Myth 20. Doctors, not bureaucrats, make decisions in national health systems.

Obama has promised that doctors, not bureaucrats, will be making the decisions under his “health care reform” plan.

If Obama’s promise is true, why do central planners need extensive data on every encounter with every patient?

Doctors, it appears, would indeed be making day-to-day decisions about what to do for individual patients. The centralized planning authority, however, would make the decisions on resource constraints and permitted options, within which physicians would have to function.

Physicians would be free—to comply or to accept the penalties for “deviations.”

Some American physicians, who have contracted with managed-care plans, long for what they believe is the simplicity and professional autonomy in nationalized systems.

Physicians who actually work in these systems generally do not share this sanguine view.

In Germany, doctors complain, on video with English subtitles, that they are inundated by the masses and cannot focus on the individual. They must work faster and faster, with less and less to show for it. A fundamental change in values has crept in, and the patient/physician relationship is deteriorating. Doctors say they are in a bureaucratic straitjacket. Politicians have them by a nose ring. Drugs and procedures are all constrained by a budget; some treatments simply cannot be offered. Thus, care is expedient, rather than optimal. There are so many forms that “you could paper the office with them.” Overall, the situation is “deplorable,” “critical,” the “worst in 31 years of practice.” Physicians conclude that “state medicine is rationed medicine.”

Elsewhere in Europe, headlines read: “Belgian Doctors Take to the Streets,” “Spanish Physicians Strike for More Time [10 Minutes] with Patients,” and “French Doctors Are Burned Out.”

According to a poll conducted by Pfizer of 1,741 physicians in 13 countries, 51% of European physicians are concerned about a negative direction for medicine, compared with 44% in the U.S. The majority report spending less time with patients (53% in Europe and 55% in the U.S.); bureaucratic demands were cited, unprompted, as a reason for that by 51% of Europeans and 21% of Americans. In both Europe and America, physicians have a negative view of the politicians’ panaceas for efficiency and quality: 83% of American and 61% of European physicians think that treatment guidelines have an adverse effect on patient health, while 70% of Americans and 64% of Europeans think that health technology assessment and evidence-based medicine have a negative impact on quality of care.

Gammon’s Law of Bureaucratic Displacement was developed in a London (National Health Service) hospital. Gammon defined bureaucracy as a rigid system “governed by fixed rules and tending to exclude human initiative.” He found that bureaucracy was destroying British medical services—not destroying the NHS, he emphasized, as “it is the [NHS] itself which is the destroyer.”

It’s not just that the number of administrators has increased in a close correlation with a decrease in the number of NHS hospital beds (correlation coefficient a remarkable – 0.99). It’s the displacement of productive by nonproductive activity throughout the organization.

“An example is the progressive transformation of nurses from patient-centred carers to administroids whose requirement to produce detailed patient care plans…leaves them little time to attend to patients’ basic dietary needs or prevent them from developing pressure ulcers” (Australian Doctors Fund teleconference, Jan 24/25, 2005).

The proposal before the House, H.R. 3200, establishes some 53 new bureaucratic agencies (Human Events 8/10/09).

Obama can keep his promise—by turning doctors into bureaucrats.

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12 thoughts on “Myth 20. Doctors, not bureaucrats, make decisions in national health systems.

  1. Medicare’s RAC contracted bounty hunters are not just downcoding for lack of E&M documentation to the Medicare bureaucratic standard. They are also downcoding for having delivered a not “medically necessary” level of care. The bureaucrat makes the decision- and the more he does so the more he is paid.

  2. Fellow colleagues, after hearing so many complaints about what is wrong with healthcare, here and abroad, you would think that instead of many thousands of upcoming academic medical conferences to discuss the latest and greatest advances in medicine–most of which we cannot implement due to costs anyway–that we would see a major focus on workshops, “Manhattan projects”, taskforces and the like concerning:

    1. What we physicians as a group can CREATE as a better plan so that patient outcome is restored as the prime directive in healthcare.

    2. How do we recapture some significant degree of authority about who makes the decisions involving the care of our patients. How outrageous that we end up having to interact with clerks about such decisions.

    3. How can we impact the ridiculous cost of medical malpractice insurance (I believe the USA is the only country in the world where such insurance is so costly).

    4. How we can embark on a pro-active and pre-emptive approach to medicine instead of the reactive band-aid approaches currently being used by so many docs.

    5. How we can employ concepts of reward and punishment for both doctors and patients if medical goals are not achieved and maintained.

    We have become a fat and lazy society that is waiting for someone else to solve the obvious problems that currently affect us and, over time will become worse and degrade the lives of our children and future generations. We will never see a solution through the bureaucrats in Washington since they have their own healthcare plans. It is time we showed some real collegiality and collaboration and worked together as true professionals to solve problems that are in our domain of expertise.

  3. There is a fundamental principle that most commentators fail to consider:
    Optimal medical care requires an unimpeded relationship between patient and doctor. Any medical insurance, whether commercial or “public” disrupts the patient-doctor relationship. Furthermore, medical insurance increases the cost of medical services, exponentially in many instances. There is an almost universal imperative that no human should be without medical insurance, as none should be without food and clothing. Insuring the provision of food and clothing would be equally ridiculous. Without the intervention of third party payers, doctors would serve patients better, operate practices more efficiently, and be compensated more promptly.

  4. I would submit that it is unethical for a physician to practice in an environment where a government agent interferes with a confidential, personal decision between the doctor and patient. Ergo, doctors should opt out of any such system.

  5. “Unless we put medical freedom into the Constitution, the time will come when medicine will organize into an undercover dictatorship. [Laws} to restrict the art of healing to one class of men..are un-American and despotic.” Benjamin Rush, signer of the Declaration of Independence
    I believe that we are going to undercover dictatorship!
    What we need is to take AMERICA back and then go back to real money. That will take a civil war.

