In response to my item about the sociology of doctoring--the idea that, more than any particular reform, we need fewer doctors who think of themselves as profit-maximizing businessmen and more who see themselves as adequately-compensated healers--a reader writes in with a fair point:
I think you've got it backwards as far as cost control. If doctors are cold-hearted profit-maximizers, you can structure their incentives to conserve resources. If, however, their overriding concern is patient health, they are likely to remain stonily unconcerned about cost-effectiveness. Altruism will lead them to seek the most effective care for their patient, which will usually (though not always) be the most expensive. I've seen this dynamic recently as my father has dealt with throat cancer. His physicians pushed surgery to save his life (without regard to quality of life or to his comprehensive prospects for long-term survival). At the same time, they declined his offer to pay for long-shot surgeries to deal with the complications that could have added to their bottom line. Just like in medicine, in policy you have to get the diagnosis right to get the right prescription. While most doctors are in fact both businessmen and altruists, exploding costs probably have more to do with the fact that their instinct is to do whatever it takes to improve medical outcomes, even if it costs your house, their house, and their neighbors house. Second, good doctors will probably think of their patients first. If reform means that their patients (by definition already insured) will have to make do with less so that society can cover the uninsured, they will instinctively oppose it.
There's clearly something to this. In reality, there are two big forces driving health care costs on the doctoring side. One is the businessman mentality--I get paid by the procedure, so I'm always going to err on the side of more procedures. The other is the altruistic impulse--my job is to save lives, costs be damned. As convenient as it would be to believe that only the first drives up costs, the latter is a huge factor, too. (This is where Obama got tied up a bit at his press conference last week.) But I guess my feeling is that eliminating the first problem is a no-brainer--it's the low-hanging fruit. Once we've done that, we've got some tough choices to make--there's obviously only so far we want to beat the save-lives-at-all-costs impulse out of doctors. But there are places--like the Mayo Clinic, etc.--that have shown they can make these calls without sacrificing patient care once the businessman ethos gets reined in. So I'm willing to believe it's possible. (Whether it's scalable is an altogether different question, of course...).
--Noam Scheiber