Laissez-faire Healthcare Blog

Hello all. It’s been well over a month since I last blogged. A lot has happened that is preventing me from pontificating as much as I would like. First, I moved from Kansas City, Missouri to Cherry Hill, New Jersey, a suburb of Philadelphia. My doctorpricing.com partners (William Short , Craig Clayton) and I were hired by Bill Good to run the day-to-day operations of his fast-growing TPA, AmeriFlex. I’ve always had a passion for consumer-driven health care, now I’ve quit my job as a bond trader and injected myself into the movement by working at a company that manages the payments of people with Flexible Spending Arrangements (FSA), Health Reimbursement Arrangements (HRA), Health Savings Accounts (HSA), and a number of other tax-benefited accounts.

My friend William Short has recently written a piece on the weakening dollar, the rise of oil prices and the dangers of applying similar government-based remedial actions on such things as health care. As the presidential race continues to chug along, this next election will be a defining moment in our nation’s history vis-a-vis health care. Will we continue our path towards a welfare state, or will we reverse the action of increasing government intervention?

Actually, my title is a bit misleading.  Not everyone has coverage…many people have not complied with the new law mandating coverage, and simply pay the fines.  So the state still has many uninsured people, and now it has a rising shortage of primary care physicians.

Those of us who have taken a basic economics course saw this all along…but the politicians running on a “universal coverage” platform (I won’t name names), were quick to ignore common sense in an effort to push deficient legislation through the pipeline to deliver on their promise to the people.  We probably have sound-bite culture to thank for this gem. 

Here’s a quote from Dr. Katherine Atkinson, a primary care physician in Massachusetts:  “I calculated that every time I have a Medicaid patient, it’s like handing them a $20 bill when they leave.  I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?” The quote comes from a recent New York Times article which highlights the growing shortage of primary care, the increasing wait times and travel distances to see a doctor, and the resulting reduced access to care. 

The need to pay off medical school debt, which averages $120,000 at public schools and $160,000 at private schools, is cited as a major reason that graduates gravitate to higher-paying specialties and hospitalist jobs.

Primary care doctors typically fall at the bottom of the medical income scale, with average salaries in the range of $160,000 to $175,000 (compared with $410,000 for orthopedic surgeons and $380,000 for radiologists). In rural Massachusetts, where reimbursement rates are relatively low, some physicians are earning as little as $70,000 after 20 years of practice.

Dr. Atkinson, whose present insurance reimbursements don’t even cover her costs, doesn’t have an opening for an appointment until May of 2009. 

Here’s another excerpt from the article: 

Dr. Patricia A. Sereno, state president of the American Academy of Family Physicians, said an influx of the newly insured to her practice in Malden, just north of Boston, had stretched her daily caseload to as many as 22 to 25 patients, from 18 to 20 a year ago. To fit them in, Dr. Sereno limits the number of 45-minute physicals she schedules each day, thereby doubling the wait for an exam to three months.

“It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”

Primary care, research shows, is at the core of quality health care.  This is the preventative medicine, counseling, and monitoring aspect of medical care that helps patients stay healthy and prevent the need for expensive specialty care, presumably because they will have less chronic disease if they actively manage their health, rather than go to an emergency room when a problem is so big it can no longer be ignored…

The new law of forced coverage it working to effectively end primary care in its present form in Massachusetts. 

On January 27, 2008, U.S. Representative John Conyers Jr. (D-MI) introduced a new version of a previously unsuccessful bill before Congress that would turn America’s health care system into a socialized, not-for-profit, singer-payer system.  Previous iterations of the bill had few co-sponsors (25 in 2003), and the current version (H.R. 676), has gained a modicum of traction thanks to Michael Moore’s film documentary, Sicko, which contends that the United States is the only developed country that does not currently have “universal health care.”

As an advocate for market-based health care (which we currently do not have), obviously I have problems with 676.  A few days ago I attended a lecture and discussion about the bill, presented by advocates in favor of it, to an audience of comprised mostly of naive first and second-year medical students…with one of two true skeptics interspersed within.  Below I present a few of the problems with 676 and with single-payer health care in general.

