If Medicare is to have a secure future, we have to move away from fee-for-service medicine, which is all about incentives to spend more, and has no incentives in the system to keep patients healthy. The IPAB has no possibility of helping to solve this major problem and will almost certainly make the system more bureaucratic and therefore drive up administrative costs.
He does not say what we need to move to. Of course, I would say we should move to a system where consumers pay for their health care, and insurance covers catastrophic expense.
Keep in mind that there is no perfect system for compensating doctors. For example, if you pay them a fixed amount of money per patient, then their incentive is to see a lot of healthy patients and avoid the sick ones. If you pay them a fixed salary, their incentive is to work short hours. If you pay them for “quality care,” that means that a central bureaucracy, comparable to IPAB, has to define the meaning of quality.
It is comforting to see “insurance” framed as its basic function, which is the transfer of risk, such as catastrophic coverages.
By inference the function of “healthcare contracts” (now currently mislabeled as *health* “insurance”) becomes the transfer of costs, and at best the spreading of costs, imposing involuntary obligations on participants.
In the discussions about the methods for compensating Healthcare Services, by physicians and others (consider the highly skilled technicians involved), there seems to be a complete disregard of the basic freedom of individuals to determine (to the extent available) the terms and conditions under which they will render services to others. The implications of requiring persons engaged in particular activities to render their services in accordance with externally determined modes of compensation lead to the possibilities of further classifications and constraints on compensation systems in other relationships in our society. Consider first how various kinds of services have developed particular modes of compensation, from piecework, hourly wage, professional hourly rates, academic level entitlements (tenure, sabbaticals, retirement, etc.).
To impose compensation modalities is to begin new risks to economic realities in the nature of social relationships.
Is this comment a joke, a satirical take on the famous Orwell passage?
“I am going to translate a passage of good English into modern English of the worst sort. Here is a well-known verse from Ecclesiastes:
I returned and saw under the sun, that the race is not to the swift, nor the battle to the strong, neither yet bread to the wise, nor yet riches to men of understanding, nor yet favour to men of skill; but time and chance happeneth to them all.
Here it is in modern English:
Objective considerations of contemporary phenomena compel the conclusion that success or failure in competitive activities exhibits no tendency to be commensurate with innate capacity, but that a considerable element of the unpredictable must invariably be taken into account.
This is a parody, but not a very gross one… It will be seen that I have not made a full translation. The beginning and ending of the sentence follow the original meaning fairly closely, but in the middle the concrete illustrations — race, battle, bread — dissolve into the vague phrases ‘success or failure in competitive activities.’ This had to be so, because no modern writer of the kind I am discussing — no one capable of using phrases like ‘objective considerations of contemporary phenomena’ — would ever tabulate his thoughts in that precise and detailed way. The whole tendency of modern prose is away from concreteness. Now analyze these two sentences a little more closely. The first contains forty-nine words but only sixty syllables, and all its words are those of everyday life. The second contains thirty-eight words of ninety syllables: eighteen of those words are from Latin roots, and one from Greek. The first sentence contains six vivid images, and only one phrase (‘time and chance’) that could be called vague. The second contains not a single fresh, arresting phrase, and in spite of its ninety syllables it gives only a shortened version of the meaning contained in the first. Yet without a doubt it is the second kind of sentence that is gaining ground in modern English. I do not want to exaggerate. This kind of writing is not yet universal, and outcrops of simplicity will occur here and there in the worst-written page. Still, if you or I were told to write a few lines on the uncertainty of human fortunes, we should probably come much nearer to my imaginary sentence than to the one from Ecclesiastes.
