Defend Private Healthcare

[Ivor the Engineer]

Is private healthcare compatible with the principles of medical ethics?

http://jme.bmj.com/cgi/content/full/27/4/234

(You will need to be a registered user to view the full article)

PUBLIC FINANCING WITH NO PARALLEL PRIVATE FINANCE

The vast majority of countries with universal publicly financed systems of health care insurance allow a parallel private insurance sector in which individuals can purchase private insurance for publicly insured services. The benefits of such insurance to its beneficiaries may include a wider range of treatment choices, the ability to jump a public queue, and so forth. Advocates also argue that such private insurance helps improve access to the public sector by lessening the demands placed on it. Is there an ethical rationale, however, for going beyond the provision of universal public finance by prohibiting such parallel private insurance, as is done in Canada for medically necessary physician and hospital services?

Restricting private insurance this way might follow directly from certain ethical approaches that demand equal access to health care or equal maximum possible consumption of health care by all members of society (for example, perhaps some solidarity-based approaches). It would not, however, follow directly from any of the three ethical frameworks considered in this paper or many other approaches framed within the four propositions identified above. But within a wide range of consequentialist approaches, such a restriction might derive indirectly from the operation of parallel systems of finance. That is, it is an empirical question whether a system of financing that prohibits private insurance for publicly insured services better advances the access and utilisation patterns ethically demanded. Evidence suggests that this is at least plausible.

Parallel systems of private finance can drain resources from the public system, erode public support for the public system, lead to longer waiting times in the public sector, and make it harder to provide all members with timely access to high quality services.36 Parallel private insurance is in general associated with an expansion of resources devoted to health care, though these additional resources are often used for services that generate smaller health gains (otherwise, they would have been given greater priority within the public system).

These dynamics imply that a parallel private insurance sector is not, as is commonly suggested, simply an add-on to a publicly financed system. Rather, complex interaction occurs that affects the viability of the publicly financed system, which leads to cross-subsidies (most often from public to private), and which may draw scarce resources into the health sector that are allocated in ways not consistent with the ethically justified patterns of access and utilisation.

Once again, this potential empirical justification is perhaps most tentative within a utilitarian framework, as the benefits of such a restriction on parallel private insurance must be weighed against its cost in the form of frustrated preferences among those who would prefer to purchase such insurance. The rationale is perhaps strongest within the extra-welfarist approach that calls for an equal distribution of health and which strongly de-emphasises utility effects in the valuation process. Given that on average it is those who are of low income and poor health status who are hurt most by the dynamics of parallel systems of finance, such a restriction may well also be supported within a Rawlsian framework.

[Ivor the Engineer]

Here's an article about the situation in India (and we wonder why so many Indians use alt. med.):

http://www.issuesinmedicalethics.org/042ed042.html

Introduction

The medical profession is getting more and more cornmercialised. There has been a continuous erosion of medical ethics not only in the private sector but also in the Government sector. I give some examples from my own experience in Punjab.

Illegal private practice

Government doctors once had a justified grievance. They demanded adequate non-practising allowence (NPA) if they were to be disallowed private practice. However, even after adequate NPA was granted, illegal private practice did not disappear. In fact it grew along with NPA. In our unofficial survey of practices in the Government Medical College, Amritsar, we found only three professors who were not indulging in private practice. Two of them - husband and wife - have since retired. The third resigned after he suffered repeated victimisation at the hands of the Government of Punjab.

Those indulging in illegal private practice fall into two categories. There are those who charge reasonable private fees and also do not neglect patients who do not pay any illegal fee. In the second category are those who fleece patients and neglect those who do not pay the private fee. The situation is particularly troublesome for patients unable or unwilling to pay when they need surgery. A junior doctor had told one such patient: 'If you want to get the operation done properly, you have to pay.'She could not afford this amount and came to me for help. I spoke to the Medical Superintendent saying: 'Even the Devil spares the occasional home.' This helped.

[Ivor the Engineer]

http://www.myanmar.gov.mm/myanmartimes/no82/myanmartimes5-82/News/10.htm

...

Humanism in medicine is more than medical ethics. It is more than refraining from doing physical and mental harm to the patient through professional misconduct. It is more than just abiding by the Hippocratic oath. Humanism is a positive action, just as compassion is not only a feeling of concern for the suffering of others, but also prompting action to give help to promote its alleviation. Compassion is as important as scientific knowledge and skill in a humanistic physician. When we take stock, we will realise how far we have strayed from the ideal. This phenomenon is world wide and unfortunately it has also spread to our country. Not only has medical practice and the care of patients deviated from the original social ideal, the concept of humanism is almost alien in medical education and medical research endeavours. True, medical ethics is part of the curriculum in many medical schools, but it has been alleged that medical faculties insert the teaching of medical ethics in the curriculum to salve their consciences. Much more than inclusion of the subject of medical ethics in the curriculum is required for medical graduates to imbibe humanism and ethical behaviour as their second nature. Ethics has been a fundamental part of medicine since early times and dealt with the obligations and responsibilities of the physician. The code of the physician Hippocrates (460-355 B.C.), is exemplified in the oath which is familiar to all medical graduates. In this code of ethics, the graduate is reminded of the dignity and responsibility of his calling, and among other things, urged to seek above all the benefit of the patient, and take no mean advantage of the position of the medical adviser. During the 1970s and the early 1980s, business in the developed countries, particularly in the United States, saw (the potential for) a big market in the health care field, resulting in an increasing commercialisation of medical care. Large for-profit corporations were formed, offering a variety of services on a pre-payment basis.

...

[Rolfe]

In Britain, it keeps the top consultants in the NHS, contributing to it, rather than having them leave to pursue a wholly private career.

Rolfe.

[Ivor the Engineer]

In Britain, it keeps the top consultants in the NHS, contributing to it, rather than having them leave to pursue a wholly private career.

Rolfe.

I agree that's a pragmatic reason to allow physicians to make a hefty profit from the relief of the suffering of others.

http://www.bmj.com/cgi/content/full/329/7465/579

The three paradoxes of private medicine

Like many people in Britain I have inherited—and have subsequently nourished—a profound dislike of private medicine. However, it now appears that the reality is much more complicated and disturbing.

We had been told that my daughter would have to wait at least two years to see the consultant as an outpatient, and we felt that this was totally unacceptable. So we made one simple phone call to the private hospital, and she was seen in two weeks.

This much was accomplished without trauma. When we made the appointment it felt like any other—perhaps to see the general practitioner or a school teacher. But the experience began to be qualitatively different when we got there. It began with a feeling of relief that the uncertainty and waiting were over. Then, three things happened that gave me pause for thought.

Instead of the joy of clinical resolution, you are left with a tainted feeling of shameful compromise and guilt

Firstly, the staff were different. They may have had the same job titles and qualifications as staff in the NHS, they may also have had NHS jobs (the consultant certainly did), but they behaved differently. There was a perception of deference to you, the receptionist was caring, they seemed to have more time, the consultation was less pressured (you know that there is no one waiting outside, so you can take as long as you like). So far, so good. But in each of these apples is a worm. Are they only being nice because I'm paying? If so, what do they say behind my back? Do they think I'm as compromised in this Faustian bargain as they are? Is the consultant being pleasant or oleaginous, altruistic or avaricious?

These issues matter because they go to the heart of the encounter: do I respect this person, and therefore do I trust his advice and actions? This is especially important given the manifest perverse incentives, where every additional action means personal income. When he says, "I can see you for the next appointment on the NHS, but it will be a few months," do I believe him? When he suggests drugs rather than waiting and seeing, could there be ulterior motives? One of the marvels of the NHS is that you can generally trust the motives of the professionals—but here? The result is the first paradox: paying for health care can actually be disempowering.

...

ETA: BTW, consultants in the NHS are on very good salaries and have performance payments.

http://www.nhscareers.nhs.uk/details/Default.aspx?Id=553

Consultants

Consultants can earn between £73,403 to £173,638, dependent on length of service and payment of additional performance related awards.

How much more money do they want?

[Beerina]

I believe some of the top medical officials in the Canadian government also practice, openly, illegal private services. Nobody cares.


It's a curious slope. "Everyone needs health care!" turns into "Government will provide it to make sure everyone has it!" turns into "Only government will provide it, and other ways are now illegal!"


The last step is nothing but a pure power grab by politicians. Freedom means freedom from government. The right to open a new service or create a new product. To compete for a living.


As more medical treatments, drugs, device are invented, there is more to buy, and hence costs will rise. This is an awesome situation! And it will keep getting "worse". And we want it to get worse!

The more stuff to buy = more costs = longer, healthier lives. Restricting profit slows development, and more people suffer because of that than socialized medicine helps.

We want to be buried in so many treatments 50% of our income goes to it!

The fraudulent narrative is that companies are "sticking it to you". Well, if they have a patent, stick away! That's how patents aid innovation. The fraud is that socialized medicine pretends you'll have the same treatment, cheaper, when in fact you won't have it at all. Hundreds of economic "experiments" last century showed a massive, crystal-clear relationship between profit and innovation.


And to those who want to rely on doctors' kindness and desire to save lives to make up the slack in a socialized system, you are a sorry piece of humanity.

[Ivor the Engineer]

http://www.mssm.edu/msjournal/71/71_4_pages_231_235.pdf

Historically, most physicians have believed that it is their ethical duty as a patient’s agent to do everything medically beneficial for that patient without regard to cost. Of course, the patient has to pay the cost. A patient who cannot afford the care a physician believes is beneficial raises a difficult dilemma. If the patient is already in the physician’s care, duty requires that the care be provided
anyway. Therefore, to avoid financial disaster, physicians have to manage their practices so that they do not take on too many patients who will not be able to pay, taking refuge in the belief that their ethical duty extends only to those patients for whom they have accepted initial responsibility.

