In the follow report, my narrative will mostly be an attempt to emulate the voice of the original speaker, with some comments by the other speaker as seems relevant. The words are not those of the speakers exactly, but my representation from the notes I made - and both speakers have had the opportunity to review this report. My own commentary where totally separate to the speaker, will be made in italics.
The main problem with medicine is that there is an unlimited demand for life, and techies along the way who want to make money. It is best to assess things in terms of quality-adjusted life years (QUALIs), which tells us that it makes more sense to treat the young, while there is a marginal return at the end of life. However, if politicians draw attention to this, they are accused of being callous. The US has a points system, which limits what doctors are able to do.
A further problem is that there are limited Intensive Care Unit beds (ITU?), and no effective admission policy. It is frequently the very ill who are going to die anyway who end up in ICU, rather than those who would benefit the most. Patients end up in ICU beds because they are the sickest patients and the hospital / medical system wants to be seen as doing something, even if that action is ultimately wasted.
One comment I've heard separately is that it is often difficult to tell how a case in ICU will progress - but if there's a good chance, then I suppose ICU makes sense. I guess the question is how many people are probably going to die in ICU and are sent there anyway - and just how strong that "probably" is.
A problem with markets is with the sort of treatments and approaches they encourage. A last ditch treatment is the most expensive and most profitable, but it is much better to spend less money on prevention and early intervention if really necessary. However, the market operates to maximise profit, which is different to maximising health. The most cost effective option is prevention, which the market works against.
Treatments have over time moved from acute treatment to chronic treatment. In times past, you had an acute period of illness, after which you got better or died. But now diseases are chronic and require extended treatment or better still prevention - and it is easier to encourage prevention in a regulated market.
However, we still have acute cases. And it is possible for elective and other chronic treatments to be delayed because the hospitals are clogged up with acute patients.
It is possible that a centrally planned / non market approach is "inefficient", but what it loses on the turns it makes up on the straights - it is better to do the right thing "inefficiently" than the wrong thing "efficiently". It may be possible to have well oiled, efficient companies selling people what they don't need - but that sorta defeats the purpose.
A pure market approach can also be distorted by changes in technology. When keyhole surgery came in, some specialties found that they could do an operation in perhaps a tenth of the time and charge the same. As a result, they ended up doing a lot more operations and earning a lot money. And you can wonder if all those extra operations were actually needed.
A pure market operates in vegies, where you have unlimited competition and complete knowledge. But real markets are many distortions down the track from that perfect ideal.
In medicine, people do not have have much knowledge, have to rely on the doctor and cannot really compare services or shop around on the spot. Further, cost increase do not deter rich people from consuming medicine, and poor people die on waiting lists from cheap medicine - from which we conclude that the market is not working.
However, if we have tenders for hospital services this is closer to a "real" market - there is hopefully some competion between applicants and the tendering authority hopefully has some valid knowledge. In this case, the government might be seen as a knowledgeable agent acting on behalf of the "end users". However, Arthur's point about "end users" participating directly in the market is probably valid.
It is also much more effective to run a centralised funding provider than it is to have a market based insurance system. In the case of medicare, the overhead to run it is about 4.5%. If you have a private insurer, they spend a lot of their resources attracting people who don't get sick, and need to ensure it is their clients who are getting serviced - and then they monitor the cost of the service they are receiving and ensure clients are not receiving too much service. The overhead of all this is 20% or above. If everyone gets something, supervising them costs less, and universality grants savings.
While there is centralised funding, an important issue is federal-state cost shifting, where that entities' cost is minimised, usually at the expense of a greater overall cost for the whole system. The federal state arrangement is a strange one - for all the federal involvement in health, it does not own a single hospital.
Arthur praised the PBS for its assessment of drug cost effectiveness, and noted that between the Government, the FTA and Pfizer, all were conspiring to undermine the PBS.
Markets normally involve advertising. But, just as there a problems with the knowledge of end users, there are similar problems with advertising direct to consumers. This normally results in distorted patterns of usage, where people buy things they don't need.
Arthur notes that research he conducted into Hepatitis B on people who working in water and sewerage services had no greater incidence of the disease; he concludes that erroneous assumptions are driving much of the demand for Hepatitis B innoculations.
There was a question of whether doctors were overserving in the cities, and whether there was a shortage of doctors in the country. Arthur thought that overservicing was not prevalent and a small problem in the bigger set of issues, and that there was a shortage of doctors.
Arthur was not supportive of the threat of being sued as a good way of ensuring proper operation of the health system. This sort of approach does encourage doctors to close ranks and talk away problems - as they did at Chelmsford.
A more effective approach is to have a credible review organisation which while it can discipline and compensate, spends more time reviewing minor problems and correcting mistakes than running around with a big stick.
Arthur asserts that there are very few lazy or negligent workers. In most cases, problems are the result of system problems rather than negligence on the part of doctors. Further, for every major incident there are several minor ones, which if picked up and corrected, would prevent the major problems.
Further, often doctors are given limited resources but have responsibility pushed onto them. When doctors make mistakes in these conditions, they are only marginally resposible - the service provider is mainly responsible for under-resourcing the doctors. This should be also be considered in looking at mistakes.
But, it does seem that often the driving force seems to be the political need to find a scapegoat rather than fix mistakes. Someone died and a shock jock is ranting ...
