Sat Jul 4 09:34:43 UTC 2009

Gezondheids-zorg, reactie op Amerikaanse = Nederlandse privatiseringsbeleid.

Stemming: ja 1, nee 0, onbekend 0, onthouding 0, afgehandeld ja

Aan: de mensen. In reactie op - (engels).

I've thought some time about the health-care system from a fundamental economic perspective, because it is the most difficult subsystem. Infrastructure, Police, Justice, Government are easy: nationalize it. Simple productivity like backeries and farming: free market.

Health care has fundamental economic problems:

[-] Buyers don't wish to buy, they are forced to buy because of an emergency (illness).
[-] Buyers don't know beforehand they will get sick.
[-] Cost of treatment beforehand is often unknown.
[-] Serious hospitals contain so much equipment and skills that if they go bankrupt, it could disrupt society seriously.
[-] Small hospital like services can go bankrupt.
[-] Patients often visit only a few or even one hospital in their entire life, and therefore are not in a position to judge services from direct experience. They have to find the best one based on hear say.
[-] Hospitals are such complicated operations that while one department may be of world class perfection, another might be substandard in the region.
[-] Hospital visits will often be decades apart, in which time a hospital could change its competence drastically up or down wards.
[-] When patients can choose their hospital, the hospital has a reason to do well in case the payment structure is such that healing is rewarded and incompetence punished. Because of the insurance situation this link is not a given like it is in any other market: an insurer has for example a financial interest in terminating an expensive patient, and has a financial interest in rewarding hospitals who terminate expensive patients on its behalf.
[-] Hospitals can be places where many volunteers work, which is also technically not the logic of the free market (which doesn't mean I'm against volunteer labor!).
[-] The technicalities of the treatment are so difficult that only the professionals themselves understand it; and even they often don't.

In other words: I don't see a bigger economic challange then health care. Finance ? Finance is not difficult at all: it must be democratized, socialized, and nationalized. Finance is a piece of cake compared to health care.

So I thought this scheme might work, comments appreciated. These ideas are to work in a DAVID economy, which is an economy where business finance is socialized, land is distributed, companies become democracies after starter leaves, and the government is a true democracy.

[-] Small hospital/clinic operations can be free market, like backeries and shops. But, of course, they need to comply with quality standards because the public is in no position to judge quality. The public must be protected from malpractices, and so does the honorable competition who do make all the necessary costs. Health care is too final and definite to a person its life, it is a lot worse then having a bad cup of coffee for once when it goes wrong (after which one can still casually switch to a better service).

I'm not going to argue each point, takes too long, it shouldn't be hard to see why:

[-] Big hospitals could *rent* all the equipment from the Government.
[-] Big hospitals could be divided into smaller money flow independent management units (idea already done somewhere in Holland, said to work).
[-] Big hospitals are run by internal and/or state democracy.

[-] Nationalized, minimum services mandatory to be insured. Hospital does not look at who is insured but treats all patients regardless. Technically a non-insured person is someone who hasn't payed its state taxes ("state" mean country/nation Government here).
[-] Insurance (state) pays hospitals for treatments.
[-] Patients can choose freely to whatever hospital they want to go within the nation. It may be necessary to avoid insurance fraud to have a case by case examination by a state agency. For example: a fraudster and a private doctor and surgeon pretend a heart problem, pretend an operation for 80.000,-, then split the insurence money. It might also work that the examination is made afterwards, if possible (for example in case of a heart-transplant it could probably be detected that it took place ?). As things are with law enforcement: you only have to investigate a certain percentage, and punish hard. If you only test 20% of all cases, and close hospitals and throw the guilty in jail in case of frauds, then the other 80% are probably going to be ok because of fear.

Then I thought the following might work, because you run the risk that hospitals that are most expensive will attract most patients, so that can spiral out of control. Although you could limit that problem by direct management. Maybe that is sufficient already, probably is.

[-] Insurance pays, say, 99% of all medical bills, and 100% of all bills above a sum that all people should be able to afford easily (or pay back easily), say 1 month of average wages (or 2 weeks).

That way the public will also weigh in the cost of treatments, and choose a hospital that has a better cost/quality balance. They won't always want to go to the most expensive for the insurence because they don't pay the direct bills anyway. They'd be paying a small amount, if done right just enough to make the people choose cheaper if the price difference doesn't buy anything worthwhile for them. A bit of payment for hospital visits also keep the number of visits down, although some specialists say that is something that should *not* be done because people stay home with serious illnesses too long. In that case examinations should be made 100% insured.

It remains to be seen if this set up with its additional bureaucratic cost is worth the trouble - perhaps not (probably not?). But it brings in some structural market pressures to produce cheaper from the side of the public, which seems to be a good principle at least.

I don't guarantee that this is the best way, but it seems to me it is a reasonable attempt given the complexity of the field. We should listen closely to what the medical specialists say and how they want things to improve quality. People in the field tend to have the best ideas.

I think that very simple nationalized health-care tends to work historically, and that privatized health care (big hospitals, big insurence) tends not to work. That said, small time private dentists and other specialist practices also clearly work very well.

So the answer is probably at least the nationalization of insurence and big hospitals, and free market for small operations, and good quality control. There can then still be a market for luxury health care insurence.

One important point is, I think: internal hospital democracy. The nurses and support staff also know what they are doing, and should have more of a say in how they do things. As long as there is adequate quality research/control, it should be OK. Hospitals can be steered both by state quality control demands (revoking license), and the amount of money they get from state insurence for a service (finance), and the willingness of the state to purchase/hire to that hospital group equipment (finance), and the preference of partially money motivated patients (market pressures).

One might note that the state can then make the decision as to whether hospitals will provide extremely high cost treatments, using moneys which might also save or improve suffering / life elsewhere. That seems to be the proper platform to make that decision. (Compare: private health care providing extremely high cost treatments only for the super-rich, who often stole their money in the first place.)

Reasonable ? Too complicated ? Wrong ? Let's see how it works ? Doing = knowing. It won't be perfect in every instance, but I think it could more or less be a stable system. Then finally politics can get out of health care and quit their eternal re-organizations. Hospitals and medical people can then concentrate finally on their work (provided it is a functioning system). If it works in one nation it can be replicated to the others.