Monday, April 20, 2009

A Visit to a Socialized Dentist

The streets were quiet as we made our way through the business district late one night in the dead of the Norwegian winter. Sticking to the shadows, we found the professional building at the address scrawled on a piece of notebook paper.

As promised, we found the unlit rear entrance unlocked. We looked around to make sure nobody was observing the alley we were in, and then we quickly slipped inside, locking the door behind us. We quietly walked down the darkened corridor and found the office we were looking for. We knocked using the sequence we had been given. A voice quietly said to come in quickly.

On the other side of the door we found ourselves in the darkened waiting room of a dental office. A tense faced dentist quietly led us through the dark to a small treatment room that had no exterior windows. Once inside, he switched on the lights. “I have to be careful,” he said. “I could lose my job for this.”

Even though I had seen most of the office only in half light, it was apparent that it was neat, orderly, and well cared for. But everything about the office, from the appointments and furnishings to the equipment and supplies was like stepping into a U.S. dental office twenty years earlier. I marveled about this, because Norway has one of the highest living standards in the world. When I made some comment about the office’s retro appearance, the dentist looked at me strangely. “This office is among the most modern in the country,” he proclaimed.

The dentist wasted no time seating my companion in the treatment chair. He then found that he needed to return to the cabinet for some supplies. “I’m sorry,” he said, “my assistant usually handles this part, but I can’t have her here because she can’t know that you have ever been here.”

When the dentist opened the cabinet, he opened a panel to a seemingly hidden compartment, from which he drew out several items. “I can’t use the regular supplies,” he said, “because the ministry tightly controls those. I have these supplies because we secretly store anything that is left over after a procedure, just in case we need it later.”

When the dentist prepared to inject an anesthetic, my companion asked why he didn’t use gas instead. Was the cavity too deep for that? No, the dentist replied. It was just that the gas was metered so that it couldn’t be misused. Regulators could easily discover any gas usage that had not been approved.

The dentist had a pleasant treatment manner and seemed quite proficient. He drilled and filled the cavity and then prepared to send us on our way. He instructed us to let ourselves out, making sure that no cleaning people were in the outer corridor and making sure that no one saw us leaving the building.

“I don’t quite understand all the stealth,” my companion said. “Can’t you treat anyone you want to treat?” “In Norway,” replied the dentist, “all of the means to do dental and medical treatment are either owned or controlled by the state. There are strict rules about how anything can be used. The rules are all well intended, but sometimes they have unfortunate consequences.”

When my companion asked what he meant, the dentist said, “Sometimes I can’t do what I know is best for the patient. The ministry, for example, will let me do only a certain number of certain procedures each month. Once I’ve hit that limit, if a patient needs that treatment I have to tell them no, even if they’re in great pain. That’s why I hoard as many supplies as I can, so that I can treat people in the last week of the month if they need it. Everyone knows that all dentists do this, but no one can talk about it. If you get caught, you’ll lose your license. Treating foreigners like you out of charity is strictly forbidden. If anyone finds out about this visit, I will lose my license.”

“This all seems so wrong,” said my companion. “Well,” replied the dentist, “it’s one of the prices you pay for having socialized medicine. You can visit a doctor anytime you want, but you can’t necessarily get adequate treatment, even if the doctor wishes he could provide it.”

When my companion asked how much he owed the dentist, he replied, “Nothing. I can’t take any money for performing charity. In fact, I wouldn’t even know how much to charge you for it. We don’t get paid by procedure like dentists in America do; we get paid a salary. I have no idea how much it costs to do a procedure. Only the ministry knows that kind of thing.”

“Are you leaving with us?” asked my companion. “Are you crazy?!” replied the dentist. “I will wait here for at least 20 minutes after you are gone before I dare to leave. If anyone were to see us leave together, I’d be finished.”

As we made our covert escape into the dark cold night, I couldn’t help but be struck by how strange the whole experience had been. I remarked to my companion, “At least it will never be like this back home in America.” Given the current push for socialized medicine, I may have spoken too soon.