Incidentally, someone I know who works at St. George Hospital, in spite of the personality clashes and political battles, does give this hospital credit for admitting to its mistakes and having a positive attitude towards identifying problems and correcting them. In spite of its other problems, this fact alone makes it a worthwhile place to work.
A large number of tests, including X-rays, are done "defensively" - In Arthur's opinion, without real need. This is a consequence of the litigious environment - resources are wasted.
In contrast, the Medical Consumer's Association asserts that for all its litigiousness, the US has one of the lowest rates of medical mishaps in the world. They assert that the litigious environment and "defensive medicine" are not "wasteful", but rather result in a safer system.
Still, at the same time, the US spends a very large percentage of its GDP on medicine; I find it difficult to believe that this is justifiable, and suspect it is rather a "blowout" caused through market excess and excessive litigation.
Further, about a third of the US population has no medical insurance and another third would be financially ruined by a major illness - and you cannot sue if you cannot get treatment in the first place - there is apparently some very callous assessment of capacity to pay before treatement. And the cheaper health insurance plans have no choice of doctor, with the insurers sending you their preferred doctor.
So, while it may well be that the US has a low rate of medical mishaps, the US health system is callous in a lot of other ways we would not want to emulate. The cure is worse than the disease.
Dentistry is totally private, with no medicare support, and there is a shortage of dentists. It is an arbitary distinction, calling the mouth the basis for a different profession separate to medicare.
In the times before Medicare (Medibank ?), doctors were paid for what they did by private patients who could pay, and also treated public patients for Free. Since the introduction of these systems, there has been a blowout in medical costs.
Arthur questioned this, saying that the treatment of public patients fell disproportionately on some doctors and hospitals, and was not evenly shared, as you get with Medicare.
Allen noted that over the last few decades, there has been an increasing gap between cost rises and the payment available to doctors, which is now significant.
This is interesting, and does seem inequitable on the face of it. However, it does assume that at some point in the past doctors were paid what they deserved, and this has now dropped below that level. It also begs the question - what is anyone worth ? Is anyone fairly paid ? I personally would have more sympathy if we looked at this element as part of a broader assessment on whether anyone is paid what they are worth.
To be fair, we do have awards and arbitration which address this issue for other trades and professions. But there does not seem to be an objective body setting this.
One complaint I've heard about "expensive treatments" promoted by drug companies is that they have soaked up the money which otherwise would have gone to hospital services ... and indeed, doctors and others working in health.
Allen noted that improvements in diagnosis methods were a vicious circle, and a double edged sword - improvement were only sometimes towards cheaper (eg keyhole surgery) but more often towards better and more expensive.
Allen emphasised the AMA's committment to excellence, and comprehensive diagnosis. This brings up a tension between the cost effectiveness of a treatment and the worth of extending a life, and did bring up strong ethical questions.
With excellence the driving concern, Allen was concerned about the substitution of para-medical staff and nurse practitioners. This was a turf battle.
But, how do we know whether this concern is real ? Whether the Government is applying a valid policy and giving professionals a responsibility they can validly handle, or is in fact cost cutting ? It is a difficult issue.
Allen noted that the medical workforce was becoming feminised - and the reality is that child bearing falls disproportionately on women, which means that some women leave the workforce and find it difficult to re-enter it.
The profession of medicine has changed. It used to be a calling which absorbed your whole life, but now there are fewer pressures towards excellence, and there are fewer mentors as the workforce ages.
Allen acknowledged that the medical profession has previously overworked itself, and suffered from impairment through fatigue - the AMA has introduced a "safe hours" campaign.
Arthur echoed this sentiment, saying that the medical profession had an unhealthy overenthusiasm, and desire to do more even when it makes things needlessely complicated - analagous to "recklessness rather than courage".
Allen noted the need to train more doctors, with this being supressed for political reasons - the government wanted to contain medicare costs by limiting the number of doctors rather than accepting that there was a valid additional demand for services. He also felt that a lot of what went on in the medical profession was at the whim of the politicians - waiting list blowouts seemed to fluctuate according to the election cycle - and the AMA felt that it had "no friends in either side of goverment" - and Allen found Abbott's economic dogma frightening.
It is interesting that Arthur made comments about the PBS system, talking about it being subverted by major drug companies, but did not particularly challenge Allen on this point. It could be that drug companies have a greater lever on the Government than doctors do. OTOH, are doctors in favour of private health insurance ? And do what degree is the Government policy on health insurance influenced by doctors ? Or where does that policy come from ?
He noted that the AMA was conservative in its cost structures, and many doctors charged more - because their costs were higher. But he did believe there needed to be better awareness of the charging and financial consent.
A further political problem is looking after old people - which the health system does not do effectively.
One concern is that there is a tendency to treat depression through drugs, with drug companies and doctors pushing this trend. However, this was countered with the assertion that doctors don't like psychological issues - its a lot more time for less money.
However, equally the government is penny pinching about psychologists - they are the expensive and better approach, but it seems the government would prefer to treat people with medication.
So, perhaps the trend is more the fault of government and the drug companies; perhaps doctors are the innocent party here. Certainly, I'm aware of assertions that the drug companies push their anti depressant treatments vigorously.
Arthur noted that there was an innapropriate allocation of resources; it may be better to spend money on better housing rather than intensively pushing these problems onto GPs.