether of gasoline or of medical excellence) will always be permitted to spring up and to persist, at least tacitly. Trading in these special caches, after all, is how the central authorities a) maintain their power, and b) get to have some of the special stuff themselves.

Goodman’s formulation derives directly from the classic behavior of socialist systems, and thus must be correct. And being correct, it must also be compatible with the GUTH; and so it is.

But the GUTH adds a twist. The twist is: We’re Americans, and Americans don’t ration. So the central authorities who control the American healthcare system have got to do the rationing covertly. (In contrast, rationing under classic socialism is quite open.) Covert rationing corrupts everything it touches (Corollary 4 of the GUTH). Ironically, it even disrupts the inherently corrupt style of rationing classically seen under socialist systems.

Goodman points out that under classic socialism,

Since there is no financial reward for excellence and no financial penalty for mediocrity, excellence tends to be the result of the enthusiasm, energy, and leadership of a few people scattered here and there.

That is, socialism creates no incentive for excellence. Whatever pockets of excellence you get will have to be created by a few special individuals who are unusually self-motivated.

What this formulation does not account for is that under the American healthcare system, dedicated as it is to covert rationing, the Wonkonians are aggressively putting into place several powerful reverse incentives. These reverse incentives, we’ve seen (we being readers of this site), are aimed at actively stamping out, eradicating, and punishing any self-motivated physician who tries, despite all obstacles, to deliver excellent healthcare. Among these are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking the magic of P4P to determine exactly what must and must not take place during that 7.5 minutes; grabbing the right to interpret clinical science in order to formulate the “guidelines” that inform P4P; coercing doctors to agree to egregious adhesion contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making every patient encounter subject to a web of regulatory speed traps that force doctors to concentrate on keeping the OIG at bay rather than on what the patient needs. In short, in their efforts to gain control of physicians’ behavior in order to covertly ration healthcare, American Wonkonians are creating insurmountable and systematic disincentives for excellence, and severe penalties for non-mediocrity. They have placed doctors in the untenable position of being utterly unable to fulfill their professional, traditional, legal, and ethical obligations.

The only way doctors will retain a realistic opportunity to achieve excellence under such a system (so as to service at least the rich, the connected and the quick-witted), will be to abandon the system altogether.

Perhaps somebody can purchase an obsolete Soviet aircraft carrier, convert it into a state-of-the art hospital ship, staff it with renegade American physicians, park it in international waters off the east coast, and ferry Congresspersons back and forth by helicopter to receive their well-deserved excellent healthcare. Under a covert rationing paradigm, that might be the only way to fulfill Goodman’s five principles, even if we end up with a fully socialized healthcare system.

Comments

8 Responses to “Covert Rationing Even Wrecks Socialism”

  1. The Happy Hospitalist on December 11th, 2007 5:09 pm

    You wrote:

    Since there is no financial reward for excellence and no financial penalty for mediocrity, excellence tends to be the result of the enthusiasm, energy, and leadership of a few people scattered here and there.

    That is, socialism creates no incentive for excellence. Whatever pockets of excellence you get will have to be created by a few special individuals who are unusually self-motivated.

    These words are reality.

    In my own personal experience as a resident physician, training at the VA hospital, my over all experience I had of the staff, the nurses, the techs, other docs, everyone in this single payer government program was that of (in general) pure and utter laziness. The mantra of “not my problem” was so ever present. I loved the patients and hated the system we have created for them.

    The old saying “What’s the difference between a gun and a VA nurse? You can fire a gun” held so true.

    Government job
    Government benefits.

    No need to succeed.

    No fear not to be below average.

    Pockets of excellence.

    This is so true.

  2. Greg on December 12th, 2007 12:51 pm

    I actually think John would agree with you whole-heartedly. One thing we wonks try to drive home is that nothing should come between the doctor-patient relationship. The idea that a big bureaucracy, whether or private or public, is anathema to delivering access to quality care in a cost efficient manner.

    As to your A/C carrier idea, it’s already being done. Health tourism is burgeoning industry where patients are going to developing countries, staying in “5 star hospitals” and receiving care from top surgeons and doctors for the same price as a Gen. hospital in the US.

  3. SamEyeAm on December 12th, 2007 8:36 pm

    Dr. Rich, where does sham peer review fit into the GUTH?