ETA: The author of the paper recommends physicians' remuneration is in the form of salary, rather than fee-for-service.

[D'rok]

I believe some of the top medical officials in the Canadian government also practice, openly, illegal private services. Nobody cares.
Citation needed.

The Canadian system is a single-payer insurance system - i.e. the govt pays for everyone's insurance. Delivery is a mixed bag of public and private, but it is not not the federal govt that is providing health care and delivery is, in fact, largely private. This is partly due to Canadian federalism wherein provinces have constitutional jurisdiction over administration of health care, but only the federal govt has sufficient resources to fund it.

Long story short...there is nothing illegal about private health services. Private for profit health services would violate the Canada Health Act if those services were part of the existing govt funded universal coverage.

I go to see my doctor at a private clinic; he sends the bill to the govt.

[Safe-Keeper]

Sick around the world (http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/) is an interesting look at how other countries do health care.

It's a curious slope. "Everyone needs health care!" turns into "Government will provide it to make sure everyone has it!" turns into "Only government will provide it, and other ways are now illegal!"What's your point? If you have to take things to extremes to argue against them, what point do you have? I could do the same thing to you and take the right-wing stance to a Dystopian extreme out of Jennifer Government (http://en.wikipedia.org/wiki/Jennifer_Government), in which the police (sorry, the NRA) only respond to 911 calls from people who can pay them, employees' last name denote which company they work for, taxation is abolished, and narcotics sold in supermarkets... but I wouldn't make much of a point if I did, would I?

[dudalb]

It's a curious slope. "Everyone needs health care!" turns into "Government will provide it to make sure everyone has it!" turns into "Only government will provide it, and other ways are now illegal!"

That is my big fear about National Health Care in the US.
I believe in some sort of Health Coverage for everybody, but I sure as hell do not want a Government monopoly on it, and feel that if somebody wants to pay extra for health care above what he pays in taxes, that is his right.
And I don't see why making a profit from Health Care is any more evil then making a profit from selling food, or any other necessity.

[Mark6]

Long story short...there is nothing illegal about private health services. Private for profit health services would violate the Canada Health Act if those services were part of the existing govt funded universal coverage.

Assuming a doctor wanted to do that, how would he even go about doing it?

I go to see my doctor at a private clinic; he sends the bill to the govt.
Is it legal for a doctor to charge the patient extra -- above what government will pay? I know a dentist in Albany, NY who charges patients 2-3 times what most insurance companies will pay. He still submits claims to the insurance companies, and they do pay what they normally would for a given dental procedure -- the patient makes up the difference. The reason patients still go to him is because he is so much better than other dentists. Is this possible in Canada?

[balrog666]

Government provided Medicare for everybody!

What a good idea! Yah! :rolleyes:

[D'rok]

Assuming a doctor wanted to do that, how would he even go about doing it?

I don't know. I'm pretty sure that a private clinic that was charging patients for publicly insured services would get shut down in a big hurry.

Is it legal for a doctor to charge the patient extra -- above what government will pay? I know a dentist in Albany, NY who charges patients 2-3 times what most insurance companies will pay. He still submits claims to the insurance companies, and they do pay what they normally would for a given dental procedure -- the patient makes up the difference. The reason patients still go to him is because he is so much better than other dentists. Is this possible in Canada?

Definitely not. The govt sets the prices for billable services and the Canada Health Act explicitly prohibits extra billing.

[Ivor the Engineer]

<snip>

And I don't see why making a profit from Health Care is any more evil then making a profit from selling food, or any other necessity.

Making a living from health care is not evil. Making a lot of money from health care by exploiting the inevitable market failure that occurs because the consumer is unable to make an informed choice is unethical. Claiming to operate under the principles laid down by medical ethics and then refusing to (or more likely pretending someone else will) treat those that cannot meet your fee is hypocritical.

There is a better chance a market will work as desired for products such as food, since consumers have access to most of the information they need to make an informed choice.

[Mark6]

There you go. If I were that dentist, I would not live in a country with Canada's laws. Why should I settle for being paid less than what patients, free to choose a cheaper dentist, are willing to pay me?

Notice that the patients in question were not paying him "2-3 times" what they would pay elsewhere. More like seven times. Insurance company in US will pay maybe $100 for a filling. Most dentists charge about $120, with patient paying $20. If he charged $250 and insurance company still reimbursed only $100 -- you do the math.

Which gives you an idea just how good that particular dentist is, as he does not lack in clients. Canada-style health care drives out quality service.

[D'rok]

There you go. If I were that dentist, I would not live in a country with Canada's laws. Why should I settle for being paid less than what patients, free to choose a cheaper dentist, are willing to pay me?

I should have been clearer. Dental care is not covered by public insurance. Dentists can charge whatever the market will bear. My statements are only true for covered services. Dental insurance is private.

Nonetheless, I don't understand your objection. If Dental care was publicly covered, all dentists would bill the govt the same amount for the same service. No one would be "free to choose a cheaper dentist" because all patients would pay the same thing for dental care at the point of delivery - nothing.

Notice that the patients in question were not paying him "2-3 times" what they would pay elsewhere. More like seven times. Insurance company in US will pay maybe $100 for a filling. Most dentists charge about $120, with patient paying $20. If he charged $250 and insurance company still reimbursed only $100 -- you do the math.

Which gives you an idea just how good that particular dentist is, as he does not lack in clients. Canada-style health care drives out quality service.

I am missing the logical connection between your premises and your conclusion. Your conclusion seems to be ideological rather than factual.

[Bob Blaylock]

There is a better chance a market will work as desired for products such as food, since consumers have access to most of the information they need to make an informed choice.


In other words, consumers are too stupid to shop for their own medical services in a free market, so we need Big Brother to protect us by removing all our choices, lest we make the wrong ones.

[Mark6]

I should have been clearer. Dental care is not covered by public insurance. Dentists can charge whatever the market will bear. My statements are only true for covered services. Dental insurance is private.

Sounds like we have a failure in communication. This is the situation I am describing:

1. Insurance provider pays X amount for a dental procedure.

2. Most dentists charge X + some small Y. Patient pays Y out of his pocket. Y value may vary.

3. Some dentist only charge X. Patient pays nothing.

4. Nothing prevents a dentist from charging X + very large Y, possibly more than X. Insurance provider will still pay only X. Patient will pay much larger amount. Obviously, he will get business only if he is significantly better than other dentists.

My impression from your previous post was that (4) is illegal in Canada. Looks like impression was wrong for dentists, but not for doctors.

In US the situation in question is the norm for dental care -- insurance companies will pay fixed, known amount for any given procedure. In medical care it is more flexible, but still insurance carriers will not pay much more than "average" cost of procedure. But that's the average of what all doctors charge. Those at high end charge more. Patient makes up the difference.

Nonetheless, I don't understand your objection. If Dental care was publicly covered, all dentists would bill the govt the same amount for the same service. No one would be "free to choose a cheaper dentist" because all patients would pay the same thing for dental care at the point of delivery - nothing.

My conclusion is that an outstanding dentist -- or doctor, -- in US can get more money than an average one, yet people who can not afford him can still get average care for relatively very little money. (Assuming they have health insurance.) Doctors have an incentive to become outstanding, which they lack in Canada. And may lack under national health care plan in US, if it ends up identical to Canada's.

[Kestrel]

Citation needed.

The Canadian system is a single-payer insurance system - i.e. the govt pays for everyone's insurance. Delivery is a mixed bag of public and private, but it is not not the federal govt that is providing health care and delivery is, in fact, largely private. This is partly due to Canadian federalism wherein provinces have constitutional jurisdiction over administration of health care, but only the federal govt has sufficient resources to fund it.

Long story short...there is nothing illegal about private health services. Private for profit health services would violate the Canada Health Act if those services were part of the existing govt funded universal coverage.

I go to see my doctor at a private clinic; he sends the bill to the govt.

Your doctor is also free to practice medicine without checking first with an insurance company clerk.

[D'rok]

Sounds like we have a failure in communication. This is the situation I am describing:

1. Insurance provider pays X amount for a dental procedure.

2. Most dentists charge X + some small Y. Patient pays Y out of his pocket. Y value may vary.

3. Some dentist only charge X. Patient pays nothing.

4. Nothing prevents a dentist from charging X + very large Y, possibly more than X. Insurance provider will still pay only X. Patient will pay much larger amount. Obviously, he will get business only if he is significantly better than other dentists.

My impression from your previous post was that (4) is illegal in Canada. Looks like impression was wrong for dentists, but not for doctors. (2) and (4) are illegal in Canada (but not for dentists or other providers of non-public services). Doctors that provide publicly insured services must conform to (3).

In US the situation in question is the norm for dental care -- insurance companies will pay fixed, known amount for any given procedure. In medical care it is more flexible, but still insurance carriers will not pay much more than "average" cost of procedure. But that's the average of what all doctors charge. Those at high end charge more. Patient makes up the difference.

My conclusion is that an outstanding dentist -- or doctor, -- in US can get more money than an average one, yet people who can not afford him can still get average care for relatively very little money. (Assuming they have health insurance.) Doctors have an incentive to become outstanding, which they lack in Canada. And may lack under national health care plan in US, if it ends up identical to Canada's.Ok. I understand what you're saying. Here's where I think you aren't making a good argument. You are making an assumption that the only incentive for excellence in the medical profession is the opportunity to bill high. I think you would have to back that up with data. Are medical professionals in universal systems like Canada's really less outstanding? Would you admit the possibility that doctors could have incentives other than money to strive for excellence?