First, the highlights of the proposed law.  676 purports to cover the following: primary care and prevention, inpatient care, outpatient care, emergency care, prescription drugs, durable medical equipment, long term care, mental health services, the full scope of dental services (other than cosmetic dentistry), substance abuse treatment services, chiropractic services, basic vision care and vision correction (other than laser vision correction for cosmetic purposes), and hearing services including coverage of hearing aids.  Basically everything.  And you can go to any doctor or provider you want.  And there’s no deductibles, copayments, coinsurance, or other cost-sharing to be imposed with respect to covered benefits.  Sounds nice doesn’t it?

The cost.  I haven’t read the feasibility studies, but the text of the bill says all of this wonderful stuff, for every American citizen, will be paid for with income tax increases on the top 5% of earners, a progressive excise tax on payroll and self-employment income, existing government health care revenues, and a tax on stocks and bonds.  Additionally, the bill foresees a 15-year integration process, which will be paid for by issuing Treasury Securities.  Congress reserves the right to decide how much to tax the American public, it’s a basic tenet of our system of government…and with the guidelines above, we’re looking at a legislated equivalent of a blank check.  Why?  Because providing comprehensive, quality, accessible care to every citizen will command a budget possibly larger than any other ever conceived by man.  The U.S. Treasury will issue hundreds of billions upon hundreds of billions in debt to fund the 15 year transition period.  Just to “integrate” the new system, we are looking at compounding our debt (which is owned mostly be foreign investors), by nightmare proportions.  We will no longer own our own country.  Our grand-children and great-grandchildren will spend their lives paying interest to Dubai, India, China, Russia, and Japan.  The dollar will continue to weaken…perhaps it will reach parity with the Mexican peso.  Additionally, depending upon the size of the taxes necessary just to drive the operational side of this beast, there will be significantly less incentive for businesses to continue to exist on U.S. soil.  An excise tax on self-employment income is the government’s way of telling entrepreneurs and business owners to get f***ed.  

Medicare is poised to make up a record amount of our GDP in a few years…it’s already unsustainable and will soon be bankrupt in its current form.  It should be noted that the current form of Medicare covers only elderly people, and only pays for a fraction of the services listed above.  The USNHI proposes no revolutionary way to reduce the costs associated with administering an undertaking, which expands Medicare’s coverage on a exponential scale.  This is an atomic bomb. 

Private insurance becomes illegal if 676 is passed.  We use the term “universal health care” in quotations to describe countries like Israel and the United Kingdom, because these countries HAVE private insurance options.  People who can afford to, pay for supplemental private insurance, because even with smaller, more homogenous populations, these countries are not able to provide a fraction of what 676 promises.  And that’s with high personal income taxes, and very little defense spending (with the exception of Israel, most countries with quasi-socialized medical care depend on us for this).  In Canada, people routinely pay bribes to skip the line. 

This brings me to my next point.  Banning something the market is screaming for is like leaving picnic food at a park and putting up a “no ants” sign.  It’s a comical act of futility.  And it costs billions of dollars.  We have a country with a revolving door border policy.  Our government has spent hundreds of billions on drug enforcement…how well is that working?  How many people in this country own firearms purchased without proper licensing on a black market?  If you don’t allow for a private tier of health care payership, you force a black market to form.  Then you have to create government agencies to enforce and prosecute illegal “pushers” of private health care.  This cost isn’t factored into 676. Perhaps we could charge a “modest” excise tax…

Doctors will have no opportunity to attain true wealth.  Under 676, providers may elect to be paid government-dictated salaries, or reimbursed at government-dictated rates for services rendered.  Current private Health Maintenance Organizations (HMOs), who are the target of 676 supporters, reimburse doctors at a MULTIPLE of Medicare reimbursement rates.  This is because doctors cannot afford to stay in business strictly on Medicare payments.  With skyrocketing malpractice premiums forcing many doctors into retirement, we could be looking at a future with no domestic doctors.  676 does not (and legally cannot) address medical malpractice – medical licensing and tort reform are handled on a state level.  Doctors have little incentive to exist in this environment, particularly those doctors facing hundreds of thousands in student loans…which is most of them.  676 does not address medical school tuition.  With no primary care physicians, the queues will grow quickly.  In Canada it takes 10.1 weeks to get a CT scan.  How long will it take in a country our size?

