Healthcare is a subject which I tend to avoid. But a rather staggering graphic accompanying a David Leonhardt article from the New York Times prompted me to think about why the U.S. has such high healthcare costs compared to other countries. The gut response is that the U.S. might be more expensive, but must be more effective. This graphic has that covered. It isn't.
Data like this leads those who want heavier government involvement in healthcare to tremble with certainty. It inspired Leonhardt to argue for healthcare rationing. I have two different suggestions to reduce healthcare costs that I have not heard discussed very much: get more doctors and malpractice tort reform.
First, for anyone interested, here's that graphic:
Ugly. I am going to assume that the picture this graphic paints is accurate. It may not be. For example, maybe a greater percentage of all people with the given ailments are treated in the U.S., while in the other countries shown only those who have the best chance of survival are treated. I have no evidence to back this up, but selection bias should always come into question when looking at such charts. But like I said, let's assume it's accurate.
This graphic raises two problems: First, healthcares cost are too high. Second, healthcare appears to be less effective than it should be. Although my second suggestion only addresses the first of those problems, my first suggestion has both covered.
Get More Doctors
Anyone who has even the most basic grasp of economics knows that, when supply increases, price decreases. If we had more doctors, and other medical professionals, healthcare costs would go down.
So how do you get more doctors? Maybe rather than plowing billions into universal healthcare, the government should plow millions into universities for medical programs.
First, they could use this money to subsidize medical-field tuition. The prospect of paying back easily over $100,000 in medical school loans must deter many smart, capable college graduates from giving it a shot. Instead, they flock to careers like law or finance, where they can make just as much or more money, but owe less money to do so. Even undergraduate degrees in nursing or medical fields could be more scholarship-based to encourage careers in healthcare.
Second, universities can use this funding to create programs that don't currently exist. More medical schools or other healthcare-related programs mean more doctors and healthcare workers.
More doctors might also make healthcare more effective. Lighter workloads mean doctors will be less stressed and can take better care of patients.
Malpractice Tort Reform
This is very basic and popular in some circles on the right. Malpractice insurance for doctors is insanely high and grows each year. It causes doctors to charge more for services to cover those costs. But for lawyers, malpractice lawsuits can be incredibly profitable. We need to make it less profitable.
Unfortunately, given that the huge portion of Congress consisting of lawyers who got rich through legal fees, tort reform actually happening seems like a long shot. There's no question, however, that it would help the problem of healthcare costs.
Feel free to share your thoughts on these suggestions. I don't claim that they'd solve the problem entirely, but I do think they could help.
I would make medical education free to anyone who could get into med school. Several of my friends who went to med school were never money focused people until they had 100,000 dollar loans to pay off, now they are. When doctors start thnking about how to make more money rather than how to have the healthiest patients they are more likely to do things for the wrong reasons.
Brian
I wish you'd do some research on these issues before you post.
The federal government already "plow[s] millions into universities for medical programs."
National Health Service Corps funds scholarships for all sorts of health care providers to go into underserved areas. NHSC funding increased by 10% to $135 million this year.
Through Medicaid and Medicare, the federal government directs huge sums to teaching hospitals -- it pays higher reimbursements to those hospitals in order to fund the teaching programs and those sums add up to billions of dollars per year.
Agreed (on the money, not the research). The high cost of medical school is a result of the carteling of medicine, not anything inherent in the system. You can't practice medicine without a government license, and doctors' groups control the licensing requirements. It behooves their own salaries to make themselves scarce. A while back, the cost of living in London got so high that the government started giving every Londoner a stipend to defray the expenses. Did it work? No, rents just rose by the same amount. I'm willing to bet that landlord groups were behind it. Same thing is going on here, and influx of federal loans, grants, and funds goes a long way to explaining the exorbitant costs of undergraduate education as well.
As for tort reform, you're right. There may be hope, though - several European countries have passed "loser pays" laws that put suing lawyers on the hook for frivolous lawsuits.
Medical malpractice claims are brought in state courts and not generally subject to federal lawmaking. However, my understanding is that the deep red states that have enacted very tough malpractice restrictions (like Texas, as mentioned in the great Atul Gawande New Yorker article) have succeeded in virtually elminating malpractice suits but failed in restraining costs.