As I have tried to show, modern writing at its worst does not consist in picking out words for the sake of their meaning and inventing images in order to make the meaning clearer. It consists in gumming together long strips of words which have already been set in order by someone else, and making the results presentable by sheer humbug. The attraction of this way of writing is that it is easy. It is easier — even quicker, once you have the habit — to say In my opinion it is not an unjustifiable assumption that than to say I think. If you use ready-made phrases, you not only don’t have to hunt about for the words; you also don’t have to bother with the rhythms of your sentences since these phrases are generally so arranged as to be more or less euphonious. When you are composing in a hurry — when you are dictating to a stenographer, for instance, or making a public speech — it is natural to fall into a pretentious, Latinized style. Tags like a consideration which we should do well to bear in mind or a conclusion to which all of us would readily assent will save many a sentence from coming down with a bump. By using stale metaphors, similes, and idioms, you save much mental effort, at the cost of leaving your meaning vague, not only for your reader but for yourself. This is the significance of mixed metaphors. The sole aim of a metaphor is to call up a visual image. When these images clash — as in The Fascist octopus has sung its swan song, the jackboot is thrown into the melting pot — it can be taken as certain that the writer is not seeing a mental image of the objects he is naming; in other words he is not really thinking…
A scrupulous writer, in every sentence that he writes, will ask himself at least four questions, thus: 1. What am I trying to say? 2. What words will express it? 3. What image or idiom will make it clearer? 4. Is this image fresh enough to have an effect? And he will probably ask himself two more: 1. Could I put it more shortly? 2. Have I said anything that is avoidably ugly? But you are not obliged to go to all this trouble. You can shirk it by simply throwing your mind open and letting the ready-made phrases come crowding in. They will construct your sentences for you — even think your thoughts for you, to a certain extent — and at need they will perform the important service of partially concealing your meaning even from yourself. It is at this point that the special connection between politics and the debasement of language becomes clear.
In our time it is broadly true that political writing is bad writing. Where it is not true, it will generally be found that the writer is some kind of rebel, expressing his private opinions and not a ‘party line.’ Orthodoxy, of whatever color, seems to demand a lifeless, imitative style. The political dialects to be found in pamphlets, leading articles, manifestoes, White papers and the speeches of undersecretaries do, of course, vary from party to party, but they are all alike in that one almost never finds in them a fresh, vivid, homemade turn of speech. When one watches some tired hack on the platform mechanically repeating the familiar phrases — bestial atrocities, iron heel, bloodstained tyranny, free peoples of the world, stand shoulder to shoulder — one often has a curious feeling that one is not watching a live human being but some kind of dummy: a feeling which suddenly becomes stronger at moments when the light catches the speaker’s spectacles and turns them into blank discs which seem to have no eyes behind them. And this is not altogether fanciful. A speaker who uses that kind of phraseology has gone some distance toward turning himself into a machine. The appropriate noises are coming out of his larynx, but his brain is not involved as it would be if he were choosing his words for himself. If the speech he is making is one that he is accustomed to make over and over again, he may be almost unconscious of what he is saying, as one is when one utters the responses in church. And this reduced state of consciousness, if not indispensable, is at any rate favorable to political conformity.”
– George Orwell, Politics and the English Language
If not, you need to read the linked essay in its entirety.
Apologies:
in referring to “health care contracts,” I should have been more precise in noting that they impose **politically determined** in voluntary obligations.
That is a very important feature of the current difficulties and conflicts.
To point out the big advantage of Arnold’s proposal, letting consumers choose means that consumers get to choose the rules for deciding what merits higher pay. As things are right now, the rules for compensation are nearly fixed, so doctors can learn to game it.
“Of course, I would say we should move to a system where consumers pay for their health care, and insurance covers catastrophic expense.”
So the “veterinary” model?
One could also call it the “laser eye surgery” model
In the 50’s of my childhood, health care was organized Dr. Kling’s way (the “veterinary model” as Russell puts it). We also had the ideal way to pay doctors, namely at the receptionist’s counter on the way out after an office visit.
Ken
Yes, in my childhood as well. I seem to recall something called “Major Medical” insurance that I suspect had to do with hospitalization or other non-routine medical or dental services (each of which were paid for in cash at the time of service.)
That’s my memory as well. What a concept: “health insurance” that was actually insurance!
We exploited Milton Friedman’s famous observation that “nobody spends somebody else’s money as wisely as he spends his own” and add (tip of hat to Floccina below) that when the spending is face-to-face, the payee has to treat the payer’s money with respect.
In all fairness, it’s also my recollection that 100% of medical/dental expenses were deductible from federal taxable income. In (or about) 1986, that was limited to some amount in excess of some percentage of AGI (~7.5%, I think), or somesuch (I’ve never had enough of those expenses to exceed the deductible [knock on wood]).
Also, I think I read just lately that one of the many [unread by our legislators] provisions of Obamacare raises that deductible limitation to 10%.
My experience with Doctors has lead me to believe that GP’s could and would help to control costs if they knew that their customers were paying themselves. Most Doctors do care about their patients’ money, they just do not care at all about the insurance company’s or Government’s money.
BTW I think that it should be much easier to become a GP than it is today.