  6. Pingback: Who makes the decisions in Europe's national health care plans? - TDR Roundtable

  7. Stephen B. Strum, MD, FACP: Looking at your proposal for academic medical workshops and just the first concern to be considered – “1. What we physicians as a group can CREATE as a better plan so that patient outcome is restored as the prime directive in healthcare.” – there are foundational points that are missing here and in your entire comment, which I accept as well intended, as well as those of the others here to date.

    A physician, like any other person, when s/he acts (and thinks) is doing so as an individual – not part of a group; humans are not hive animals (ie. ants & bees) nor are they sci-fi borg. This basic fact of physical individuality is ignored completely with a society based on physical force, upon which all governments must necessarily base their operations – while declaring their version of physical force “legal” as opposed to the “illegal” variety used by ordinary citizens (or often as opposed to that of governments of other countries). As long as individuals continue to accept the premise that governments are necessary for an orderly society in which parties can interact (eg. physicians and those who seek their services), many people will be and continue to be dissatisfied with various aspects of most (?all?) interactions/relationships. Governments are always a 3rd party to every interaction/relationship that takes place in their declared jurisdiction; in some locales and/or situations this presence is viewed by most as an annoyance, in others it is nothing less than egregious interference – but it is always there.

    Secondarily to the immediate above, is the point that in a true simple physician-patient relationship both are trading to mutual satisfaction – the patient and physician agree on the service for an agreed fee, which may be ongoing and agreeably modified over time, or terminated by either of them. Each patient is an individual and as such has an individual set of values – his/her (hir) value priorities will determine how much of hir assets (from income and savings) s/he will put towards maintaining or regaining (or improving) a particular desired level of health. (There will *always* be trade-offs.) Government is a 3rd party even when not paying the bills (with taxpayer money of course) – all the existing regulations limit the choices of either or both of the parties, making the relationship between them less than voluntarily mutually beneficial.

    As long as these basics points with all their ramifications – and there are many many more when considering other interactions/relationships – are not recognized and truly understood by a major portion of society, any solutions will be but band-aids on a mortally wounded body. Individual physicians are in a position to become informed and communicate with their colleagues *not* how to enlist government as an agency of force to accept their “better plan”, but how government is the major impediment to a mutually beneficial physician-patient/client relationship. And since government presents similar obstacles for almost all other voluntary interactions, it follows that those involved in all such actions, and who want to become truly self-responsible, will seek the same information and level of understanding – all of it relating to a self-ordering society. (More on the foundational concepts: “Social Meta-Needs: A New Basis for Optimal Human Interaction” – http://selfsip.org/fundamentals/socialmetaneeds.html. Additionally I wrote an article last April that addresses what is necessary beyond “activist” protesting over taxes and regulations towards the goal of a “better” society – http://selfsip.org/focus/protestsnotenough.html , the essence of which applies to this subject as much as any other.)

  8. I guess when you put the most right-wing, pro insurance company spin on national healthcare systems, including only unnamed critics and excluding any contradictory facts or points of view, you end up with a fake scenario that sounds almost as bad as doctor’s experience with private insurers in this country.

    Like your other “Myth Busters”, this is yet another straw man argument. Who is proposing a national healthcare system? Even radical left-wing progressives like myself don’t want a national healthcare system along the lines of Great Britain. I would much prefer a more efficient system as found in Japan or Singapore. Now, look at what’s actually being proposed in Congress. In what way does it even slightly resemble a “national healthcare system”? It’s simply insurance reform with a tiny, nearly impotent public insurance option that is completely dwarfed by Medicare (a partial coverage, national healthcare system which you hypocritically support, right?).

    Anyway, since you brought up national healthcare, take a look at what Canadians think about their’s:

    “2009 Harris/Decima poll found 82% of Canadians preferred their healthcare system to the one in the United States, more than ten times as many as the 8% stating a preference for a US-style health care system for Canada[6] while a Strategic Counsel survey in 2008 found 91% of Canadians preferring their healthcare system to that of the U.S.”

    http://en.wikipedia.org/wiki/Health_care_in_Canada

  9. The Bill of Rights is based on fundamental rights the individual can exercise without imposing on other individuals.

    A right to health care implies someone else is yoked to your service. It is fundamentally contrary to the notion of intrinsic rights that rest within the individual.

    People have an intrinsic right to take care of their own health. They can take individual action to insure they remain healthy. The care they provide themselves they certainly have a right to. The care provided by others they do not. To imply otherwise is anti-individual liberty, anti-individual rights and fundamentally un-American.

  10. Patriot, the socialists always point to the “satisfaction” of Canadians and Europeans with their healthcare systems. What these surveys fail to discern is that yes, the majority HEALTHY population “likes” their healthcare system. It’s the minority SICK who take the brunt of the rationing and substandard healthcare within these systems and their responses get drowned out. That’s the dirty secret statist governments understand. Spreading healthcare dollars as thinly as possible saves money and keeps the masses happy that they can go to the doctor “for free” while the sick are quietly relegated to the back of the bus.

  11. Pingback: Myth 23. Private insurance and self-payment are relics of an oppressive past, confined to the United States and backwater, poorly developed nations. « AAPS News of the Day

  12. Patriot: Have you read the healthcare bill? It IS a nationalization plan. And YES, I AM a supporter of private insurance companies by virtue that I am a supporter of free market economics and very much opposed to government-run enterprise, whether that be healthcare, automobiles, finances or anything else.

    And living in Montana, you wouldn’t believe the number of Canadians that come to our hospitals for treatment. Why? Because they CAN’T get it at home! They are more than willing to come here and pay cash because their vaunted single-payer system is PREVENTING them from getting the care they need!

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