Malpractice vs. "Malresult"
Malpractice vs. "Malresult"
A new form of insurance for an eternal problem
January 10, 2005
by Thomas Szasz
http://www.reason.com/hod/ts011005.shtml
posted by Jeff Schaler @ 9:20 PM
7 comments
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The purpose of The Szasz Blog is to advance the debate about Thomas S. Szasz's basic ideas and their practical implications. The Szasz Blog is part of The Szasz Site, www.szasz.com Comments are published at the discretion of the administrator (Jeff Schaler). Please stay on topic. The length should not exceed 250 words. E-mail comments to jeffschaler@attglobal.net
Monday, January 10, 2005
A new form of insurance for an eternal problem
January 10, 2005
by Thomas Szasz
http://www.reason.com/hod/ts011005.shtml
7 Comments:
I'm not sure I really like this idea, especially where he writes: "People who choose to undergo diagnostic and therapeutic procedures ought to be able, and be expected, to purchase medical malresult insurance" (emphasis mine).
Are premiums going to be based on how satisfied people tend to be? Are unsatisfied patients going to pay higher rates than satisfied patients? Will it reduce the number of patients written off as "psychiatric", "psychosomatic", "hypochondria" or "Munchausen" cases?
If we're going to have "medical malresult insurance", why not also have "unsatisfactory food insurance" for restaurants, entitling you to a full refund if you don't like the food? (I'm a picky eater :)
As the article says, patients suffer both wealth and physical risk today. So the answer is to give patients more freedom in decision-making, to be more proportional to the risks they take.
If patients suffer wealth and physical risks, then they should be more involved with decisions involving which procedures are done, how much each of them costs, and what their respective tradeoffs are.
Right now health "insurance" hides some of the wealth risks from the patients, and medical paternalism hides some of the physical risks (falling back on malpractice insurance to protect the doctor if something goes wrong).
Almost no-one would be willing to pay extra for "malresult insurance", given the way things are today. They would demand more autonomy and decision-making, before they would be willing to pay more.
Right now patients have little decision-making power, and so they value their medical care less and less, and are willing to pay less and less for it, expecting "insurance" or the government to pay it for them.
Making more drugs available over the counter, and promoting more self-diagnostic procedures, such as do-it-yourself cat scans (which have opened up in some small walk-in clinics), would be better than "malresult insurance" as first steps towards patient freedom and responsibility.
The patient has to feel that they have a choice. Many patients would be willing to pay for diagnostic tests and drugs themselves, if they truly had a choice, and if the tests and drugs were priced in a free market. Give them a choice, and they will pay for it themselves. They are also less likely to cry foul if something goes wrong, since they were the ones who did it.
Lee Killough makes some points with which I agree, but none of which invalidate the novel Szasz proposal.
My view of the medical industry is, I think, darker than that of Dr. Szasz. Physicians often knowingly behave in ways that present mortal risks to their clients. They don't properly clean their hands, they doll out millions of worthless antibiotic prescriptions, they don't write prescriptions and directions legibly, and a host of other insults to competency. Imploring them to behave better has not been effective. (Today's news includes a report of the "overwhelming majority" of New York cardiologists choosing not to do surgery on high-risk patients so they won't be hurt on the state's scorecard. Unintended consequence with a vengence, but can we really only blame the state?)
Physicians comprise a particularly malignant cartel, which is a major source of injury and death. The present tort system is a moral and practical abomination. As Dr. Szasz says, it fails to distingish between inescapable risk and real negligence, but can we really make that distinction in a socialized medical market? The most important reforms would be to end state licensing and the flowering of doctor-patient contracts. Until we have those reforms we have no idea what the "real" risks of medical procedures may be.
Physicians are (as Milton Friedman famously noted) as resistent to technological and other innovations that might reduce their income as postal workers. If the cartel was disempowered, it is possible that, not only would doctors behave more responsibly, but that technology might dramatically reduce the risks which Dr. Szasz seems to consider inevitable. Or new types of medical specialists might appear, including some devoted expressly to patient safety. (At present, the most important patient safety experts in hospitals are in charge of infection control. For influence they rank just above the manger of the gift shop.)
That said, one wonders whether the proposal for malresult insurance might be comparable to "medical marijuana" proposals that fail to address the core issue of hazardous state-sponsored physician power. The insurance plan leaves the cartel intact, and possibly gives it another layer of defense.
But I think the Szasz proposal is well worth considering, and it would seem to solve some of the prevailing problems. I hope he submits it to insurance industry publications so that the insurers have a chance to give it the once over.
If the restaurant industry maimed and killed as many people as doctors, we might need "unsatisfactory food insurance." I wouldn't oppose it.
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I should have noted Lee Killough's error in comparing medical malresult insurance with what he calls "unsatisfactory food insurance." Malresult insurance would be provided by an insurance company, not by a physician, and it would never entitle the policyholder to a "refund." The comparison with dining satisfaction is inapt.
I should have noted Lee Killough's error in comparing medical malresult insurance with what he calls "unsatisfactory food insurance." Malresult insurance would be provided by an insurance company, not by a physician, and it would never entitle the policyholder to a "refund." The comparison with dining satisfaction is inapt.I disagree.
I never said that malresult insurance would be provided by a doctor, or that "unsatisfactory food insurance" would be provided by a restaurant.
"Unsatisfactory food insurance" could be provided by, say, Diners Club. For a slightly higher club fee, you get unsatisfactory food insurance. If you don't like a restaurant's food, and you used your Diner's Club card, you can file a claim and get your money back, not from the restaurant, but from the Diner's Club insurance. (Using the word "refund" was probably my original error, which probably led to misunderstanding.)
I still think the comparison is apt.
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Lee Killough makes some points with which I agree, but none of which invalidate the novel Szasz proposal.His proposal may be good for the distant future, but not until patients have more autonomy. Right now patient freedom is limited so much that Szasz's proposal is both politically impossible and economically unfair.
We (here) all want to move in the direction of greater freedom and responsibility for both doctors and patients. Right now there's too little responsibility for patients as compared to doctors, which Szasz's article is trying to correct, but at the same time, my point is that there is far too little autonomy, for both patients and doctors.
Doctors: Some freedom, lots of responsibility
Patients: Very little freedom, almost no responsibility
We all want to move towards:
Doctors: Lots of freedom and reponsibility
Patients: Lots of freedom and responsibility
Szasz's article moves towards:
Doctors: Some freedom, lots of responsibility
Patients: Very little freedom, more responsibility
I suggest first moving towards:
Doctors: Some freedom, lots of responsibility
Patients: More freedom, more responsibility
Buying over-the-counter drugs would increase both freedom and responsibility for patients, as long as drug companies are not held responsible for patients taking drugs ill-advisedly. So would patient self-diagonstics, as long as patient negligence is not blamed on doctors or test equipment manufacturers.
Malresult insurance would increase patient responsibility and patient costs, without increasing patient freedom significantly enough in today's environment.
Now if we were in a situation where patient freedom was much better, and doctors were not so heavily regulated by the FDA and DEA, then yes, Szasz's idea has merit. I am not totally invalidating his idea.
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