Then there’s the problem of illegal immigrants.  676 only covers American citizens.  Are we prepared to deny all care to illegal immigrants?  I doubt so.  The cost of providing similar care to this demographic (making up a significant chunk of the population), has not been factored into the bill.  Taxes go up more.  A true welfare state. 

There’s a slippery slope here.  At some point you have to decide whether you’re country’s mission is Capitalism (the American Dream), or Communism (from each according to his ability to each according to his need).  I don’t think we’re ready to give up the ghost quite yet.  The great empires of the world had much longer tenures than 200 years.  Are we ready to become a welfare state, and give the crown to a new empire?  The next empire probably isn’t going to be as nice as us.  It probably isn’t going to drop food and vaccines on African villages…

Finally, the perfect irony.  The purveyors of USNHI tout it as the answer to large for-profit HMOs that put shareholder interests and CEO salaries before patient well-beings.  What?!  By putting the government in charge of it?!  The same government that takes handouts from special interests groups that represent all kinds of nasty interests perpendicular with those of individual American health care users?  Corruption was invented in Congress.  Congress created the original food pyramid to promote the interests of the U.S. Agricultural industry, not our health.  That’s why it recommended 5-11 servings of starch per day.  One could cogently argue that the government created type II diabetes to help the American farmer.  If you read history, governments, especially those with absolute power, don’t have the best track record in the human rights category.  There was this guy named Stalin, maybe Michael Moore should do a documentary…

Medical Tourism isn’t like regular tourism.  It’s a euphemism for traveling to a foreign country for more affordable medical care.  And with skyrocketing health care costs in the United States, it’s becoming a reality.  Thomas Black of Bloomberg News writes that insurance companies are now offering plans that include procedures in foreign countries, in exchange for reduced premiums and out-of-pocket expenses to the policyholder.  “Yielding to pressure from employers, health insurers such as Health Net, Aetna Inc. and Blue Cross Blue Shield of South Carolina are offering cost savings to policy holders who take their ailing backs, hips and knees to foreign countries for non-emergency medical treatment. Mexico has emerged as a favored place for American medical tourists because of its proximity and U.S. insurer incentives.”

According to Yosef Woodman, author of “Patients Beyond Borders,” about 180,000 Americans leave U.S. soil for elective medical procedures every year.  Woodman predicts 15-20% annual growth.  Even with a weakened currency, medical procedures in developing nations cost a fraction of what they cost here.  Some of the early sovereigns partaking in medicine outsourcing include: Mexico, Singapore, Turkey, Saudi Arabia and Brazil.  It’s not a coincidence that these aren’t countries you’d elect travel to for non-medical tourism.  

Obviously quality of care, feasibility of follow-up care, and redressability of malpractice claims are factors.  But you (or your insurer) are paying less so you should expect less.  Or should you?  Obviously you don’t want tainted blood for a transfusion or rat droppings in the operating room, but it’s no secret that paying more isn’t necessarily associated with higher quality or better outcomes.  This is because health care in the U.S. is artificially expensive…mostly due to terribly inefficient administration and lack of price transparency.  

Ironically, these problems are caused primarily by the Medicare model espoused by the government and copied by the very insurance companies that are now incenting their customers to take it abroad…

Seems like a great business model for the time being, instead of charging ridiculous premiums, charge slightly lower premiums and cut your claims liabilities by 88% (Angioplasty can cost $84,000 in the U.S. vs. $10,000 in Mexico).  You can’t tell me margins aren’t widening here…

Curiously, I’m not against medical tourism or incentives to taking it abroad.  We live in an increasingly globlized economy…a little healthy competition might be what forces our health care system to go on a much needed diet.

People like to scoff at the idea of blending health care with shopping.  Uttering the very words “consumer driven health care” sends shivers down the spines of “purists” - your local medical specialist, whose life-saving work necessitates the confidence and ego driving the indignancy of the thought.  Does consumerism cheapen health care?  Well, yes…if you caught the double entendre.  Those of you who are too good to have your profession sullied by associating it with value probably think so as well…but not in the good way.