    I think I know but I am curious what you think. Also the concierge care channel that accepts a set number of patients that pay a yearly fee completely infuriates the wonks. These concierge practices still bill insurance including medicare but extract a premium from the patients for a non-covered service.

    Infuriated wonks are dangerous wonks. For example, Senator Bill Nelson of Florida recognized potential conflicts of interest with concierge care and in 2002 introduced a bill, S. 1606, that would ban doctors who charge access fees from billing Medicare for their services.
    This is no differet than the Canadian wonks preventing patients for paying for higher quality care except control is being exerted on the physician not the patient.

  4. DrRich on December 12th, 2007 10:07 pm

    Greg,

    I’m aware of medical tourism, and may even try it myself the next time I need life-saving but expensive medical care (that is, when I really, really don’t want to be covertly rationed against). The aircraft carrier idea may not be much of an advance over today’s medical tourism, as you say. I am just looking for something useful for disaffected American doctors to do without relocating to Malasia. Also, for a convenient way for our noble Congresspersons to get their share of medical excellence without having to junket half way around the world. It’ll save all of us a bundle.

    DrRich

  5. DrRich on December 12th, 2007 10:13 pm

    Happy,

    In the VA hospital I worked in in the 1970s, being around the full-time staff was like being in a George Romero movie. I had hoped morale and attitudes might have improved, along with the higher regard most Americans seem to hold for the military than they did in the Viet Nam era. But, as Goodman accurately informs us, such an improvement isn’t likely to happen in a government controlled enterprise.

    DrRich

  6. DrRich on December 12th, 2007 11:01 pm

    SamEyeAm,

    Wonkonians fervently desire to kill the Concierge Medicine baby in the nursery. And they want to kill concierge medicine whether these docs take any insurance or not. In my book, I discuss at some length the ongoing and concerted efforts being made to stamp out concierge medicine (and offer concierge docs some advice as to how to counter these efforts). Wonkonians are rapidly advancing their agenda to make it a federal crime for doctors and patients to contract directly with one another for medical services. If I’m not mistaken, in Canada I think this sin is only a misdemeanor.

    A sham peer review, as I understand the term, is the misappropriation of the peer review process (ostensibly a quality process), for the purpose of getting rid of “troublemaking” (i.e., whistleblowing) doctors. Classically, these docs are complaining loudly and persistently about hospital policies and procedures that put patients at risk. Obviously they must go. Because peer review is generally a secret, closed-door process that the courts are loath to challenge, it’s perfect for such a thing. The beauty of this expediency is that, in the process, you wreck the reputation of the object physician, and render any subsequent public statements they make the unreliable utterings of a disgruntled former staff member, who, it is whispered, was thrown off the hospital staff for undisclosed peer review (i.e., quality) reasons.

    Here is how sham peer review fits the Grand Unification Theory of Healthcare. Covert rationing (the GUTH explains why we’re doing that) requires complex, obtuse, inefficient policies and procedures at every level (so that you can say you’re doing one thing while all the while doing another). Obviously, with policies like this people will occasionally get hurt - but there it is. There’s simply nothing to be done about it. Physicians who rail against such policies might as well rail against the weather. You can, of course, tweak these broken policies a bit in response to such complaints, and pronounce them “fixed.” (Tweaking bad policies actually makes them even more convoluted and obtuse, and is a useful mechanism for evolving truly abysmal, covert-rationing-friendly policies. So to at least some degree, occasional complaints, to which one can express appropriate concern and make appropriate responses, are a good thing.) Using carrot or stick, you can get most docs to see the light at this point, shut up, and pretend they agree everything will be better now. But the persistent ones, the ones who just won’t let it go, who perseverate and fixate on the issue (indeed, whose clearly abnormal obsession with patient safety might even suggest to you that they have a form of Aspergers syndrome), who refuse to see how the game is played, and who may even threaten to go public, well, they threaten the whole infrastructure. They’re a serious problem. You’ve got to peer review their *ss right out of there. It’s the only thing to do.

    DrRich

  7. SamEyeAm on December 13th, 2007 9:26 pm

    Dr. Rich,
    That was a perfect answer.
    Where do i get an autographed copy of your book?
    Thanks

  8. DrRich on December 14th, 2007 5:16 am

    SamEyeAm,

    You can get an autographed copy of Fixing American Healthcare here: http://publishorperishdbs.com/buy-the-book
    (Look about half way down the page.)

    Thanks for asking.

    DrRich

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