People actually do research on this and they've found that malpractice cases (and defensive medicine) don't contribute appreciably to the growth in health care costs. See, for example, page 8 this PDF: http://www.cbo.gov/ftpdocs/89xx/doc8948/01-31-HealthTestimony.pdf (Peter Orszag's testimony to the Senate Finance Committee last year).
If malpractice reform gets Republicans on board with overhauling health care, then I'm all for it, but let's not pretend that it's going to make a meaningful difference to cost growth.
I'm not seeing that data on page 8. Could you be more specific?
In general though, I find it extremely unlikely that if doctors' costs increase, that increase would not be passed on to patients. It defies all economic logic.
Table 1: Page 6 as numbered on the pages; Page 8 as numbered in the PDF file.
Estimated Contributions of Selected Factors to Growth in Real Per Capita Spending on Health Care
Defensive Medicine and Supplier-Induced Demand:
Study 1: 0
Study 2: not estimated
Study 3: 0
There are any number of studies that contradict this testimony by Orszag.
Harris:
•79 percent said they had ordered more tests than they would have based only on professional judgment of what was medically needed, and 91 percent had noticed other physicians ordering more tests
• 74 percent had referred patients to specialists more often than they believed was medically necessary
• 51 percent had recommended invasive procedures such as biopsies to confirm diagnoses more often than they believed were medically necessary
• 41 percent said they had prescribed more medications, such as antibiotics, than they would have based only on their professional judgment, and 73 percent had noticed other doctors prescribing medications similarly
Studdert et al:
studied more than 800 physicians and found that “nearly all” (93 percent) reported practicing defensive medicine.
Price Waterhouse Coopers:
costs associated with medical liability account for between 7 percent and 11 percent of health insurance premium dollars; direct costs of litigation and widespread practice of defensive medicine increase healthcare spending by 10 percent, with a disproportionate increase in outpatient and physician costs.
Kessler and McClellan:
limits on noneconomic damage awards, such as those California has had in effect for 25 years, can reduce health care costs by between 5 percent and 9 percent without “substantial effects on mortality or medical complications.”
Hellinger and Encinosa:
laws limiting malpractice payments lower state health care expenditures by between 3 percent and 4 percent.
Replying to Orthodoc:
None of those studies contradict the testimony by Orszag.
Even if the studies are methodologically sound (and they sound closer to polls than rigorous studies), the first two studies cover the level rather than the growth of healthcare costs.
It could very well be that we defensive medicine is currently widespread but is basically stagnant and has not contributed to growth in some time. In fact, the two second two studies seem to indicate that overall costs due to malpractice could be declining as various states have put malpractice reforms in place.
In any case, it still appears that malpractice and defensive medicine is playing no role in health care cost growth.
A parallel option: have more physician extenders. Physician extenders are highly able care givers (physicians' assistants, nurse practitioners) who can handle many or most "bread and butter" issues, but who may cost much less. We already have a system like this working for many surgical services. Surgeons are not paid for each visit; rather, they receive a global fee for the operation and all associated care. They hire physicians' assistants to assist with (and perform) much of the post-operative care while they do the thing they love (operate), which is also how they make money. Physicians' assistants are trained to provide this care, and they are always supervised by the surgeon. When they need help, they call the surgeon or other specialists.
We could imagine a system in which a great deal of primary care (routine health maintenance checks, renewing prescripts, so forth) is provided by physician extenders who are supervised, and the physician, who has more training, can step in when there is a problem or a difficult diagnosis. Schooling and training of physician extenders is much less expensive, and their salaries are lower, so the net cost to the system would be lower too.
The physician extenders could spend more time with each patient, improving the quality of care provided.
A possible unintended consequence of Get More Doctors: Doctors find that their income levels are less than what they expect, so they spend less time per patient and overtreat the ones they have to compensate.
Are you sure you want this outcome?
Right, but if they were not so concerned about paying back absurd quantities of med school debt, maybe they would not be so driven to overtreat and make more money for needless procedures. BTW, given the data in that graphic, it doesn't seem like overtreatment is close to a problem, since our treatment often tends to be less effective than in other countries. Maybe we can worry about that if it happens.
Overtreatment does not imply better outcomes, quite the opposite in fact. See
http://www.overtreated.com/excerpts.html (Chapter 2) or
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
Those are good suggestions. Some more:
1. The biggest single chunk of expenses that Doctors deal with is getting reimbursed by the insurance company. Solution: switch from a "like car insurance for oil change" insurance model to a "gym membership" model.