Joe Jarvis said...

No one, not even the most liberal elements of Congress, is pressing for socialized medicine in the United States. Quit fearing the socialization of health care in this country. Fear the status quo here, in the US. The world's highest tax rates for health care. Preventable hospital caused patient injury is the 5th leading cause of death. $1 trillion in wasted health care spending. The US is least able in the first world to prevent death amenable to known and accepted clinical science. Wake up.

Anonymous said...

Because this is EXACTLY what Obama has been planning all along. It's in the white paper on 'How The Ob(s)ama Nazi-Communosocialst Cabal will implement bad ideas from every socialist welfare state' available only by secret squirrel subscription.

Seriously. What's the point other than total fear mongering?

Charles D said...

I would think that Americans, being the smart folks we are, could learn from other nation's health care systems both what to do and what not to do. Owning and controlling health care providers is obviously a bad policy and that's why no one is proposing it here.

The best proposal so far is Senate Bill 703 which sets up health security programs in each state. The state would guarantee universal coverage, determine the proper qualifications for providers, and sets the rates for services.

The services would be performed by the same private providers that we have today in private practices, group practices, or hospitals. By keeping the key controls at the state level, there is an increased ability for citizens to have a voice in system-wide decisions, and programs can be tailored to the unique needs of each state. Your Norwegian dentist might want to move to Idaho if this bill passes.

No danger of that, of course. The bill would get rid of private health insurance so most of our Congress critters wouldn't touch it with a 10-foot pole, lest it damage their fund raising.

Cameron said...

He who pays the doctor, controls the doctor.

Scott Hinrichs said...

I concur with Cameron.

Charles D said...

Yes, Cameron you are right. That's why we need to a national single-payer health care system. I don't want my doctor to be paid by someone who is interested only in maximizing profit. I want my doctor paid by someone who is focused on delivering quality care.

The private health insurers actually pay incentives to reviewers based on how many claims they deny. The penalize providers who provide "too much" care. They overrule doctors who prescribe drugs or treatments they think are too costly. I would much rather the doctor be paid by an agency that is subject to the democratic process and where the incentives are on quality of care.

Scott Hinrichs said...

While private insurance certainly has some perverse incentives, you naively ascribe only altruistic ones to government. In fact, government is ALWAYS politically motivated in all that it does. What's worse, profit motives or political motives? Both are perverse.

No one has better motives for achieving quality healthcare for me than ... ME. Go figure. It would be better to transfer as much responsibility to individuals as possible, taking care to handle catastrophically expensive care and care for those that are unable to afford basic care. This would reduce the role of all third party payers, whether they be private or public insurance schemes. Healthcare providers would suddenly find better ways to provide the care being demanded by the payers (i.e. the patients and their families) than what is being demanded by bureaucrats.

Charles D said...

No, government is not always pure and noble, but it is reliant on support by the public. If you have a health security system in your state and you don't like the way it is managed, you can complain to your governor and legislature and if they don't act, you can vote them out. If a private insurer won't pay my claims, I have little or no recourse.

A market-based approach to health care sounds good, but markets are dependent on the ability of consumers to make informed and rational choices.

First of all, you and I are simply not capable of determining what health care we need. We cannot diagnose ourselves, nor do we know about all the treatments available. We are reliant on professionals. We can't assess their performance until it's too late.

Second, we have virtually no choice in the market. If we are lucky enough to be employed by a firm that provides health care, we are usually restricted to one insurer and can only choose between an inadequate plan we can afford and an adequate one we cannot afford. If we are in the private market, we are lucky to find an insurer at all. The more likely we are to need insurance (older, sicker, etc.) the less likely we are to get it.

Third, the market is not one in which providers and consumers are on equal footing. Consumers acting individually will have no effect on provider costs or quality. Only by banding together can we hope to drive down costs. That's why we need a public, democratically controlled health system.