Check out these two posts from Brian Klepper on The Doctor Weighs In Blog.  The first, entitled “The Myth of Healthcare Consumerism” points out a recent study that shows only 19% of people would research their doctors and switch providers if they found their doctor had received a low rating.  Now, even if this number is lower than expected, I don’t think healthcare consumerism has anything to worry about.  First of all, as the post points out, 19% is 38 million adults.  Secondly, the data says nothing about using online research to find a provider in the first place.  Switching doctors is difficult and inconvenient.  Picking one in the first place isn’t…and it certainly will only get easier as more information comes available to make an informed decision.  This is sort of the point.  Surveys ask people to describe what their behavior will be in a given set of circumstances.  These circumstances have never existed…so the utility is unknown.  However, the early sites seem to be showing promise.  How many hits do you think drugs.com or wedmd.com get in a day?  My startup, doctorpricing.com gets thousands a month and it’s still a beta version.

Klepper’s second post: “Health Care and the Gathering Storms“ compromises the theme of his first.  Warren Brennan, the CEO of SMA Informatics in Richmond, provides economic data (S&P/Case Shiller Home Prices Indices, wage data) that supports what any informed American already knows - we are experiencing and economic contraction that may become, or possibly already is, a recession.  The individual consumer makes up 70%+ of our country’s economy, and health care has been riding a wave of economic prosperity that is ending.  The conclusion?  Health care businesses (doctors, hospitals, technology companies, etc.) are going to hurt just like every other industry.  What can we deduce from this?  Health care consumers are, at some level, price sensitive, just like every other type of consumer.  It is a basic tenet of economics. 

Why do Americans spend more per-capita than any other country in the world on medical care?  Because they can….  When the can’t any longer, they won’t.  Price matters.  And it’s going to matter more as health care costs continue to outpace inflation by 200-500 basis points.  Employers will no longer be able to provide standard insurance to employees…cheaper alternatives like High Deductible Health Plans will become more mainstream.  People will have to manage some of their own health care risk…one way or another.

At least I hope so…for the sake of all of us…

Shawn Tully, editor-at-large of Fortune Magazine, wrote a fantastic summary of each of the presidential hopefuls’ health care plans on CNN Money.  He reaches the same conclusions I have have as of late on this blog - we must get health care costs under control.

I haven’t spent a lot of time on the candidates’ plans yet…and this editorial says it better than I ever could.  McCain’s plan attempts to give the consumer control over medical coverage and health care decisions.  The creation of something resembling a free market will drive down the costs of care.  Hillary and Obama’s plans, being similar, seek to make coverage mandatory by forcing everyone to pay for it.  Two very opposite approaches to a staggering problem.

Having studied economics and worked in a market-based industry, I am incapable of wrapping my head around the Democrats’ plans.  How is forcing everyone to buy insurance going to make health care more affordable and accessible?  How does shifting all these costs directly to tax payers improve care and reduce costs?  I don’t understand this.  Can someone explain it to me?  The Democrats do have an advantage though, their plans, while more complicated than McCain’s, sound simpler.  Health care for everyone.   They win on political viability.

Read the article and let me know what you think…..

Robert Pear’s New York Times article about Hillary Clinton’s and Barack Obama’s health care plans has an alarming statistic.  Medicare and Medicaid, our two government-funded health programs, cost our country $627 billion last year - or 23% of all federal spending.  Many people like to criticize the Iraq War for its cost - proclaiming that it could bankrupt our nation.  Over the past 3 years, defense spending (that includes everything….not just Iraq) has accounted for about 4% of the U.S. Economy…the same percentage enjoyed during the “peace dividend” in the early 90’s after the fall of the Soviet Empire — a historic low.

If anything is going to bankrupt us, it’s the rising costs of health care.  According to the Congressional Budget Office, with no change in law or coverage policies, in 10 years costs will double, and Medicare and Medicaid will make up 30% of our annual budget. 

Not only is this unsustainable (we’ll be Greece), the notion of covering additional people under these programs…those not currently covered under either program’s mission, presents a fiscal impossibility. 

I could only draw one conclusion from these facts.  We must rein in the cost of administering health care in this country BEFORE we do anything else.  If we could create a market for health care, we could reduce costs through simplified billing and collections, and price transparency.  More people would be able to afford preventative care and wouldn’t need Medicaid.  www.doctorpricing.com. 