(There is a company that does this in the Pacific NW with good results, but I can't remember the name).
2. The biggest costs in healthcare are treatable by patient behavior. Reward good behavior.
http://www.medicalnewstoday.com/articles/62879.php
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Most importantly though: More innovation & competition! Right now each State has a regulator, and any company that wants to provide healthcare in that state must meet the regulator's requirements. The regulatory barrier to entry is huge.
Solution 1: Be regulated by one State only, offer services Nationally. This change, all by itself, would increase competition in every state by an order or magnitude or more.
Solution 2: End the employer tax credit and all portable insurance you buy yourself. This will increase competition another few orders of magnitude as the number of buyers will increase several thousand-fold.
Yet US medical schools are so overwhelmed by applicants that the foreign medical school business still thrives. And I don't see any evidence that doctors charge large amounts because medical education costs so much, as opposed to it being what the market will bear.
Rather than adjust the number of doctors, why not instead increase the number of procedures that other medical professionals, such as nurse practitioners and physicians assistants can perform without a doctor getting a piece of the action? And if you want to drive down prices, also break the monopoly on prescription authority held by doctors, and spread it out to these professionals and psychologists -- the trial programs run by the US military were highly successful.
If you want to solve the problem without even look to move medical education from a university-driven training environment towards a purely certification-based program, much as board certification and apprenticeship (called residency) already does for medical specialties. Much of a doctor's training that is later used is in the practical phases which is just dealing with enough cases of a given category to be able to address a specific problem, which suggests that the eight years of undergraduate and graduate medical education is much less crucial to their end specialty than the three to five years spent in the residency phase. Permitting those who can demonstrate the skills required to read x-rays or clean and suture a wound to do so without spending twelve years in a training program might increase our general health care options. The conversion of anesthesia from a doctor-focused program to one capably delivered by nursing specialists illustrates this, as do the existence of highly-paid technical jobs in perfusion, and medical technology.
If malpractice lawsuits were a significant factor in health care costs, then California would be a wonderful place to be both a patient and a physician. In 1974, the California Legislature enacted MICRA, which placed a $250,000 cap on non-economic damages. That cap has never been changed or adjusted for inflation.
Apparently, it is true that malpractice premiums in California are lower than in states without malpractice reform. There is a debate over why, however, with some arguing that lower rates didn't arrive until 1988, when Proposition 103 was passed.
However, I don't see these savings being passed on to patients.
One reason might be that malpractice costs are not a significant portion of the reason health care is expensive. According to this article, less than one half of one percent of all health care spending is done on malpractice claims.
While I certainly have my biases, I think the connection between malpractice and the cost of health care is far less certain than you posit. Furthermore, to the extent that you are correct, I think you have the solution backwards. You wish to make malpractice lawsuits less profitable. Would not the better solution be to reduce incidences of malpractice?
It would be interesting to compare the additional health care costs due to malpractice to the cost of adjusting malpractice claims.
This suggests that simply because malpractice awards were capped at $250K in 1974, California physicians would have no longer worried about, and attempted to protect themselves against, malpractice suits. In focusing solely on the reduction of malpractice insurance costs, it ignores the issue of the enormous cost of "defensive medicine" as a second component of “malpractice costs,” the former being a pittance against the latter. As a physician who practiced in California for 33yrs - beginning in 1974 - I will tell you that any notion that wariness of quarter million dollar lawsuits is or should be any less than that for million plus dollar lawsuits, is patently obtuse. Nothing was changed in that respect. Every day of those years I practiced with the oppressive awareness that the next patient could be *the one*, cap or no cap, and I practiced accordingly. This did not involve wanton ordering of tests - I was in fact often derided by colleagues for my judicious test ordering - but it definitely did involve ordering, surely, hundreds of thousands of dollars worth of more tests than I would have in a legally sane system.
As for the idea that it might be a better solution to reduce incidences of malpractice, you betray yourself as someone who believes that all of the malpractice suits that are filed in the US every year actually involve malpractice. They don't; not hardly. Malpractice certainly exists, of course, and reducing it is obviously a worthy goal. But, in a system where doctors are viewed as prey by trial lawyers who can make a tidy little income by filing meritless malpractice suits just for the "go-away" insurance settlement money they promise, reducing actual malpractice will have minimal effect on the cost of health care and no effect whatsoever on the astronomical cost of the practice of "defensive medicine."
