Another surprising public debate becomes for what should we pay? In Canada, the National health system does not pay for dental care. Apparently, teeth are superfluous. In Holland, from where I am today returning, the government is about to decide that psychiatrists will no longer be paid for psychotherapy, only for prescribing medications for depression because medication is more cost-effective than psychotherapy and people can get cheaper psychotherapy from others. I learned this at a Dutch hypnosis conference attended by a number of psychiatrists and family physicians. Actually, the evidence in the literature does not support this contention. A number of studies have shown that psychotherapy is more effective than medication or medication plus psychotherapy at 16 weeks. For depression, a 2010 meta-analysis using the Freedom of Information Act to obtain all the clinical trials ever done on antidepressants (all must be reported to the FDA but not necessarily published) found no difference between medication and placebo. A 2010 study compared behavioral activation (prescribing behaviors that cause the person to become more active) to cognitive-behavior therapy and to medication over 16 weeks. Most antidepressant studies last 6 weeks, not long enough for psychotherapy to show its full effect.
However, how much control should the payer have over how we physicians choose to treat people? Typically, there are many equally good ways to treat a problem, though bureaucrats are not apt to notice this. They wish the best way. They wish a quick and easy answer. And a bias exists! Therapies that involve human interaction are always less trusted than technology. We live in a world in which the bias is toward technology solving problems. Payers for health care have an interest in what is provided just as do recipients of health care. Where do the two intersect? Her again, I would prefer Bernie Sanders (Senator, Vermont) solution of giving control of health care to local governmental units. I think I would have a better chance of arguing my methods and why they should be compensated to a local board than to a faceless, nameless government agency.
Thus, in thinking about a single payer system, we must consider the politics of power. Who decides what will be covered. Who decides what we physicians are allowed to do and what we are not allowed to do.
Even as we consider who pays for health care, we must consider the kind of health care that we wish to have and how to insure that we get it. Today's health care relies extensively on technology which often fails to achieve its desired goals. Some of us at the margin of health care want more human-oriented care. We believe that health improves in the context of relationship and that physicians need to take the time to develop relationships with patients. We need to have the time to develop the relationships to help people change the way they live and to change the way they see the world. We need ways to provide care that allows us to spend time with patients and provide care that we and the patients believe will help. The downside of single payer systems that are far removed from the doctor-patient relationship is that the control lies far from the relationship. Bureaucrats don't necessarily even make evidence-based decisions, and evidence changes constantly. Doctors and patients need some autonomy over what they decide to do to improve health.
Himmelstein, D. U., et al. (2003). Administrative waste in the U.S. health care system in 2003: The cost to the nation, the states and the district of Columbia, with state-specific estimates of potential savings. Cambridge MA: The Division of Social and Community Medicine, Department of Medicine, The Cambridge Hospital and Harvard Medical School; Washington, DC: The Public Citizen Health Research Group.
Lewis will be in Maine, May 11-13, 2012, for Changing Story, Changing Self: The Power of Personal Narrative for Self-Healing. For details : Dr. Magili Quinn, DO 207-450-7151, Email address removed