Heck, maybe if we pulled 30-40% of current costs out of the process through a well-oiled free market system, everyone in this country could be insured….and we could reduce government spending and taxation.  Maybe…

Expanding goverment medical coverage to cover more people without addressing the soaring oresent costs of administration will create a budgetary black hole.  Our country will collapse in on itself. 

A reader of mine left an interesting comment on my post about selling your kidney. Here is an excerpt:

“I am waiting for a kidney and have been dialysising for 2 [and a] half years on hemodialysis and 5 years on capd - a gentler type of dialysis… I am…using up resources and cos[t]ing a lot of money for the UK government. My family has the money to buy a kidney but we have been advised not to go abroad by the doctors…. so…. still waiting…. still taking up resources….. still being a burden on the N.H.S… still costing the government money…. apparently it costs over £40,000 a year to keep someone on dialysis!!! in the UK”

It got me thinking about the quasi-socialized system of health care in the U.K., and how Socialism, in almost any capacity, can yield absurd results in the real world. The New York Times, despite being a decidedly “liberal” publication, sheds light on a particular example.

Sarah Lyall writes about Debbie Hirst, a British cancer patient who was denied Avastin, a common breast cancer drug. The peculiarity isn’t that the drug wasn’t covered by the British National Health Service (NHS)…it’s that Debbie was offering to pay for it herself and the British government wouldn’t allow it.

The reason wasn’t medical - her oncologist thought the drug, widely prescribed in Europe and the United States, was medically necessary.

It wasn’t based on money either - as stated above, once turned down by the socialized health care system she’d paid into her whole life, she offered to pay for the drug out of her own pocket.

It was philosophical…

British officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.

Patients “cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs,” the health secretary, Alan Johnson, told Parliament. “That way lies the end of the founding principles of the N.H.S.”

Without question, a ridiculous outcome…

There are two strong arguments against such a position:

(1) Committing to Mr. Johnson’s position would mean preventing better overall outcomes at no additional cost to the government. In other words, a Socialist ethos demands across-the-board equality, the idea being that a socialist regime should bring everyone up to the same level of care. In economic reality, adherence to this principle doesn’t mean bringing everyone up, but rather, dragging people down to a mediocre level of care…for nothing more than the sake of the equality. The argument states that people should not be allowed to pay for life-saving care because it wouldn’t be equal. I’d be curious to see if Mr. Johnson would try to pay for a cancer drug he needed, if the government turned him down. I’d put all of my money on “yes.” You can’t substitute academic justice for natural justice… see my next point.

(2) The argument above is moot because the British health secretary can’t boast equality anyway. Here’s an excerpt for the NY Times article: “In fact, patients, doctors and officials across the health care system widely acknowledge that patients suffering from every imaginable complaint regularly pay for some parts of their treatment while receiving the rest free. ‘Of course it’s going on in the N.H.S. all the time, but a lot of it is hidden — it’s not explicit,’ said Dr. Paul Charlson, a general practitioner in Yorkshire and a member of Doctors for Reform, a group that is highly critical of the health service. Last year, he was a co-author of a paper laying out examples of how patients with the initiative and the money dip in and out of the system, in effect buying upgrades to their basic free medical care. ‘People swap from public to private sector all the time, and they’re topping up for virtually everything,’ Dr. Charlson said in an interview. For instance, he said, a patient put on a five-month waiting list to see an orthopedic surgeon may pay $250 for a private consultation, and then switch back to the health service for the actual operation from the same doctor. ‘Or they’ll buy an M.R.I. scan because the wait is so long, and then take the results back to the N.H.S.,’ Dr. Charlson said. In his paper, he also wrote about a 46-year-old woman with breast cancer who paid $250 for a second opinion when the health service refused to provide her with one; an elderly man who spent thousands of dollars on a new hearing aid instead of enduring a yearlong wait on the health service; and a 29-year-old woman who, with her doctor’s blessing, bought a three-month supply of Tarceva, a drug to treat pancreatic cancer, for more than $6,000 on the Internet because she could not get it through the N.H.S.”

The ironic bit is that Ms. Hirst’s cancer has advanced to the point that now the British government will approve Avastin, and pay for it. But she’ll probably die first. There is an economic argument in favor of Britain’s inept system - Ms. Hirst: “I’m a person who left school at 15 and I’ve worked all my life and I’ve paid into the system, and I’m not going to live long enough to get my old-age pension from this government.” Here it is: if the level of care at which everyone is equal is low enough, people won’t live long enough to collect the money they’ve paid into the system through high taxes. Ouch.