The 2 ways proposed by Mr. Indiviglio would unlikely to bring much savings in total health care cost, but would surely require a lot of upfront investment in real money and political capital. I just bring up a few things to consider, to show how expensive and complicated this health care debate could get just by considering these 2 proposed ways.
1) To increase total supply of practicing doctors requires at least a million dollars a year for 7 years per doctor. That is my top of my head estimate, WITHOUT capital spending to build more schools/labs and more teaching hospitals. (my hospital scrubbed its plan for building when the cost per bed exceeded 1 mil Last year!).
2) US medical schools produce about 16 thousand graduates a year, pretty constant in decades. Residency training slots amount to about 22 or 23 thousands. About 30% or so of these slots are taken by international medical graduates (IMG). To produce more US graduates without increasing residency slots means less utilization of IMG (the best the world has to offer the US, for free)
3) many studies show regions with more doctors get more Medicare money, but people in those regions are not more sick or less sick to begin with. Just ask people from Minnesota, vs Boston, vs Los Angeles.
4) Many states with tort reform and cap on pain and suffering payouts have lower malpractice insurance premiums, but NOT lower in healthcare spending per patient.
With limited money, limited time, limited political will or capital, I suggest we limit ourselves to reforms that have the best chance and the best "bang for our buck". The 2 ways proposed by Mr. Indiviglio are not any of them.
A more effective way to increase the supply of doctors would be to increase the number of residency slots, which is effectively capped due to a number of reasons, and medical school slots. That's the bottleneck. I doubt the prospect of taking out large loans deters many pre-med students. And medical schools are not hurting for applicants.
As a surgeon I will tell you that if you simply increase the number of doctors without first developing some way to manage what they do, costs will go up. We love to operate, and the more operations we do the more we earn. Market forces don't apply here; it' s not like costs decreasing when Walmart come in. Surgeons can always generate more revenue, if they want. No ethical surgeon will say that reimbursement guides his decision-making, but no honest surgeon will deny that it has an effect on his practice.
The argument is confounded by the flawed assumption that survival rates are only attributable to health care. They could easily be related to any number of other factors including family support, general supportive care, nutrition, obesity levels, sanitation and adherence to doctors recommendations. Any of which could influence survival time and could also vary substantially from country to country. Note that England with cradle to grave state medical coverage for all is at the bottom in virtually every category. That may be more telling than any U.S. stat.
I gather that the author and commenters are unaware that the federal government, through the Medicare program, is already subsidizing medical education to the tune of $80,000 or so per year for each and every medical resident. That hasn't produced more doctors. It has, however, increased the cost of medical school.
I'd suggest that Medicare attach more strings to its subsidies. We should only be subsidizing the education of primary care physicians.
Sorry, resident education has nothing to do with the cost of medical school.
Hospitals receive funding for their residents to pay them a salary (and $40-50,000 is a pretty good deal for someone who works 80 hours/week), provide benefits, and cover insurance costs. The number of positions is set by CMS. I'm assuming that you don't believe trainees should pay for 4 - 7 more years of training than they already do, but my assumption may be wrong. As for strings, the regulations regarding resident education look like a phone book.
Regarding subsidizing only primary care, how would you like to train specialists? I realize that specialists are the new bogeymen because we "cost too much," but we actually do stuff. And with an aging population, our services are going to be in significant demand.
The AAMC has projected a projected shortage of 124,000 FTE physicians by 2025; while 37% of the shortage will be in primary care, 33% will be in surgery, 6% in medical specialties, and the remaining 23% in other specialties. Where do you think those physicians will come from? In general surgery, for example, half of the physicians are over 50.
Statistics. Yeah.
None of this takes into account demographics or lifestyles. I would like to see those same charts with adjustments made for same.
In countries with government paid care some of the costs are hidden in general fund government accounts.
Those adjustments need to be made too.
But finally, I trust my doctor who told me at my age, I am now considered a liability by the government. No thanks, gov.
Don't most of the comparison countries already ration health care at least in a defacto way? Are the lower survivor rates in the US attributable to the fact that doctors in the US are treating more cases that have a lower probability of survival in the first place?
Your observation about doctors is brilliant and obvious. Instead of investing huge tax dollars in the muck of state health insurance, why not create three medical schools for which the standards would be the highest, and the cost free? This I would spend tax dollars on.
