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A doctor once explained this to me. Let me try to repeat it.
Malpractice insurance does start at about $50,000 a year. After the first
incident the insurance company pays out because it is cheaper than fighting,
the annual premium goes to at minimum of $100,000 per year. A doctor has to
get that money some place. It does not matter if the insurance company chose
to pay because it was cheaper. It does not mean the doctor was at fault. If
the doctor was at fault expect an even higher premium.
Do not fault the insurance companies. They have to pay out and still make a
profit else they go out of business. They have to take in their expenses,
their payouts and make a profit. When an insurance settlement runs over
$1,000,000 they have to take that and all their costs and a bit more for a
profit.
Lets say a doctor is like you and me and works 40 hours a week and fifty
weeks a year. That is 2000 hours a year. That means if we divide $100,000 by
200 hours we find the amount he has to make per hour just to cover insurance
premiums. That number if $50 per hour. If he sees four patients an hour
$12.50 of the fee for a visit is to pay for the insurance. And if you want
more than 15 minutes the fee cost has to increase to cover the actual cost.
If you take a half hour that is $25.00 worth of insurance and everything
else you have to cover.
To keep it easy, if the doctor pays himself $70,000 a year and a nurse
$30,000 a year that is another $100,000 a year and another $12.50 per office
visit. So just on the minimum essentials there is $25.00 per office visit.
And then of course office rental and renter's insurance, local business
licenses and taxes, all of these are included in the cost of an office
business. Contrary to popular belief there are no breaks for doctors. Office
space and all the attendent costs run $20,000 a year. Are there oxygen tanks
on the premises? That is a hazardous material which is greater insurance
costs and another license.
Other expenses are obvious. The rent for the office, the equipment for the
office. An OB-GYN is expected to have a $200,000 sonogram machine. An
oesteopath is expected to have a $150,000 X-Ray machine and a specialist to
operate it for another $30,000 per year.
All these costs vary by geography, New York City as compared to New Orleans
as compared to Tampa for example. And the suburbs of those cities as
compared to small towns. Malpractice awards, salaries, office space are all
higher in downtown Manhattan than in Omaha.
So look at the above numbers and if the average malpractice award is
$2,000,000 then $25 of an office visit goes to insurance. And you thought
$50 was a lot of money for just a visit? Half only pays for the insurance.
Income of the doctor, nurse/medical assistant and rent and equipment are
clearly the rest of the cost.
Medical care costs money. We can deal with hundreds of things these days
that were fatal fifty years ago. When a person had a serious heart attack
fifty years ago the person was sent home and advised to say goodbye to his
family. Today we can even produce a heart transplant for a price.
So there could be no frills doctors without the expensive equipment. About
95% of deliveries have no need for any fancy equipment just knowledge and
experience. But in a malpractice case failure to use the latest equipment is
a fault and liable so insurance is required. And insurance will not be
issued unless the OB-GYN has and uses the latest equipment. So there is no
way to go bare bones.
So we bootstrap ourselves into the high cost of medicine. Clearly if there
were an attempt to give everyone the best possible medical treatment and
price were no object we would run out of physicians to provide it. And we
always have to ask ourselves if ability to pay is what should govern medical
services.
We have to look at the alternative. It is impossible to give everyone the
best possible medical care. There are not enough people to give it. So what
should determine who gets what? At the moment in the US it is mostly a
matter of money. Can we do better?
Other countries have tried and they do great at basic medical care.
Emphasize the basic. And basic is all most people need. With basic care most
of the benefits of modern medicine are available to most of the people. That
means for example treating hypertension is ungodly cheap gives the greatest
bang for the buck. There are several other issues in this category favoring
the same results.
When it comes to expensive treatments other countries have failed. They
appear to fail because of the principle of greatest need rather than
greatest benefit. It is the reason the US organ transplant program fails.
The choice of who gets what depends upon the greatest need.
That sounds right until you discover most of the people in the greatest need
are those who have been waiting longest and they have been waiting so long
that they advance up the waiting list because their condition has
deteriorated because they have been waiting so long. But the longer they
wait the lesser the long term benefit. The consequence is average life
expectancy for all.
In other words, we have not rational criteria other than maximizing the
average lifespan without regard to the quality of life. We agree we cannot
judge the quality of the life of others. We have criteria which are so
neutral they present us with a moral issue by their very neutrality.
If everyone in need of an organ transplant were given one just short of
their dying for lack of the transplant we have maximized both the survival
and the suffering. As we cannot give the transplant to everyone, we maximize
suffering but not survival.
I do not have a better premise but then I don't think much about medical
ethics. I do know that wealth trumps group ethics but is the essense of
individual ethics. The essense of individual ethics is to live to ponder the
ethical issues this side of the place from which none return to reveal
ethical answers to the living.
And if wealth should not trump current medical ethics then just who gave the
tribal elders the power to use and enforce a set of rules which mandate the
greatest suffering for the greatest number so that the average lifespan is
equalized?
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