Also, I should point out that doctors are very well paid in the Canadian system, even though they surely do not make as much as the top, top earners in the USA.

[D'rok]

Your doctor is also free to practice medicine without checking first with an insurance company clerk.
Yup. I can't be denied service.

[Ivor the Engineer]

In other words, consumers are too stupid to shop for their own medical services in a free market, so we need Big Brother to protect us by removing all our choices, lest we make the wrong ones.

I do not equate stupid with having a lack of information or the knowledge to make informed decisions based on information provided.

Having said that, should physicians be allowed to exploit people of low intelligence or those who cannot make informed choices?

[Mark6]

Ok. I understand what you're saying. Here's where I think you aren't making a good argument. You are making an assumption that the only incentive for excellence in the medical profession is the opportunity to bill high. I think you would have to back that up with data. Are medical professionals in universal systems like Canada's really less outstanding? Would you admit the possibility that doctors could have incentives other than money to strive for excellence?
Yes, I admit that doctors have incentives other than money to strive for excellence. However, I think that giving them money incentive as well is a positive thing.

"Are medical professionals in universal systems like Canada's really less outstanding?" Yes, I would have to do research to answer this question. Which is not easy considering that "outstanding" is a somewhat subjective term. But I will try :)

[ponderingturtle]

There you go. If I were that dentist, I would not live in a country with Canada's laws. Why should I settle for being paid less than what patients, free to choose a cheaper dentist, are willing to pay me?


And I am sure you would never want to live in a country that you couldn't use your money to live longer than someone of less means. Provided you were not the person of less means.

[ponderingturtle]

In other words, consumers are too stupid to shop for their own medical services in a free market, so we need Big Brother to protect us by removing all our choices, lest we make the wrong ones.

Damn you FDA, for all the things you have outlawed.

[Mark6]

And I am sure you would never want to live in a country that you couldn't use your money to live longer than someone of less means. Provided you were not the person of less means.
Life is not fair. Bill Gates, Bill Clinton, and Hugh Hefner can afford medical care I can not. So what? Prices drop. Ten years from now I will be able to afford what they can afford now -- even while some newest procedure will remain out of my reach. I still prefer to live in the country where medicine advances fastest, even if the price of it is newest life-saving procedure are only available to those of great means.

[quixotecoyote]

Life is not fair. Bill Gates, Bill Clinton, and Hugh Hefner can afford medical care I can not. So what? Prices drop. Ten years from now I will be able to afford what they can afford now -- even while some newest procedure will remain out of my reach. I still prefer to live in the country where medicine advances fastest, even if the price of it is newest life-saving procedure are only available to those of great means.

Are you sure you have your facts straight?

I have a sneaking suspicion the thought process here went:

"US style healthcare systems lead to the fastest health care advances.

We know this because the fastest health care advances come from US style systems."

[Mark6]

I have a sneaking suspicion the thought process here went:

"US style healthcare systems lead to the fastest health care advances.

We know this because the fastest health care advances come from US style systems."
Are you saying that's not the case?

[Ivor the Engineer]

Life is not fair. Bill Gates, Bill Clinton, and Hugh Hefner can afford medical care I can not. So what? Prices drop. Ten years from now I will be able to afford what they can afford now -- even while some newest procedure will remain out of my reach. I still prefer to live in the country where medicine advances fastest, even if the price of it is newest life-saving procedure are only available to those of great means.

Got access to a stem-cell trachea transplant (http://www.guardian.co.uk/society/2008/nov/19/stem-cell-transplant-claudio-castillo) in the US?

[thesyntaxera]

The more stuff to buy = more costs = longer, healthier lives. Restricting profit slows development, and more people suffer because of that than socialized medicine helps.

Is there any evidence that backs this statement up, or is this just a blanket assumption based largely on a personal bias against national health systems?

The fact is:
http://student.pnhp.org/content/what_about_physician_salaries.php

Salaries are not that different...
Any drop in income a physician might experience under a single-payer system would be mitigated by a drastic reduction in practice costs. For instance, the average malpractice premium for an Ob/Gyn, the medical specialty with the highest malpractice rates, was $195,000 in Florida for 20045. Comparatively, in the most expensive province in Canada for 2008, the malpractice rate for an Ob/Gyn was $33,563.28 annually, or $161,000 less than Florida’s6.

If a person is only practicing medicine because it makes them a lot of money then perhaps they should be doing something different for a living. These debates almost always seem to revolve around the idea of income and who is making more, when it seems the most logical and certainly the most humane position is one that values human life more than money.

The United States is one of the most, if not the most expensive health care systems in the world...
The US Health Care system: Best in the World, or just the most expensive?
http://dll.umaine.edu/ble/U.S.%20HCweb.pdf

The World Health Organization's ranking of the world's health systems:
http://www.photius.com/rankings/healthranks.html

The US is 37th.

The WHO life expectancy Rating:
http://www.photius.com/rankings/healthy_life_table2.html

The US is 24th.

WHO Health Performance Ranking:
http://www.photius.com/rankings/world_health_performance_ranks.html

The US is 72nd.

WHO Total Health Expenditures as % of GDP, 2002-2005 - Country Rankings:
http://www.photius.com/rankings/total_health_expenditure_as_pecent_of_gdp_2000_to_ 2005.html

The US is number 2, after the Marshall Islands.


So, the quick summary is that countries with National Health Insurance have better care all around, and have lower spending compared to completely private systems. Also, that wage differences aren't that significant.

[Mark6]

Got access to a stem-cell trachea transplant (http://www.guardian.co.uk/society/2008/nov/19/stem-cell-transplant-claudio-castillo) in the US?
It happens to be today's news but does not prove anything. Some spectacular advances are bound to happen outside US. Thesyntaxera's post is much more convincing -- it is true that US life expectancy is 24th in the world despite 2nd largest per capita health care expenditures. However, US health care costs are driven up by absurdly litiginous climate which does not exist in Europe. Without it, US costs would have been much lower.

[gtc]

Sounds like we have a failure in communication. This is the situation I am describing:

1. Insurance provider pays X amount for a dental procedure.

2. Most dentists charge X + some small Y. Patient pays Y out of his pocket. Y value may vary.

3. Some dentist only charge X. Patient pays nothing.

4. Nothing prevents a dentist from charging X + very large Y, possibly more than X. Insurance provider will still pay only X. Patient will pay much larger amount. Obviously, he will get business only if he is significantly better than other dentists.

Australia has a mixed public/private medical system. We are covered by the public system and can choose to take out private insurance.

Amongst other things, the public system involves public hospitals and subsidies for visits to GPs and medicines.

The government will pay a certain amount towards the cost of visiting a GP, I am free to choose which GP I visit and how often I visit. Some GPs charge an additional fee on top of the government subsidy, others do not. I am not sure if there is any regulation of fees.

Generally medicines are subsidised by the government with a top up fee set by the pharmacist. Pensioners pay a nominal fee of a few dollars and generic medicines are cheaper than brand names. The top up fee varies from location to location and I don't know if it is regulated.

Private health insurance doesn't cover the costs of visiting a GP or purchasing medicine as far as I am aware.

If I need to visit a hospital I can choose a public hospital, which may involve a waiting list or a private hospital, where the waiting list is hopefully shorter. Our state government was recently accused of refusing to let patients onto the waiting list for public hospitals as a way of curbing waiting lists.

As far as I am aware, public hospitals are generally free with private hospitals charging a top up fee on top of the amount covered by private health insurance. The size of the top up fee, if any, depends on the level of health insurance purchased. I don't know if the government subsidises private hospitals as well as public. I think private insurers have lists of approved private hospitals and specialists etc to ensure that costs are reasonable.

Dentistry is covered by private insurers, I don't know of the extent to which the government subsidises this.

[Ivor the Engineer]

It happens to be today's news but does not prove anything. Some spectacular advances are bound to happen outside US. Thesyntaxera's post is much more convincing -- it is true that US life expectancy is 24th in the world despite 2nd largest per capita health care expenditures. However, US health care costs are driven up by absurdly litiginous climate which does not exist in Europe. Without it, US costs would have been much lower.

So are you saying you think physicians need an even larger share of the power in the physician-patient relationship to protect them from being sued?

[Mark6]

So are you saying you think physicians need an even larger share of the power in the physician-patient relationship to protect them from being sued?
Well, do you think British doctors are overly protected from being sued?

The difference between US tort system and that of the rest of Western world (including Britain) is that in the rest of Western world, LOSER PAYS. Consequently in Britain people initiate lawsuits only if they have reasonable expectations of winning -- in case of doctor-patient relationship, only if doctor really did something wrong. In US anyone can sue a doctor (or anyone else, for that matter) with absolutely no danger to themselves. A lot of tort lawyers accept cases on "percentage fee" basis -- if plaintiff loses the case he pays nothing, if plaintiff wins, the lawyer gets a percentage. The defendant has to pay lawyer fee even if he wins. Most tort cases never reach the court -- the defendant (doctor, in this case) pays the plaintiff just to get rid of him; it is actually cheaper than winning the case. Whether or not he did anything wrong. Doctors' malpractice insurance premiums reflect the fact that any doctor can be sued at any time. Do you see now why US medical costs are highest in the world?

[Ivor the Engineer]

But hang on. You claim to have the best health care system in the world. Why on earth would so many physicians in the US be being sued if they all provide such a good service?