The more studies I look at the more I appreciate the bastards that tried to teach me statistics.
Rather, than spending money and subsidizing college costs, we could just have a sensible immigration policy that allows for more educated immigrants to enter the United States. This would cost us no money, bring in more doctors, and increase remittances for poor countries. However, without changing doctor's incentives this would not amount to much.
There are 5 very simple steps to lower medical costs. I've listed them nearly a month ago. Each step makes perfect sense, and no side can realistically claime they are unfair. Check it out:
http://hyphenatedamericans.blogspot.com/2009/05/how-to-slash-medical-costs-in-6-easy.html
Not sure where the NYT is getting their data from, but quite a lot of times I have seen numbers on health care spending as a percent of GDP they did not include some pretty important numbers. Most Canadians purchase supplemental insurance for their health care (side note - if the fed health care is so great why do they need supplements?). These premiums are not insignificant. Oftentimes the spending numbers conveniently don't include these dollars.
What would happen if a medical practice was to adopt the following steps?
1) Would not take insurance, cutting down expenses in administration costs. Everything would be paid out of pocket, a la carte.
2) A form that would provide "local tort reform" for the medical practice. I.e., if the patient would sign the form, they would have limited malpractice options they could incur against the practice. I don't know if this is possible, but create an airtight legal document that would keep the patient from suing except in cases of obvious criminal intent.
This would encourage people to take care of their bodies, because of the direct correlation between cause and effect. Also, it could be a natural gatekeeper for people who want to siphon off the system for free.
If I could drop insurance altogether and go to a clinic and pay a fair-market value for procedures, I'd seriously think about it (I only go to the doctor on average about 2x a year, and pay $2,400 insurance for that). Is there any reason these prices couldn't fall to what veterinarians charge for similar procedures?
I've been saying it for a while now. Not only do we need more doctors, but we need to make it easier for people to set up medical services businesses so that it is easier for operations like CAT scans to be performed in a cost-effective manner. It would be a lot easier for the poor to get access to cheap health care if an enterprising group of nurses could set up a basic clinic at Wal-Mart, and things like that.
How about starting from the other end and working backward? What do the commentors here think a salary should be for a full-time (40 hrs./week 52 weeks/yr. with 30% benefits package) family physician, orthopedic surgeon, or allergist? Now, keep in mind that a physician must start with an IQ in the top 1/5 of the population even to get into medical school (and thus could master any of a variety of fields other than medicine), invest eight years of time (four years of college, four years of medical school) at zero income and living usually on borrowed money, then working 60-80 hours/week in residency (three to eight years) for barely above minimum wage. The physician fresh out of residency is now about 30-35 years old and $100,000 to $150,000 in debt. He hasn't bought a house, started saving for retirement, etc. He'll start "real" practice at the bottom as a newcomer. If he's in a group, he'll have the worst call schedule and the least "desirable" patients.
So, tell me--what level of income would be needed to attract an intelligent individual to this field, given the commitment (investment of time and effort and money) and the delayed onset of real earning power? Please state a salary and not "what the market will bear", since market forces are so distorted under our current system.
Obama is right that health care, besides being a modern miracle and source of compassion, is more importantly a big fat cow of dollars and power that he wants to make use of for his friends and to increase the reach of government.
Modern medicine is beset with rentiers who thrive on our inattention:
-Trial lawyers
-Cardiac surgeons who perform billions of dollars of ineffective invasive procedures
-Back specialists of all types who are similarly ineffective
-Screening tests for cancers that save no lives and create much misery
-Drug companies who suborn medical practitioners and researchers
The list goes on...
But not a peep about removing dollars and power from such influential groups.
However, having such a disparate group of your local neighborhood frauds and thugs, there is always hope for growth and reform and the chance that information will change the way things are done. Once the government becomes the rentier, who grabs the dollars and controls the behaviors, we are putting things in the hands of interests that control too much already. Change will stop. Interests will be entrenched and supported by federal law and bureaucracy. Money will go to deserving Democrats, and Republicans too. Medicine will become like public education, demanding more and more dollars, and providing less and less of what people really need.
