Random Thoughts from a Restless Mind

Former Budget Director Peter Orszag wrote an Op-Ed piece in the New York Times titled “Health Care’s Lost Weekend” in which he offers several reasons why healthcare in general, and doctors in particular, should be open for business 7 days a week. “Doctors, like most people, don’t love to work on the weekends…” is his first shot across the bow. He cites a study in the New England Journal of Medicine (the only medical journal to which God subscribes) which is actually a pretty darned good study, one that shows an increase in cardiac mortality of 0.9% (decimal point is correct) for people admitted to the hospital with a heart attack on the weekend in comparison with those admitted during the week.

I’m willing to buy this conjecture, even willing to say that Mr. Orszag’s conclusion, that medical services should be available 7 days a week with expanded hours of business to boot, is a desirable and necessary goal for American Healthcare. The difference between the two of us is that I will openly state what it will take to make such a thing happen, whereas Mr. Orszag has taken the cowardly politician’s route but simply saying “this isn’t right…this isn’t fair…this must be changed,” without offering anything about how.

Someone, or some someones, will pay something somewhere to make this happen. There, I said it.

There are actually a couple of really good examples of this phenomenon right now in my community,  Cleveland. The vaunted Cleveland Clinic is downgrading the trauma service at one of its hospitals, ostensibly because the city of Cleveland is “oversupplied” with trauma centers,  and because it is becoming increasingly difficult to find trauma surgeons to staff these emergency rooms. All true, but in reality it’s because the Cleveland Clinic has decided that the operating loss associated with keeping this trauma center open is more charity than the institution wishes to give to the city, especially in light of a palpable lack of civic gratitude. Similarly, all of the emergency rooms in town are finding it difficult to provide specialty coverage as specialists are declining to make themselves available. Insufficient compensation for the inconvenience associated with that availability, as well as the significant exposure to a litigious patient population are the culprits.

The funny thing is, once upon a time we actually had the equivalent of a 24/7 medical service economy. Back in the day, when Mr. Orszag and I were children, physicians were held in high esteem because they put their patients and their medical practice first, in front of every other aspect of their lives, 24/7.  They were incentivized to do this in two very specific ways: they were paid, and paid very well to perform their services, and they were afforded out–sized doses of respect, occupying a place of honor in every community. In return for this combination of handsome concrete and social compensation medical care was provided when medical care was needed, 7 days a week.

My first real job was caddying for wealthy golfers at the local country club. Not surprisingly, a significant percentage of the country club members were local physicians. Mind you, this was back in the day when only doctors carried beepers. I can’t begin to count the number of times I had a fantastic loop toting the bag for a doctor in the middle of a career round only to see some easy shot go careening into the woods when his beeper went off at the top of his backswing. I vividly remember seeing the assistant pro speeding down the fairway coming directly toward us in a golf cart to retrieve a doctor who was needed at the hospital. Saturday afternoon, Sunday morning, Wednesday evening… no matter.

What was the cost? Well, certainly the doctors didn’t do this for free. They asked for, and received, handsome compensation for this 24/7 availability. Society readily made this investment, in part because the best technology available was actually the technology available only between the ears of the physician. This is somewhat different today given all of our fantastic technological innovations and advancements, but not so different, really, because the stuff between the doctors ears is still what drives all that new technology.

There were hidden costs back then, too. Hidden costs are the ones that are actually the most expensive when we really drill down to see what the ramifications would be if Mr. Orszag had his way. Countless physician families were roadkill, collateral damage to the single-minded emphasis doctors placed on practicing medicine. Troubled children, troubled marriages, broken marriages, broken people all littered the landscape of the medical community, silent testimony to the cost of 24/7 availability. So, too, the nurses and technicians and orderlies who worked the swing shift and the graveyard shift. The social and physical pathologies of shift work are now quite well known. How does Mr. Orszag intend to handle THIS cost? Surely he’s not willing to ignore the well–documented evidence of the social and psychological harm that befalls workers and their families when they are forced to to work weekends and nights?

Behavioral economics is based on the simple concept that people will act in a manner consistent with rational self–interest. Most of the time this is EXACTLY how people behave. Over the course of the last several decades, as physician incomes have declined and as the doctors’ societal esteem has plummeted, physicians have been notably less willing to put their families in jeopardy by putting their profession first and foremost. By the same token, the vast majority of non-–physician workers in healthcare are loath to do the same, hence the difficulty filling nighttime and weekend shifts in hospitals, clinics, and the like. No one likes to work on the weekend when their family is home, when their friends are not working.

So, a  24 seven medical service economy? Sure. Who wouldn’t want THAT? Even without the data from that NEJM study it would be very convenient to have that colonoscopy I’ve been putting off on a Saturday instead of a workday, maybe even a Sunday with Saturday for the prep (prep…yuck). Heck, I found it pretty inconvenient that I couldn’t get a sandwich at one o’clock in the morning at a big convention hotel in Chicago last weekend. I was even willing to pay a premium, not only for my sandwich, but also to the person who made that sandwich appear. I would have given effusive thanks as well.

Therein lies the beginning of the solution. If you wish to have high technology medical care available seven days a week you must provide a significant incentive to those people who provide the care. Simple. I will offer as well that it probably doesn’t make a whole lot of sense to bash those very same people you are trying to convince to put aside some part of their self-interest (or the interest of their families) to work weekends; who is going to do something nice for someone when their reward is to have that same someone turn around and show nothing but disdain for not only the service provided, but also for the provider of the service?

So Mr. Herzog if you want me and my colleagues to be available on Sunday afternoon to take care of people exactly the same way we might on a Tuesday morning you  have to be willing to do two things which thus far you and others of your ilk have demonstrated no inclination to do: you must pay us what those services are worth, and you must be thankful that we are willing to provide them. It’s not enough to declare the “what”, you also have to declare the “how”. Isn’t that what REAL economist do, Mr. Orszag?

Heinlein was right. It doesn’t matter what time you serve it, There Ain’t No Such Thing As A Free Lunch.