Unfortunately health care is so expensive now that we kid ourselves if we think we can afford it without insurance. While some of the cost increase is due to technological improvements and advances in treatment, much of it is due to the need to drive up the stock price of the financial services and pharmaceutical companies and pay for their marketing and lobbying campaigns. Those expenditures provide no value whatsoever to American health care and by eliminating them we can save hundreds of billions a year. No other option offers such clear savings.

Scott Hinrichs said...

Health care is so expensive BECAUSE it is already socialized and because government mandates coverage for all kinds of things that people would opt out of if they could. The post-WWII employer based system no longer works for the way employment functions in this day and age. If you had freedom to choose the insurance you wanted, your chances of having a claim denied would decrease dramatically.

Your claims that we are powerless in the face of an expert professional class are simply laughable. There are so many other elements of life where we are also beholden to experts, and yet Americans are entrusted to make informed choices in those arenas. How much more personal can you get than healthcare?

When you say that we don't have enough information upon which to base our choices, that is because the information transfer system is broken. In other facets of life we have this information. It is called pricing. In socialized medicine (whether public or private), that information is a closely guarded industry secret. You only find out after the fact and the figures shown on your statement don't necessarily reflect reality. Quality data is also a closely guarded secret. Make this information public, and people will soon have the knowledge they need about where to go and what treatment is worth.

The savings you claim governmentalization will bring exist only in the aether. You can criticize the private insurers for having incentive to deny claims, but government will do substantially the same thing. Rationing is how government systems achieve 'savings.'

No matter what kind of third party payer you have involved, they will take a cut of the action. The ability to petition my governor for changes to the system is nothing compared to my ability to take my money and go to a different provider. It is nothing compared to the ability to seek the kind of care I want without having some bureaucrat tell me that I can't do that.

Freedom works better than what we have today or more governmentalization.

Charles D said...

Let me go through these arguments since they are all without foundation.

1. Health care costs are not driven by government mandates (which are only required because private insurers exclude as many conditions as they can). What are the real factors in our health care costs? The Kaiser Foundation says they are:
a. Intensity of services including long-term care ( in other words, demand).
b. Prescription drugs and expensive new technologies.
c. Aging of the population
d. Administrative costs (which they show are much LOWER for Medicare than for private insurance).

2. If you are hit by a car or have a heart attack, exactly how much power will you have to select a provider? If your doctor tells you that you have cancer and need radiation, how will you evaluate that? Remember, you shouldn't rely on expert professionals, just use your own wits as an "informed" consumer. That argument is totally without merit.

3. If we had pricing information available and your daughter needed major surgery, would you go to the low cost discount surgery center? Pricing doesn't give us much information in other markets either. I can't evaluate the appropriateness or quality of anything based on its price except when the price is so low that it becomes obvious. As for quality data, I certainly would approve making that information public, but that doesn't mean the high quality providers will be in your insurer's network.

4. A national health care system will not be as driven for savings as private insurers. Saving costs by denying claims and second-guessing physicians are necessary to maximize profits. A government system doesn't need profit and the savings are so obvious (marketing, administration, executive pay, duplication of services, bulk purchasing, etc.) that rationing will no longer be necessary.

5. The idea that you can easily change insurers is ridiculous. I've been working on corporate HR and benefit systems for years and my wife is a health care provider. If you are lucky enough to have an employer that provides a choice of coverages, you can only change once a year and there's little likelihood one will be significantly better than another. The private insurance market only exists for people who are young and healthy and unlikely to actually cost the insurer much money. If you are older or have a history of illness in the family, you will be denied coverage. With single-payer health care, you can change providers at will regardless of your age or medical condition and know that all your needs will be covered.

Freedom is a great thing, but if freedom means poor health care, or bankrupting my family and losing my home because of a major illness, or putting off doctor visits and procedures because I can't afford them, then freedom is just another word for nothing left to lose.