BTW, IIRC most claims in the UK are against hospital trusts rather than individual physicians.

[Mark6]

But hang on. You claim to have the best health care system in the world.

I never claimed that. I claimed it is most conducive to innovation.

Why on earth would so many physicians in the US be being sued if they all provide such a good service?
Because too many people are greedy and can get away with it.

[Lonewulf]

Well, do you think British doctors are overly protected from being sued?

The difference between US tort system and that of the rest of Western world (including Britain) is that in the rest of Western world, LOSER PAYS. Consequently in Britain people initiate lawsuits only if they have reasonable expectations of winning -- in case of doctor-patient relationship, only if doctor really did something wrong. In US anyone can sue a doctor (or anyone else, for that matter) with absolutely no danger to themselves. A lot of tort lawyers accept cases on "percentage fee" basis -- if plaintiff loses the case he pays nothing, if plaintiff wins, the lawyer gets a percentage. The defendant has to pay lawyer fee even if he wins. Most tort cases never reach the court -- the defendant (doctor, in this case) pays the plaintiff just to get rid of him; it is actually cheaper than winning the case. Whether or not he did anything wrong. Doctors' malpractice insurance premiums reflect the fact that any doctor can be sued at any time. Do you see now why US medical costs are highest in the world?

I didn't think about this angle, myself. But I have heard of it several times; my psychologist had some problems with being sued himself, and it did some real harm to his practice.

Either way, it does seem to be causing more harm than good to both doctors and patients alike.

[luchog]

But hang on. You claim to have the best health care system in the world.

No, he didn't.

Why on earth would so many physicians in the US be being sued if they all provide such a good service?

He just said why, weren't you paying attention?

In the US tort system, even if the doctor wins, he loses, because the cost of winning is often higher than the cost of simply settling the suit. This applies to many different industries besides medicine.

Because of this situation people sue for every little thing, and it's very easy and cheap to file such a lawsuit. So greed ensures that many people will file spurious lawsuits, knowing that the doctors will simply settle out of court, rather than ensuring the expensive and hassle of a trial. Even large corporations will typically settle rather than endure the cost of a suit. It's free money if you can work it right.

[Ivor the Engineer]

No, he didn't.

Quite correct.

He just said why, weren't you paying attention?

In the US tort system, even if the doctor wins, he loses, because the cost of winning is often higher than the cost of simply settling the suit. This applies to many different industries besides medicine.

Because of this situation people sue for every little thing, and it's very easy and cheap to file such a lawsuit. So greed ensures that many people will file spurious lawsuits, knowing that the doctors will simply settle out of court, rather than ensuring the expensive and hassle of a trial. Even large corporations will typically settle rather than endure the cost of a suit. It's free money if you can work it right.

Right, so Americans are greedy and will screw each other over to make an extra dollar. Do you think this attitude may extend to those in the medical profession, or are physicians different to the typical American?

How could you, as a patient, tell if your physician was selling you more health care than you would choose given more knowledge? Or perhaps even worse from a patient's point of view, was not referring you on to another more appropriate physician to avoid loosing the fee for treating you?

[Darat]

Still waiting for arguments as to why a private system is innately superior to a public funded system.

As for those in the USA who seem to be very skeptical that their government could do as good a job as other governments do throughout the world in ensuring very good health coverage for everyone, that is just an argument that your government needs improvement not an argument for private health care. (Given how successful many other governments are at ensuring all their populations receive excellent health care.)

[Boran]

Dental filling: 25 €, get 17,80 € Back. I'm not complaining.

There is still a free choice of which dentist to go to. You go to the one that makes you feel at ease and does the best job.

I dunno if the doctors and dentists think this system is great however. Who doesnt want to earn more ?

[Jaggy Bunnet]

Still waiting for arguments as to why a private system is innately superior to a public funded system.

Has anyone claimed it is?

I would also question whether there is any conflict between a private system and a public funded system. After all the NHS is public funded, but that does not mean that there are not elements of it that are private - for example most GP's are self-employed (or partners in a small partnership) and employ staff / manage costs to make their business profitable - i.e. they operate a private business.

The thread appears to be about whether it is ethical for anyone to provide medical services for profit. Most GP's in the NHS do so.

[Jaggy Bunnet]

(2) and (4) are illegal in Canada (but not for dentists or other providers of non-public services). Doctors that provide publicly insured services must conform to (3).

As a hypothetical, say I needed a non-urgent appointment with a doctor. Could I pay to get an appointment when it suited me (say an evening or weekend appointment) as opposed to having to take time off work to attend? It appears from what you have posted that this would be illegal.

[gtc]

As a hypothetical, say I needed a non-urgent appointment with a doctor. Could I pay to get an appointment when it suited me (say an evening or weekend appointment) as opposed to having to take time off work to attend? It appears from what you have posted that this would be illegal.

In Australia you might be lucky and find a late night medical centre that charges no fee on top of the government payment or you might have to pay an excess. Is that the situation in Scotland?

[Francesca R]

I would also question whether there is any conflict between a private system and a public funded system. After all the NHS is public funded, but that does not mean that there are not elements of it that are private - for example most GP's are self-employed (or partners in a small partnership) and employ staff / manage costs to make their business profitable - i.e. they operate a private business.Without smart enough rules I find it easy enough to imagine that there could be a conflict, with private healthcare supply crowding out state supply. The combination of both "works" in the UK because laws disallow that.

The thread appears to be about whether it is ethical for anyone to provide medical services for profit.It isn't unethical per-se but there are important sources of market failure that present themselves in for-profit healthcare--which are more significant than in other markets (that can be less tightly regulated)--the principal/agent problem, asymmetric information (adverse selection) and moral hazard to name a few.

[Jaggy Bunnet]

In Australia you might be lucky and find a late night medical centre that charges no fee on top of the government payment or you might have to pay an excess. Is that the situation in Scotland?

No, in Scotland you are registered with a specific GP practice and can only get an appointment at that practice. There are out of hours services but they are very much focussed on urgent treatment.

There is much talk at the moment about having "extended hours" available (covered by the NHS) - it appears that this amounts to a requirement to provide an additional 3 appointments per 1,000 patients per week. So on average each patient can have one extended hours appointment roughly every six years.

http://www.sehd.scot.nhs.uk/pca/PCA2008(M)04.pdf

http://www.scotland.gov.uk/News/Releases/2008/09/09133207

I do not see an ethical problem with a GP offering Saturday morning appointments for an additional fee to be paid by the patient rather than for an additional fee paid by the NHS.

[Jaggy Bunnet]

Without smart enough rules I find it easy enough to imagine that there could be a conflict, with private healthcare supply crowding out state supply. The combination of both "works" in the UK because laws disallow that.

Why is state supply important? If the service is free at the point of delivery, who cares if the person providing it is employed by a quasi-government body (NHS trust), a small private, for-profit partnership (GP services) or a large multinational company (independent sector treatment centres)?

[Ivor the Engineer]

Why is state supply important? If the service is free at the point of delivery, who cares if the person providing it is employed by a quasi-government body (NHS trust), a small private, for-profit partnership (GP services) or a large multinational company (independent sector treatment centres)?

The amount of profit a physician or company make should not be linked to how much treatment a patient consumes based on their advice.

The profit motive has no place in the ethical (or economic) provision of health care.

[D'rok]

As a hypothetical, say I needed a non-urgent appointment with a doctor. Could I pay to get an appointment when it suited me (say an evening or weekend appointment) as opposed to having to take time off work to attend? It appears from what you have posted that this would be illegal.Extra-billing is explicitly prohibited by the Canada Health Act. "Two-tiered" health care (where those with means can buy services unavailable to those without) is a non-starter here.

But your hypothetical is a non-issue. You could just go to your local clinic that is open in the evenings and on weekends. There's several a few minutes away from me right now. They aren't unusual.

[Ivor the Engineer]

<snip>

It isn't unethical per-se

<snip>

Because private physicians can rely on someone else to help a person in need of medical care who cannot pay their fee?

[Jaggy Bunnet]

The amount of profit a physician or company make should not be linked to how much treatment a patient consumes based on their advice.

The profit motive has no place in the ethical (or economic) provision of health care.

So you oppose the existing GP model present throughout the UK NHS?

[Jaggy Bunnet]

Extra-billing is explicitly prohibited by the Canada Health Act. "Two-tiered" health care (where those with means can buy services unavailable to those without) is a non-starter here.

Thanks for clearing that up.

But your hypothetical is a non-issue. You could just go to your local clinic that is open in the evenings and on weekends. There's several a few minutes away from me right now. They aren't unusual.

Could you clarify, are these clinics designed to provide "routine" medical services (e.g. if you need a vaccination prior to travelling abroad on holiday) or are they intended to deal with urgent cases only? The UK model is currently very much the latter, with some steps being made towards the former.

[Francesca R]

Why is state supply important? If the service is free at the point of delivery, who cares if the person providing it is employed by a quasi-government body (NHS trust), a small private, for-profit partnership (GP services) or a large multinational company (independent sector treatment centres)?In the limiting case, all suppliers move to the "for-profit" sector and charge what they like (the consumer has no incentive not to consume the service because the government pays). Health care remains universal but at the cost of a disastrous deterioration in public finances.

[Jaggy Bunnet]

Because private physicians can rely on someone else to help a person in need of medical care who cannot pay their fee?

How about those who choose to train as engineers rather than as doctors? Are they not equally guilty of relying on someone else to help a person in need of medical care?

[Jaggy Bunnet]

In the limiting case, all suppliers move to the "for-profit" sector and charge what they like (the consumer has no incentive not to consume the service because the government pays). Health care remains universal but at the cost of a disastrous deterioration in public finances.