One final point - Dr. Paul Charlson’s paper (quoted above) is evidence of what common sense dictates - socialized programs DO NOT work in the real world. Even dedicated supporters of the academic notion of equal care will always secretly favor that which their means will allow. If you’re dying, and you have the money to pay for a treatment that just might save your life, you’re going to put your politics aside and pay for it - even if you have to leave the country.

A while back I wrote a post entitled “Health Care Like the DMV” in which I chronicled my efforts to collect a tax refund from Jackson County, Missouri after they double billed me for my ‘07 property taxes and pulled the money out of my bank account.

I paid the taxes on November 21st of last year, found out about the mistake just before Christmas, and begin my appeal to the good bureaucrats of Jackson County that same day.  It is now February 28th , over three months later, and the county has yet to reimburse me for the interest-free loan I have provided them.  Up until today my efforts to collect included numerous phone calls/voice mails to the county, several emails with scanned copies of my duplicate receipts, and several actual conversations with live people assuring me the glitch had been fixed and was being processed.

I had enough.  I physically went to the collections office today, spoke with a very nice mustached lady, and filled out the same paperwork I filled out in December.  I was assured once again that the refund would be mailed to me in 2-3 months.  From today.  At the 6 month mark, perhaps I will provide another update.

Why do post about this?  Because I wouldn’t ever want to trust these people with the task of keeping track of my blood type…

Journalists Ezra Klein and Peter Suderman debate the government’s role in the future of U.S. Health Care (thank you Healthcare Economist).  Whose argument carries more weight?

Klein’s main argument is decidedly anti-libertarian, which makes perfect sense because I don’t think he is a Libertarian.  Klein’s conclusion is that it will take substantial government resources, research and intervention to improve health care economics and yield better outcomes.  He supports it with the following statements: “the individual consumer will never have enough information or enough expertise to exert effective control over the medical industry. People don’t comparison shop when they have a heart attack, they don’t know how to effectively contrast chemotherapy providers when their doctor tells them they need to start treatment now. Confronting illness — much less physical trauma — is not like buying a television. You can’t walk away from the deal, and you’re in a terrific state of fear and urgency before you ever speak to a salesman.”  Essentially he’s saying that giving the consumer access to price and procedural information will not make them discernably more efficient consumers of health care - because health care is more fear-driven than any other money-spending endeavor.  In some cases this is true.  If you’re imminent fear of dying, you want the best care, rather than the cheapest.

There are three fundamental flaws with this: (1) very few medical decisions contain the type of fear Klein describes - in fact most health care dollars are spent in preventative care and chronic disease management where cost certainly does play a role – all the crap that, if you screw it up, leads to the coronary artery bypass situation described above; (2) even if the decision is emotional (aren’t all decisions at some level?), price transparency still provides valuable feedback - perhaps the patient wants the most expensive treatment…associating it with the highest likelihood of survival.  If the information lacks the requisite transparency, the patient could err and make the wrong choice.  More and better information is always better than less and worse information, regardless of the emotional state of the consumer; and (3) if the consumer will “never have enough” information to make an informed decision, who will?  Life and death decisions are made between physician and patient everyday.  If we’re going to say the patient isn’t qualified to act on his or her own behalf, are we prepared to say Medicare is?  

(3) really gets at the heart of my philosophical issues with Klein’s argument.  If we are prepared to strip consumers of the right to make their own medical decisions, we must be prepared to say they are not moral agents.  The government should decide all kinds of things about how they live their lives, no?  Isn’t that contrary to the very notion of freedom? 

Suderman’s response is right on: “I’m apprehensive about the idea that individuals shouldn’t be trusted—or at least given the option—to manage and determine as many of their own health decisions as possible. And for another—and this was my original point—even if your government-run comparative effectiveness research board consists of the most honest, decent, and committed public servants in the history of the nation, they’re still going to be subject to a variety of outside incentives.”

In the case of biased bureaucrat and emotional patient - emotional patient is the lesser of two evils…particularly when the issue at bar is the patient’s life.

If I’m wrong, tell me…