Scott Hinrichs said...

No one is arguing that you can exercise choice in emergency situations. But relatively few conditions actually fit into that category. Why try to regulate the entire industry based on this narrow category? Instead, different approaches should be used for different categories.

If medical insurance were not tied to employment, you would be able to switch as easily as you can switch you automobile insurance.

Pricing provides plenty of information in every exchange, but it is not the only piece of information needed, just as pricing is only a piece of the information you need in deciding which auto mechanic to take you car to. Currently, all information is tightly controlled in the insured medical industry so that consumers can't begin to make an informed decision.

People make informed decisions every day on medical procedures that are not covered by insurance -- especially elective treatments such as vision improvement and cosmetic surgeries. My state's association of underwriters argues that not all procedures lend themselves to this kind of approach, but that a remarkable number of procedures do. Those procedures should move to the model that better suits them. We do not need a single faceted approach to every type of treatment.

To deny that government run insurance will be driven by the need for cost savings is to deny reality. This single issue is one of the major political issues of the day in every government entity that involves itself in healthcare.

Every time I hear someone say that government won't need to do marketing, I think of the endless commercials advocating Medicare Part D. I think of the government workers that go door-to-door trying to sign people up for SCHIP that qualify but apparently don't want it. I think of the government paid flyers promoting various Medicare options that are included in my Mom's Social Security statement each month.

No one wants people to avoid getting necessary healthcare. But millions of people WITH coverage do this every year. I also watched as my Dad received plenty of treatment that did him no good simply because it was covered. The problem was getting useful treatment that didn't happen to fit well into Medicare's coverage system. Doctors were unable to think outside of the framework forced upon them by the payer. (Also happens with private insurance.)

No one wants indigent people to be unable to get healthcare. However, several paradigms seem to be working in different areas, including privately and publicly sponsored community health centers aimed at the population that can't pay. Some of these offer to pay some of a doctor's med school expenses in return for a certain period of paid work at a clinic.

If a doctor were to tell me that I have cancer and need radiation, I sure as shootin' would seek a second opinion (from someone other than that guy's associate). Under a freer market, you'd see more cancer treatment centers that cater strongly to a patient's needs.

Regardless of the payment system, much of our current problem will remain as long as we let government dictate how many of which kinds of doctors can attend medical school. These quotas are designed to serve special interest groups. They are not designed to serve the public.

Charles D said...

If medical insurance were not tied to employment, most people couldn't afford adequate coverage - especially those who need it the most.

Yes you see lots of commercials for Medicare Part D because it is privatized. As a result it is too expensive, doesn't cover enough, and is hopelessly confusing for seniors. SCHIP suffers from being a new program that only covers some people. A universal program wouldn't have that problem.

Ideally decisions about necessary medical care should be made by doctors and patients. Currently those decisions are second-guessed and restricted by insurers whose only interest in the transaction is reducing their cost. Patients also have the additional pressure of having to weigh the necessity or advisability of care against their ability to pay the co-pays and deductibles, which can be considerable.

Doctors today are forced to work within the framework imposed on them by the payer, usually a private insurance company with no motivation to care about patients and their needs. Medicare also subcontracts their claims to private firms which usually delay payment. Because of the wide variety in coverage levels and reimbursements between private insurers, hospitals usually charge as much as they can for every service because they don't know how much of the cost any given insurer will reimburse. Having a single payer with a public schedule of prices will make that problem disappear. In addition hospitals will not have to charge insurance patients more to compensate for their losses on uninsured patients.

I would agree that we need to build community health centers and Sen. Sanders has proposed such a plan along with his health care proposal. Increasing the number of students in medical schools is also a good idea. The medical profession has restricted admissions (not the government) and the cost is prohibitive as well. We could also consider removing or relaxing the restrictions on doctors immigrating to the U.S. At this point, the average doctor graduates from med school with about $140,000 in debt. That's ridiculous.