Given that we currently have pretty much all GP services provided in the "for-profit" sector, do you consider that this has already happened?

If not, what has prevented it and why would that not apply to other areas of healthcare?

[Francesca R]

Because private physicians can rely on someone else to help a person in need of medical care who cannot pay their fee?Because private physicians are not violating ethics in seeking profit from their activity.

[D'rok]

Could you clarify, are these clinics designed to provide "routine" medical services (e.g. if you need a vaccination prior to travelling abroad on holiday) or are they intended to deal with urgent cases only? The UK model is currently very much the latter, with some steps being made towards the former.

Definitely "routine". These types of medical clinics are staffed by General Practitioners, and patients go to them for all basic medical services. From there, a patient may get referred to a specialist if necessary (at a hospital or a special clinic). For an urgent problem I would go directly to the emergency room of a hospital.

[Jaggy Bunnet]

Definitely "routine". These types of medical clinics are staffed by General Practitioners, and patients go to them for all basic medical services. From there, a patient may get referred to a specialist if necessary (at a hospital or a special clinic). For an urgent problem I would go directly to the emergency room of a hospital.

I'm jealous. Hopefully we will get to that stage one day.

In the meantime, I see no ethical problem with a GP who is meeting his contractual obligations under his contract to supply the NHS with services choosing to offer an additional service that is not covered under that contract directly to patients willing to pay for it.

[D'rok]

I'm jealous. Hopefully we will get to that stage one day.

In the meantime, I see no ethical problem with a GP who is meeting his contractual obligations under his contract to supply the NHS with services choosing to offer an additional service that is not covered under that contract directly to patients willing to pay for it.

Don't be too jealous. Our constitutional order (federalism, with health care under provincial jurisdiction) means that we can never have a truly nationalized system. We're stuck with a patchwork system run by the provinces and (under)funded by the feds and plagued by power struggles between the two levels of government.

[Ivor the Engineer]

So you oppose the existing GP model present throughout the UK NHS?

Where they are paid extra for providing medical treatment, yes.

Medical treatment is either required or not required.

[Francesca R]

Given that we currently have pretty much all GP services provided in the "for-profit" sector, do you consider that this has already happened?Not yet in my view, but movement in that direction has occurred. As I understand things, the government (via the NHS) negotiates what it pays to GP businesses, and apparently gave providers a pretty generous deal when the GP contract was set up in 2004, so there has been room for GPs themselves to significantly increase their income under those terms, which I believe they have. Politically the message has been that doctor's pay was "too low" before so there is nothing wrong with this. Recall this was accompanied by a large increase in the Department of Health's budget. But it is not clear what happens when GP pay is no longer "too low" and what forces stop it rising "too high".

If not, what has prevented it and why would that not apply to other areas of healthcare?What has prevented it so far is the short history. What can prevent it in the future is government spending caps and government bargaining power.

[Mark6]

Because private physicians can rely on someone else to help a person in need of medical care who cannot pay their fee?
Partly, yes. Food is a necessity, and most modern countries recognize that people who can not afford it should receive sufficient assitance from the state not to go hungry. Nobody thinks that state assistance should pay for caviar, and very few think that caviar should be banned because some people can not afford it.

I think you and I (or you and Francesca) have a very basic disagreement. You think it is unethical for some people to have access to medical care which some others have no access to. I disagree. As I said, I do not begrudge Hugh Hefner and Bill Clinton top-flight experimental care I can not afford. First it means Hugh and Bill are paying for the significant chunk of medical research -- as opposed to it being entirely funded with my taxes. Second, it creates motivation for medical researchers which do not exist otherwise. Again, basic disagreement -- you think profit motive has no place in medical care. I say profit motive is essential in ALL innovation, whether medical, or space, or food production. Almost all major technological breakthroughs in history were done by people who wanted to get rich.

And there is one more, highly ironic benefit. Buying latest experimental treatments, rich people serve as additional (and often ONLY) human trials for these said treatments. I am all for guinea pigs paying for the lab!

[Jaggy Bunnet]

Don't be too jealous. Our constitutional order (federalism, with health care under provincial jurisdiction) means that we can never have a truly nationalized system. We're stuck with a patchwork system run by the provinces and (under)funded by the feds and plagued by power struggles between the two levels of government.

Lets see, patchwork system that is not truly nationalized: Check - we have primary care trusts (303 in England alone) that set their own priorities and decide whether or not to fund certain treatments.

Underfunded - some would say it is, some would say it isn't. I think few would argue that the huge additional resources committed in recent years have been matched by a corresponding increase in results.

Power struggles: Check - do a google on postcode lottery NHS. An almost inevitable outcome of the existing structure.

[Francesca R]

Medical treatment is either required or not required.Suppose there are not enough doctors? Raise their income or coerce people to practice medicine?

[Jaggy Bunnet]

Not yet in my view, but movement in that direction has occurred. As I understand things, the government (via the NHS) negotiates what it pays to GP businesses, and apparently gave providers a pretty generous deal when the GP contract was set up in 2004, so there has been room for GPs themselves to significantly increase their income under those terms, which I believe they have. Politically the message has been that doctor's pay was "too low" before so there is nothing wrong with this. Recall this was accompanied by a large increase in the Department of Health's budget. But it is not clear what happens when GP pay is no longer "too low" and what forces stop it rising "too high".

The GP contract was not set up in 2004, it was renegotiated. I absolutely agree that the deal the GP's got was very generous. However I don't see what that has to do with the fact they have a profit motive - had they been employed they would simply have negotiated a large pay rise, instead of a large increase in charges.

What has prevented it so far is the short history. What can prevent it in the future is government spending caps and government bargaining power.

Short history? GP's have always been private businesses operating within the NHS. Is 60 years really too short a period to judge it?

The controls seem to be exactly the same things that would apply whether the government was negotiating with the BMA about new contract terms for provision of services by GP businesses or if the government was negotiating with a hypothetical NHS doctors union over a new pay deal. I don't see why the latter (a state supply model) is necessarily any more efficient/cheaper than the former - if the people negotiating on behalf of the government are poor at their job (as they appear to have been) then the public finances suffer either way.

[Jaggy Bunnet]

Where they are paid extra for providing medical treatment, yes.

Medical treatment is either required or not required.

So you think that paying a bonus to a GP practice that has achieved a target rate of flu vaccination coverage among vulnerable sections of the population is unethical?

[Ivor the Engineer]

How about those who choose to train as engineers rather than as doctors? Are they not equally guilty of relying on someone else to help a person in need of medical care?

No. The OP was with respect to medical ethics. I.e. How people who have been trained and agreed to help people with their medical problems should behave.

Do private physicians take a different ethics course at medical school to those physicians who don't discriminate based on potential patients' ability to pay?

[Francesca R]

Short history? GP's have always been private businesses operating within the NHS. Is 60 years really too short a period to judge it?Have private firms been able to completely buy out GP businesses (so that they no longer provide any services under the NHS) before very recently?

[Ivor the Engineer]

Suppose there are not enough doctors? Raise their income or coerce people to practice medicine?

Raise their income. Just make sure they can't increase their income by advising their patients to consume more treatment.

[Francesca R]

Raise their income. Just make sure they can't increase their income by advising their patients to consume more treatment.Well I agree with that, but it's completely different from not allowing them to make a profit. So you've climbed down from that? (Or did you never say it?)

[Ivor the Engineer]

So you think that paying a bonus to a GP practice that has achieved a target rate of flu vaccination coverage among vulnerable sections of the population is unethical?

No. Payment for achieving prescribed extra output is not unethical.

I do think it is potentially counter-productive from a PR point of view.

[Jaggy Bunnet]

Have private firms been able to completely buy out GP businesses (so that they no longer provide any services under the NHS) before very recently?

I'm not sure what you mean. Can you clarify?

GP businesses ARE private firms. They are typically run as partnerships where the doctors are the partners and entitled to the profits the business makes.

GP businesses have always had the choice of providing NHS services or not.

[Ivor the Engineer]

Well I agree with that, but it's completely different from not allowing them to make a profit. So you've climbed down from that? (Or did you never say it?)

I think I said the profit motive has no place in the provision of health care. I.e. the decision of how much medical treatment to provide (including no treatment at all) to a person in need should not be based on that person's ability to pay.

[Jaggy Bunnet]

No. Payment for achieving prescribed extra output is not unethical.

Strange, it was you who said you opposed the GP model "Where they are paid extra for providing medical treatment, yes." was it not?

Now you are saying that when they are both paid for doing it (per vaccination) and paid a BONUS if they achieve a target level, this is OK?

Which is it? Either it is unethical to pay them to provide medical treatment or it is not - you can't have it both ways.

[Jaggy Bunnet]

I think I said the profit motive has no place in the provision of health care. I.e. the decision of how much medical treatment to provide (including no treatment at all) to a person in need should not be based on that person's ability to pay.

But it can be based on the state's willingness to pay, as in the vaccination example?

So it is unethical for a doctor to charge me to administer a vaccination to go on holiday, but ethical for him to charge the state and earn a bonus to vaccinate me against flu?

Lets say I was one day too young to qualify for a free flu jab under the incentivised NHS scheme but I offered to pay him as a private patient at exactly the same rate as he would have earned from the NHS had I been a day older. Is it unethical of him to agree to provide the vaccination?

[Ivor the Engineer]

Strange, it was you who said you opposed the GP model "Where they are paid extra for providing medical treatment, yes." was it not?