Thank goodness someone finally brought up tort reform as a key way to lower healthcare costs. Federal tort reform will -- by far -- yield the greatest cost savings. The true savings will not be in lowered malpractice insurance rates (though that will help a little) but in allowing doctors to cut down on the awesome costs of 'defensive medicine.' Physicians routinely order labs and imaging and perform procedures for patients when there is no clinical reason for doing so. They do this to to avoid the 1/10,000 chance that if the patient actually needed the test and had a bad outcome because the doc would be forced into a multi-million dollar settlement/judgment. Consequently, inpatients routinely receive 'million dollar workups' that they don't truly need.
In our litigious society, there is a powerful incentive for physicians to over-utilize healthcare resources.
I just graduated med school with $184,000 in debt and will be starting residency at $44,000/year. Yeah, I think some loan forgiveness for med school graduates is a good idea.
Go practice in an underserved area, and the NHSC will be happy to help pay off your loans.
Reminds me of this Onion-style parody entitled "Obama Plan Calls for Making the Health Care System More Efficient by Having Trial Lawyers Provide Medical Services More Directly": http://optoons.blogspot.com/2009/06/obama-plan-calls-for-making-health-care.html
"Anyone who has even the most basic grasp of economics knows that, when supply increases, price decreases. If we had more doctors, and other medical professionals, healthcare costs would go down."
Sounds good, but fallacious reasoning as medical reimbursement stands now. Here's why.
Supply driving down prices for goods works to some extent, but not as clear cut relationship with services. There is no shortage of lawyers, but contingency fees and other fees do not go down simply because there are more lawyers.
Also, I guarantee you that more doctors would translate into more care, but not necessarily better care...for many reasons, but especially the following.
Currently, medical services are reimbursed by codes, not demand or even necessarily risk/skill involved. I call it code farming...some medical codes pay a lot more money than other codes, even for the same service. Hospitals have figured out this game, and employ legions of chart reviewers to tweak patient charts and eke out dollars...for example, using code numbers to call something acute systolic heart failure might upcode the diagnosis and reimbursement for a medicare patient, vs. just calling a disease heart failure. Similar things happen for office practices. Therefore, under current reimbursement schemes, pricing is somewhat irrelevent.
Finally, it is pretty easy to game the system as the reimbursement scheme stands now...put 1000 doctors out on the street doing what 500 did the year before, and you will probably see proportionately more medical care given for the same fixed reimbursement, not fewer procedures done more cheaply.
2. "Parallel option: have more physician extenders. Physician extenders are highly able care givers (physicians' assistants, nurse practitioners) who can handle many or most "bread and butter" issues, but who may cost much less."
Not necessarily, in fact may be quite the opposite. The fact of the matter is, many diseases seen by primary care physicians/practitioners are self limited...one could prescribe eye of newt or a bloodletting,and the disease would get better.
Some physician extenders practice with a physician. Others are clamoring to practice "independently". Problem is, they do not have the training or experience physicians do, and they use far more tests, x-rays, etc than physicians. Also, most of them demand and get equal pay for the same code number that physicians do.
Medicine is an economic activity, nothing more. The reason "costs" are high is because there is no market incentive to truly lower costs because the reimbursement is fixed and limited by rules. Medicare and Medicaid pay less for most services, too much for others, but the savings are illusory even with all the so called pay for performance payment schemes out there. The fundamental problem is that all providers are treated the same, and reimbursement is fixed for the first and last procedure.
This means that if a hospital does 100 heart catheterizations, they essentially are paid the same for the last catheterization as they are for the first.
In a competitive marketplace, reimbursement would not be fixed...it would be negotiable. Doctors and hospitals would compete on a cost basis, and so more efficient centers would be able to offer services at a lower cost.
However, this would mean some hospitals would not be able to afford to keep doing the procedures. There would be increased specialization of certain centers to do things that others simply could not.
Right now, the hospital lobby has successfully tied up its competition. Physicians have started hospitals but the legacy hospital chains force legislation which puts them out of business, claiming they "cherry pick" paying patients and leave charity care to the legacy hospitals. Fact is, the legacy hospitals charity care is far less than you would think...sometimes on the order of 1% of total revenue.
There is also a prejudice against doctors profiting from medicine. Like "not for profit" hospitals don't. Admit there is a profit and let people compete on price and quality.
In conclusion, your ideas are not necessarily all wrong, but given the current reimbursement schemes, and the realities of a service industry made up of people who take years and years to become a physician...more is not necessarily less.
The way to reduce medical costs would be to deregulate the marketplace
Medicine is a business which has been screwed up by