Doctors vs. Accountants©: Part III

Alexander Fleming, discoverer of penicillin

I began writing this series with the best intentions. Affected by a single, emotionally raw tweet, I simply wanted to express why the most common proposal to remedy insurance bureaucracy, nationalizing American healthcare, will only put new bureaucrats in charge of the same system. I’m no fan of private insurance, which privileges corporate interests over the patients it’s supposedly organized to serve. But even less do I like bureaucracy.

As I’ve attempted to clarify my positions, however, I’ve apparently made things even murkier. A dear friend, recently diagnosed with a rare and painful genetic disability, praised my thoughtful responses, but replied, “it feels like you’re saying that people like me are going to be screwed no matter what.” This criticism pierces my heart, because I struggled with this very thought while writing, fearing I was condemning my friend, and people like her, to a lifetime of suffering without remedy.

The more I thought about things, however, the more I’ve realized this isn’t necessarily true. Yes, advances in medical technology have meant people once doomed to early, painful deaths can now live longer, do more, and thrive abundantly in ways once unthinkable. And as I wrote earlier this week, that technology is cripplingly expensive, meaning some bean-counter somewhere needs to make life-or-death decisions about who gets priority access.

But, conversely, the most important advances in medical history haven’t been either high-tech nor particularly expensive. Scottish microbiologist Alexander Fleming discovered penicillin accidentally, after leaving a petri dish unattended overnight. Louis Pasteur, famous for discovering a rabies treatment, and Edward Jenner, who invented vaccinations, worked in similarly low-tech environments, pioneering practices that, today, aren’t very expensive or difficult to acquire.

Louis Pasteur, discoverer of multiple
medical procedures

Even my friend’s diagnosis of Ehlers-Danlos Syndrome, a rare connective tissue disorder, didn’t come through expensive, specialized innovations. Her doctor simply listened to her symptoms, compared them to known research, and referred her to a geneticist. It took years for her to reach the point where a physician would trust her enough to simply listen, but I suggest that’s a whole other problem.

So let me suggest a remedy.

Let’s return to a source I cited at the beginning of this series, Princeton economic historian Jerry Z. Muller. He writes that doctors and accountants have always sparred over treatments: doctors often want to pursue heroic lifesaving measures, even when these measures are expensive, and divert resources from a larger pool of deserving patients. Accountants, by contrast, strive to keep costs down, sometimes despite a patient’s treatments being both affordable and cost-efficient.

This ordinary conflict becomes exacerbated by both private insurance, and nationalized health-care, because the accountants responsible for the economic side no longer work within the medical treatment environment. They occupy external positions in corporations and governments, making decisions based on Xeroxed checklists, without consulting the doctors, and without the doctors having any avenue of appeal. In other words, the problem isn’t accountants, it’s their bureaucratic framework.

Professor Muller suggests a straightforward response to this problem: trust those intimately familiar with the problem, to also have intimate familiarity with the solution. Muller doesn’t make this suggestion only for health care. Teachers know better than corporate standardardized-test writers whether their students are prepared to graduate. Farmers know better than ConAgra or Monsanto how to husband the land. Doctors and on-site accountants know how to treat patients.

Edward Jenner, discoverer of vaccines

My friend’s Ehlers-Danlos diagnosis took twenty years, but I propose the problem isn’t the doctors. I witnessed several, though not all, of her interactions with medical professionals, and I feel confident in saying, they rushed through the diagnosis process, asking checklist questions and assigning her a pharmaceutical diagnosis, because that’s all that insurance would pay for. In order to cover operating expenses, doctors need to rush their patients, lest they go broke.

Return, please, to the image I first conjured: Doctor House struggling for days, weeks even, over one patient. Staying up all night consulting medical journals and concordances. Working to parse the diagnosis. That’s not realistic for most patients, certainly, or their bills would run into the millions of dollars. But imagine if doctors, and their on-site accountants, had time to converse with their patients before settling on whatever diagnosis the insurance bureaucrats will cover.

I suggest my friend might’ve gotten her diagnosis years ago, if the bureaucracy hadn’t held the process hostage for profit. Government bureaucrats, cognizant of the next election and pot-luck outrage over “taxpayer dollars,” will do no better. We need to trust skilled professionals, intimately familiar with their field, to make these decisions. The solution to bureaucracy isn’t reshuffling the bureaucrats; it’s removing them entirely.