Now you are saying that when they are both paid for doing it (per vaccination) and paid a BONUS if they achieve a target level, this is OK?

Which is it? Either it is unethical to pay them to provide medical treatment or it is not - you can't have it both ways.

Flu vaccination is not a good example because it is possible to argue it is not a medical need.

A better example would be a reduction in the average number of days patients spend waiting for surgery. In this case the need for treatment is not open to subjective interpretation and extra payment for increased output is not unethical.

In general the promise of reward for a particular course of treatment should not be in physicians' minds when they are deciding on treatment because it will distort their judgement to some extent.

[Ivor the Engineer]

But it can be based on the state's willingness to pay, as in the vaccination example?

So it is unethical for a doctor to charge me to administer a vaccination to go on holiday, but ethical for him to charge the state and earn a bonus to vaccinate me against flu?

Lets say I was one day too young to qualify for a free flu jab under the incentivised NHS scheme but I offered to pay him as a private patient at exactly the same rate as he would have earned from the NHS had I been a day older. Is it unethical of him to agree to provide the vaccination?

As I said before, flu vaccination is a poor example because it can be argued it is not a medical need, rather a wanted risk reduction.

[Jaggy Bunnet]

Flu vaccination is not a good example because it is possible to argue it is not a medical need.

Would you say the same about MMR vaccination? Guess what, incentive payments based on results apply there as well.

[Jaggy Bunnet]

As I said before, flu vaccination is a poor example because it can be argued it is not a medical need, rather a wanted risk reduction.

No flu vaccination is a great example, because it shows that you can deliver healthcare benefits by giving doctors financial incentives.

I can understand why you want to try and ignore that, but that does not make it a bad example.

[Jaggy Bunnet]

In this case the need for treatment is not open to subjective interpretation and extra payment for increased output is not unethical.

This is simply not true. There are a number of conditions where surgery is an option as a treatment, but not the only option.

One simple example:

http://orthoinfo.aaos.org/topic.cfm?topic=A00349

"Treatment
A partial tear of the ACL may or may not require surgical treatment. A complete tear is a more serious injury. Complete tears, especially in younger athletes, may require reconstruction. Both nonsurgical and surgical treatment options are available for ACL injury. "

[Ivor the Engineer]

No flu vaccination is a great example, because it shows that you can deliver healthcare benefits by giving doctors financial incentives.

I can understand why you want to try and ignore that, but that does not make it a bad example.

Vaccination is a poor example because it generally does not address an individual need, but a public health initiative for a group. I.e. the objective is to persuade people to choose to be vaccinated. If it is know the medical professional giving them information on the benefits and risks of vaccination is being paid for every person they get to choose to be vaccinated, his/her advice is runs the risk of being discounted because of perceived bias.

[Jaggy Bunnet]

Vaccination is a poor example because it generally does not address an individual need, but a public health initiative for a group. I.e. the objective is to persuade people to choose to be vaccinated. If it is know the medical professional giving them information on the benefits and risks of vaccination is being paid for every person they get to choose to be vaccinated, his/her advice is runs the risk of being discounted because of perceived bias.

I seriously doubt that risk is higher than if the person giving them information is a paid employee of a government agency that is promoting the benefits of vaccination. Both have a perceived bias.

There are problems with incentives and piecework in the medical field (in particular I am aware of some horrific stories involving dentists). However there are problems with having no incentives as well - if a doctor can do no extra work and earn the same amount of cash, what is going to encourage him to commit effort, time and his own resources to deliver better results?

For example, the flu incentive might make it worth while for a GP to contact unvaccinated individuals rather than wait for them to show up at the surgery.

[Francesca R]

I'm not sure what you mean. Can you clarify?

GP businesses ARE private firms. They are typically run as partnerships where the doctors are the partners and entitled to the profits the business makes.

GP businesses have always had the choice of providing NHS services or not.I don't think you mean what I do. The first such example dates from 2006

http://www.networks.nhs.uk/news.php?nid=800

[Jaggy Bunnet]

I don't think you mean what I do. The first such example dates from 2006

http://www.networks.nhs.uk/news.php?nid=800

We do appear to be talking at cross purposes.

What I mean is that your local GP surgery is (very probably) owned and operated by a partnership. The partners in that partnership are likely to be some or all of the doctors that operate out of the surgery. That partnership then has a contract with the local primary care trust to provide services - for which it is paid at agreed rates. The partnership pays its own costs and the difference between the two is profit, which is shared by the partners.

It is a private sector business.

[Francesca R]

I think I said the profit motive has no place in the provision of health care. I.e. the decision of how much medical treatment to provide (including no treatment at all) to a person in need should not be based on that person's ability to pay.This is inconsistent with your previous statement. If you have to entice a person into being a physician with higher income, you are giving them a profit motive to provide a medical service, relative to doing something else, and effectively leaving putative patients to go whistle.

[Francesca R]

It is a private sector business.Yes--regulated, reasonably smartly perhaps, or as smart as it is possible to do so under the doctrine of freely delivered essential medical service to all. Dismantle a few of those regs and there exists a potential for conflict between that doctrine and private supply of medical care. The conflict is not entirely absent now either. How could it be? It is not as if the interests of all parties are perfectly aligned.

[Ivor the Engineer]

This is inconsistent with your previous statement. If you have to entice a person into being a physician with higher income, you are giving them a profit motive to provide a medical service, relative to doing something else, and effectively leaving putative patients to go whistle.

It is not inconsistent at all. What you are talking about is the provision of medical professionals, not the provision of treatment by those medical professionals.

[Francesca R]

It is not inconsistent at all. What you are talking about is the provision of medical professionals, not the provision of treatment by those medical professionals.Can't really see how you separate the two. It seems that you want to attract people to medicine with monetary incentives, but thereafter have no connection between their contribution to the profession and any monetary incentives. Right?

[Jaggy Bunnet]

Yes--regulated, reasonably smartly perhaps, or as smart as it is possible to do so under the doctrine of freely delivered essential medical service to all. Dismantle a few of those regs and there exists a potential for conflict between that doctrine and private supply of medical care. The conflict is not entirely absent now either. How could it be? It is not as if the interests of all parties are perfectly aligned.

Is there any evidence that the GP practice referred to in the link you posted will operate under a different regulatory environment? Apologies if this is in the link, I only skimmed it and didn't see anything.

BTW, my knowledge of GP practice structures is not completely current - it is entirely possible that since I dealt with them they may have changed their legal form to use limited companies or limited liability partnerships. However they are, and always have been, private sector businesses.

http://216.239.59.132/search?q=cache:J3Es-l4s2DIJ:www.uk200group.co.uk/nmsruntime/saveasdialog.asp%3FlID%3D2061%26sID%3D397+business +structure+general+practice+partnerships+NHS&hl=en&ct=clnk&cd=3&gl=uk

I don't understand what you mean by the doctrine of freely delivered essential medical service for all. As far as GP's are concerned, they do not do it for free, they do it for payment - that the payment comes from the NHS rather than direct from the patient does not make it free.

[Francesca R]

Is there any evidence that the GP practice referred to in the link you posted will operate under a different regulatory environment? Apologies if this is in the link, I only skimmed it and didn't see anything.It's not about evidence so much as about incentives, to my mind. Evidence in the form of quite steep rises in GP salaries since the 2004 reform of the GP contract might qualify for what happens in the absence of effective control of state purse strings. But I imagine(d) from what you've written on this that your knowledge is greater than mine

I don't understand what you mean by the doctrine of freely delivered essential medical service for all. As far as GP's are concerned, they do not do it for free, they do it for payment - that the payment comes from the NHS rather than direct from the patient does not make it free.I mean, this is public policy. No it is not GP policy I know. So you have partially--but not completely--aligned interests and partially--but not completely--opposing interests. I would say that this makes for a somewhat, but not completely, stable co-operative equilibrium.

[Ivor the Engineer]

Can't really see how you separate the two. It seems that you want to attract people to medicine with monetary incentives, but thereafter have no connection between their contribution to the profession and any monetary incentives. Right?

I want no connection between the provision (or not) of treatment to individual patients and monetary incentives. Further, I do not see how a physician refusing to treat those in need of medical attention because they cannot afford his/her fee is compatible with the principles of medical ethics.

There is a straightforward solution. Physicians accept their remuneration via a salary from a third party rather than fee for service.

[Francesca R]

I want no connection between the provision (or not) of treatment to individual patients and monetary incentives. Further, I do not see how a physician refusing to treat those in need of medical attention because they cannot afford his/her fee is compatible with the principles of medical ethics.

There is a straightforward solution. Physicians accept their remuneration via a salary from a third party rather than fee for service.Then I think you substitute one moral hazard (the risk of a patient not being able to afford treatment and going without) for another (the risk of a physician not delivering beneficial treatment because they are paid the same regardless). I don't think that is a smart solution. I think the "hybrid" represented by the UK NHS is superior to both of those.

[luchog]

Right, so Americans are greedy and will screw each other over to make an extra dollar. Do you think this attitude may extend to those in the medical profession, or are physicians different to the typical American?
What makes you think it's just Americans? Do you truly believe that Canadians, British, Australians, Dutch, French, etc. wouldn't do the same thing if their system permitted it? If you believe that, then explain why Americans are so inherently different.

It's nothing to do with being Americans, it has to do with simple human nature, and a system with a huge, exploitable loophole.

And this is hardly limited to the medical industry. It affects every major industry in the country. It indicates a need for tort reform, not for socialism.

[gtc]

Medical treatment is either required or not required.

That isn't true at all. As an example, take a 90 year old person who is assessed to be at a significant risk of developing a fatal stroke. The treatment available would lead to severe side-effects that would drastically reduce their quality of life. Should the patient be given the treatment?

This is a real example, although I forget whether it was a stroke that was the danger, and it was the treatments that were prescribed for the side-effects of the treatment that were drastically reducing the quality of life.

As I said before, flu vaccination is a poor example because it can be argued it is not a medical need, rather a wanted risk reduction.

Arguably, all treatments are 'risk reduction'. From antibiotics to pills that reduce blood pressure.

Then I think you substitute one moral hazard (the risk of a patient not being able to afford treatment and going without) for another (the risk of a physician not delivering beneficial treatment because they are paid the same regardless). I don't think that is a smart solution. I think the "hybrid" represented by the UK NHS is superior to both of those.

That bears repeating. I also think it is wrong to presume that Doctors have to be shielded from the profit-motive lest they start turning patients away. It is presuming that no doctor would work 'pro-bono' or that they wouldn't feel ethically bound to help the needy.

I know lawyers, physio-therapists, occupational therapists, engineers and financial planners (all of whom work in profit-driven industries) who volunteer their time to help the needy.

[ConspiRaider]

Okay troops, quiet down. Quiet down I said! Got an announcement to make so... SHUT UP, EVERYONE! All right, now as... Corporal Kroger? You want to take the band-aid off your tongue now? No. No, I've already tried that and so has half the platoon. You cannot get high off the band-aid adhesive, check? C'mon people, cut it out and listen up.

So. We got our orders and are moving out at 1830 hours to defend Pvt Healthcare. Yeah, I know. Quiet down, folks. Don't like him much neither... Kroger? The probe? Get the hell away from PFC Lewis and lose the probe! The probe doesn't go in there, it goes back in your medikit. He does? Well I don't want to hear about it. What happens in your foxhole STAYS in your foxhole. Foxhole! Yes, you're foxy. And you have a nice tongue depressor. Hoo boy, can you please let me finish??? Sheez!

Back to Private Healthcare. He'll never make PFC if I have anything to say about it. Reckless jerk-weed. Anyway he's stormed the enemy's camp hospital, is now holed up in the vasectomy ward and he needs our support. By the way the enemy demanded his surrender and you know what he said? He said: "Nuts!" Hey, okay HEY it wasn't... stop throwing stuff at me... it wasn't THAT BAD of a joke, huh? Lewis, put down the MRI machine. Kroger, button up your peekaboo sweater and pay attention! Is that sweater authorized, government issue? Hey who cares, I won't write you up. But come to my tent at one-thirty in the morning so we can discuss alternate maneuvers...

[Ivor the Engineer]

Medical treatment is either required or not required.

That isn't true at all. As an example, take a 90 year old person who is assessed to be at a significant risk of developing a fatal stroke. The treatment available would lead to severe side-effects that would drastically reduce their quality of life. Should the patient be given the treatment?

This is a real example, although I forget whether it was a stroke that was the danger, and it was the treatments that were prescribed for the side-effects of the treatment that were drastically reducing the quality of life.

This story highlights how important it is that physicians give unbiased advice to their patients. Only the patient can decide if this kind of treatment is required or not after weighing up the advantages and disadvantages.

As I said before, flu vaccination is a poor example because it can be argued it is not a medical need, rather a wanted risk reduction.

Arguably, all treatments are 'risk reduction'. From antibiotics to pills that reduce blood pressure.

Yes, no treatment is 100% effective and no diseases have guarenteed outcomes, though many do come close.

Then I think you substitute one moral hazard (the risk of a patient not being able to afford treatment and going without) for another (the risk of a physician not delivering beneficial treatment because they are paid the same regardless). I don't think that is a smart solution. I think the "hybrid" represented by the UK NHS is superior to both of those.

That bears repeating. I also think it is wrong to presume that Doctors have to be shielded from the profit-motive lest they start turning patients away. It is presuming that no doctor would work 'pro-bono' or that they wouldn't feel ethically bound to help the needy.

It is presuming no such thing. Fee for service is a conflict of interest. Refusing to treat patients based on their ability to pay is incompatible with medical ethics. The hybrid system for NHS GPs that Francesca seems to prefer raises another moral hazard: get as many patients through the office doors to maximise revenue at the minimum expenditure. Effective treatment becomes secondary!

I know lawyers, physio-therapists, occupational therapists, engineers and financial planners (all of whom work in profit-driven industries) who volunteer their time to help the needy.

Good for them (and those they help).

[Ivor the Engineer]

What makes you think it's just Americans? Do you truly believe that Canadians, British, Australians, Dutch, French, etc. wouldn't do the same thing if their system permitted it? If you believe that, then explain why Americans are so inherently different.

No, I don't believe Americans are fundamentally different.

It's nothing to do with being Americans, it has to do with simple human nature, and a system with a huge, exploitable loophole.

I agree.

And this is hardly limited to the medical industry. It affects every major industry in the country. It indicates a need for tort reform, not for socialism.

So how is that a defence of private healthcare? You seem to be making my case for me by stating human nature is to be greedy, and systems need to be set up so this inherent greed does not significantly disadvantage other people or groups.

[Gurdur]

.... And this is hardly limited to the medical industry. It affects every major industry in the country. It indicates a need for tort reform, not for socialism.


Luchog, IMvHO this is bollocks. Could you please give some actual data to show what percentage of American health costs are caused by legal problems/insurance against suits, and show therefore that that plays a significant role in the reason why Americans have to pay on average as taxpayers more than twiceas much per year than an average French, British, Danish or German taxpayer for the equivalent level of healthcare? And explain why 100% of French, British, Danish and Germans are covered by health insurance, but only 85% or less of Americans are?

I'm saying the tort matter is a red herring and is immaterial to the real costs. Please feel very free to prove me wrong.

[Thanz]

However, US health care costs are driven up by absurdly litiginous climate which does not exist in Europe. Without it, US costs would have been much lower.
The absurdly litigious climate has been, in large part, fostered by the lack of a universal health care system. Let's say some dude slips and falls and breaks his leg, and he doesn't have medical insurance. He needs to go to the hospital and is eventually charged $20,000 for the services he receives. He is now in the hole $20,000 that he really can't afford. So, he sues the building/store owner/ city or whoever to recover these medical costs, even if he thinks it was just an accident as he really needs the money to pay off the hospital. He goes before a jury, they sympathize with his plight, and he gets some cash. And this cycle continues.

On the other hand, the same guy breaks his leg in Canada but has no $20,000 medical bill. He recognizes it as just an accident, but doesn't have a huge financial incentive to sue, so he gets on with his life without suing. And therefore you don't have a huge litigitious climate.

[gtc]

This story highlights how important it is that physicians give unbiased advice to their patients. Only the patient can decide if this kind of treatment is required or not after weighing up the advantages and disadvantages.

With the doctor.

It is presuming no such thing. Fee for service is a conflict of interest. Refusing to treat patients based on their ability to pay is incompatible with medical ethics. The hybrid system for NHS GPs that Francesca seems to prefer raises another moral hazard: get as many patients through the office doors to maximise revenue at the minimum expenditure. Effective treatment becomes secondary!

You say it is presuming no such thing and then you post something that does appear to be presuming just such a thing.

[thesyntaxera]

The absurdly litigious climate has been, in large part, fostered by the lack of a universal health care system. Let's say some dude slips and falls and breaks his leg, and he doesn't have medical insurance. He needs to go to the hospital and is eventually charged $20,000 for the services he receives. He is now in the hole $20,000 that he really can't afford. So, he sues the building/store owner/ city or whoever to recover these medical costs, even if he thinks it was just an accident as he really needs the money to pay off the hospital. He goes before a jury, they sympathize with his plight, and he gets some cash. And this cycle continues.

On the other hand, the same guy breaks his leg in Canada but has no $20,000 medical bill. He recognizes it as just an accident, but doesn't have a huge financial incentive to sue, so he gets on with his life without suing. And therefore you don't have a huge litigitious climate.

Exactly. When you remove the cost factor to the recipient it streamlines the whole process. It could also be one of the reasons why malpractice insurance is cheaper in countries that supply free medical services as well.

[Ivor the Engineer]

<snip>

You say it is presuming no such thing and then you post something that does appear to be presuming just such a thing.

Why do you presume the only way for a doctor to make money from his/her medical knowledge and skills is by treating patients?

[Francesca R]

What makes you think it's just Americans? Do you truly believe that Canadians, British, Australians, Dutch, French, etc. wouldn't do the same thing if their system permitted it? If you believe that, then explain why Americans are so inherently different.

It's nothing to do with being Americans, it has to do with simple human nature, and a system with a huge, exploitable loophole.

And this is hardly limited to the medical industry. It affects every major industry in the country. It indicates a need for tort reform, not for socialism.With respect to the healthcare business--nonsense. It is because American healthcare has a less optimal incentive structure than most of Europe. With that comment you appear to join the list of people who "defend" the US system by attempting to point out that universal health care does not work any better. Again, nonsense.

[Francesca R]

Fee for service is a conflict of interest. Refusing to treat patients based on their ability to pay is incompatible with medical ethics. The hybrid system for NHS GPs that Francesca seems to prefer raises another moral hazard: get as many patients through the office doors to maximise revenue at the minimum expenditure. Effective treatment becomes secondary!That's right I prefer it. It is superior to both "fee regardless of whether you serve or not" and "if you can't pay, no service". There exists no system with perfectly aligned interests. It is a question of rigging the incentives so that the price system delivers the best outcome that is compatible with society's moral preferences.

[Francesca R]

With respect to the healthcare business--nonsense. It is because American healthcare has a less optimal incentive structure than most of Europe. With that comment you appear to join the list of people who "defend" the US system by attempting to point out that universal health care does not work any better. Again, nonsense.ETA--your post is probably saying no such thing, actually. So please disregard that /apologies.

However, tort reform is less of a need if the system is set up so that tort injury is not likely to be your first recourse. If you denounce changing the system (to universal health care) on some doctrinarian principle ("because it's socialism") then, well, I think you have the blinkers on.

[Ivor the Engineer]

Francesca, may I ask what your profession is?

(I have an idea, but I don't wish to jump to conclusions.)

[Ivor the Engineer]

That's right I prefer it. It is superior to both "fee regardless of whether you serve or not" and "if you can't pay, no service". There exists no system with perfectly aligned interests. It is a question of rigging the incentives so that the price system delivers the best outcome that is compatible with society's moral preferences.

Strangely my terms and conditions are not "fee regardless of whether you serve or not", but "salary if you serve, fired if you don't".:)

I have little chance of earning significantly more money (excluding standard yearly pay rises), yet I am expected to continue to innovate for the company and its shareholders. And I do, because by and large I enjoy my work.

Do you really think the NHS would struggle to find competent, enthusiastic people to fill jobs paying £40000 to £100000 (depending on job role and responsibility) per year?

[Francesca R]

Strangely my terms and conditions are not "fee regardless of whether you serve or not", but "salary if you serve, fired if you don't".:)Ok then. That's "service-related" compensation and whereas the system has moved significantly towards "performance-related" compensation.

Do you really think the NHS would struggle to find competent, enthusiastic people to fill jobs paying £40000 to £100000 (depending on job role and responsibility) per year?I think that performance-related compensation should and does find more of them, and improves the quality of service delivered.

[ponderingturtle]

It happens to be today's news but does not prove anything. Some spectacular advances are bound to happen outside US. Thesyntaxera's post is much more convincing -- it is true that US life expectancy is 24th in the world despite 2nd largest per capita health care expenditures.

Wait, who out spends the US in health care?

[ponderingturtle]

Partly, yes. Food is a necessity, and most modern countries recognize that people who can not afford it should receive sufficient assitance from the state not to go hungry. Nobody thinks that state assistance should pay for caviar, and very few think that caviar should be banned because some people can not afford it.

So when is living and not being in pain a right vs a luxury?

[boooeee]

In regards to private healthcare, much is made of how much the US spends per capita on healthcare, relative to other OECD countries, with the blame often placed on our private healthcare system.

It is true that in 2006, the US spent $6,102 per capita, compared to France, which spent $3,159, and the UK, which spent $2,508 (Source (http://assets.opencrs.com/rpts/RL34175_20070917.pdf))

However, of the $6,102 that the US spent, 44.7% was publicly financed. That works out to $2,728. That's already more than the UK and very close to what France spends. Publicly financed healthcare in the US primarily covers the poor (Medicaid) and seniors (Medicare).

What I take away from this is that healthcare in the US is expensive, regardless of public or private delivery, and that blaming the private system for our high cost of healthcare doesn't really hold up.

So, why is our healthcare so much more expensive? Is our delivery system that much more inefficient than European-style systems?

Are we somehow subsidizing the cost of developing medical technology for the rest of the world? To me, that is the best argument in defense of private healthcare. Unfortunately, it seems hard to come up with evidence either way to answer that question. Any links would be appreciated.

[jimbob]

Wait, who out spends the US in health care?

The Marshall Islands on a per-capita basis

[jimbob]

Is there any evidence that backs this statement up, or is this just a blanket assumption based largely on a personal bias against national health systems?

The fact is:
http://student.pnhp.org/content/what_about_physician_salaries.php

Salaries are not that different...


If a person is only practicing medicine because it makes them a lot of money then perhaps they should be doing something different for a living. These debates almost always seem to revolve around the idea of income and who is making more, when it seems the most logical and certainly the most humane position is one that values human life more than money.

The United States is one of the most, if not the most expensive health care systems in the world...
The US Health Care system: Best in the World, or just the most expensive?
http://dll.umaine.edu/ble/U.S.%20HCweb.pdf

The World Health Organization's ranking of the world's health systems:
http://www.photius.com/rankings/healthranks.html

The US is 37th.

The WHO life expectancy Rating:
http://www.photius.com/rankings/healthy_life_table2.html

The US is 24th.

WHO Health Performance Ranking:
http://www.photius.com/rankings/world_health_performance_ranks.html

The US is 72nd.

WHO Total Health Expenditures as % of GDP, 2002-2005 - Country Rankings:
http://www.photius.com/rankings/total_health_expenditure_as_pecent_of_gdp_2000_to_ 2005.html

The US is number 2, after the Marshall Islands.


So, the quick summary is that countries with National Health Insurance have better care all around, and have lower spending compared to completely private systems. Also, that wage differences aren't that significant.


Here was my earlier analysis of this:

It gets better than that:

The US state spends a similar amount on healthcare to the UK state, and in 2004 (at least) a higher proportion of its GDP than the UK....

So more tax was spent on healthcare in the US than the UK.


Yup: some further evidence from an earlier thread:

The US state alone spends more of its GDP on healthcare than the UK: for as system that is far form universal.




The death rate is higher in the US too, and not all can be explained by higher gun ownership:



In answer to the assertion that the rest of the world is freeloading on the US medical research, which is lowering death rates, a lot of the mortality and morbidity is preventable with better primary healthcare.

[Beerina]

So, why is our healthcare so much more expensive? Is our delivery system that much more inefficient than European-style systems?

Are we somehow subsidizing the cost of developing medical technology for the rest of the world? To me, that is the best argument in defense of private healthcare. Unfortunately, it seems hard to come up with evidence either way to answer that question. Any links would be appreciated.

It would be interesting to see the statistics. Some people claim a big chunk is dealing with all the paperwork, others say that's not an issue.

Some say it's drug costs, others say that's not really an issue.



At the very least, though, since we don't have laws mandating this or that price for things, that the companies developing them do charge more than they otherwise would because the rest of the world doesn't kick in to reward their hard work.


Shame! :mad:



If the Twilight Zone teleported the US, Europe, and the rest of the world to different planets, I think the stats show the US's medical technology would pull ahead of Europe's or the ROW's.

What benefit, then, of socialized medicine?


But because the world shares medical tech, such a massive and obvious problem never shows up. A person with cancer and no insurance in front of the cameras today is worth millions dying fifty years from now because a cancer cure was delayed by two decades.

It's a sickening version of compound interest. :(

[volatile]

Beerina - do you have any evidence for that ludicrous statement at all? I continue to be perplexed why you remain so ideologically committed to a worse, more expensive, less effective system.

[Ivor the Engineer]

Beerina - do you have any evidence for that ludicrous statement at all? I continue to be perplexed why you remain so ideologically committed to a worse, more expensive, less effective system.

No, he got it from the Cato institute (http://en.wikipedia.org/wiki/Cato_Institute).

The Cato Institute is a libertarian think tank headquartered in Washington, D.C.

The Institute's stated mission is "to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets, and peace" by striving "to achieve greater involvement of the intelligent, lay public in questions of (public) policy and the proper role of government." Cato scholars conduct policy research on a broad range of public policy issues, and produce books, studies, op-eds, and blog posts. They are also frequent guests in the media.

ETA: He also seems to be unable to separate the development of healthcare from the provision of healthcare, believing providing equity in the latter will negatively affect the former.

[ponderingturtle]

The Marshall Islands on a per-capita basis

Becuase of the high rate of Leprosy?

[ponderingturtle]

But because the world shares medical tech, such a massive and obvious problem never shows up. A person with cancer and no insurance in front of the cameras today is worth millions dying fifty years from now because a cancer cure was delayed by two decades.

It's a sickening version of compound interest. :(

Not really. Look at all the people dying from diseases that can be cured now, that no one cares about.

This also takes it as an assumption that the US health care system is much better at medical innovation than other systems. You would expect the US to develop many new medical technologies for the same reason the US develops many new technologies of all kinds. Being the weathiest and most advanced nation on earth.

[ponderingturtle]

ETA: He also seems to be unable to separate the development of healthcare from the provision of healthcare, believing providing equity in the latter will negatively affect the former.

he also totaly ignores the falures of the current methods of distributing health care.

Think of the millions of lives in africa that could be saved every year for a small percentage of the US health care budget. It is a sickening form of compound intrest.

[Darat]

Lets see, patchwork system that is not truly nationalized: Check - we have primary care trusts (303 in England alone) that set their own priorities and decide whether or not to fund certain treatments.

Underfunded - some would say it is, some would say it isn't. I think few would argue that the huge additional resources committed in recent years have been matched by a corresponding increase in results.

...snip...

Put me in with the "few" - I have been a regular "customer" of the NHS since I was 13 and the difference that I have seen over the last 10 years or so is, well the only word I can think of is revolutionary. The standard of care has just leaped beyond recognition.

[Darat]

It would be interesting to see the statistics. Some people claim a big chunk is dealing with all the paperwork, others say that's not an issue.

Some say it's drug costs, others say that's not really an issue.



At the very least, though, since we don't have laws mandating this or that price for things, that the companies developing them do charge more than they otherwise would because the rest of the world doesn't kick in to reward their hard work.


Shame! :mad:

...snip..

So lets see: there is a market for company's products, a company wishes to maximise its profits so it charges each customer the maximum it can get them to pay for the product and that is "Shame! :mad:"

You are arguing against a "free market" approach!