@rsellin @SaySandra @KikkiPlanet @eadnams @tricmstrat @lizasunley

Right now a rigorous Twitter debate is taking place about the "inefficiencies" that can be found in public healthcare, and how removing those inefficiencies can improve service while holding or even reducing expenditures.

There are now about three different issues being discussed within the same conversation, and with the number of participants obviously the (140 - (all over their unnecessarily long Twitter handles because 5 chars should be maximum)) character limit is really keeping my long-windedness down. So here, briefly, are the issues:

  1. Waste in healthcare: @KikkiPlanet has been talking about unnecessary trips to the waiting room. Are these really all that common? Probably. Certainly the fact that people don't pay for it is causing some individuals to use it when they don't have to. Conversely, and paradoxically, despite being free there's a serious time wasting inherent in our public system. Every two hours you're waiting for a doctor is two hours you aren't at the office pulling down $27.50/hr or whatever. Naturally, because the fat Walmart clerk with two welfare babies suffers less lost time versus perceived (note that word for later) quality of care than the Suncor executive (or curmugeonly 30-something magazine columnists) who just needs his prescription refilled or a minor question answered, one group tends to fall in one and one in the other. Naturally, the latter doesn't have its NDP and Alberta Party defenders fawning over their "compassion" towards them (at my expense). This lends itself quite handily to the next issue being discussed:

  2. Inefficiencies: The Alberta Party's @LizaSunley suggested that these inefficiencies are what's keeping healthcare high. And in a way, she's right. However, just hunting down "inefficiencies" is a popular political claim that never works (and in this video, Mitchell's reference to "BNP" applies foresquare to the Alberta Party while "Green" means the Alberta Separatists), and while certainly there are the kind of large scale wastes that make it into the paper and can be easily solved by administrative directives, the primary inefficiencies are systemic, caused by the system of government funded healthcare that the Alberta Party types are quick to defend on the Mason-the-Moron principle -- to wit, government-run healthcare is awesome and amazing, if only the government didn't keep running it all the time. In the talk about waste in emergency rooms, I made a reference to this on Twitter. Why, because of our third plank.

  3. User fees: Noted right-wing-extremist (but inexplicable ass-pirate defender) @KikkiPlanet brought this one up again, ideally as a solution to (1) above for when the inevitable attempt at (2) failed. This was instantly attacked as (a)unfair and (b)cruel and (c)ineffective (roughly in order of importance as government healthcare defenders are wont to do). After all, it was noted that I mentioned that in the case of (1) patients are only half the problem with doctors being the other half [strict adherence to percentages from the use of this word is not advised -ed] and how on earth were user fees supposed to scare doctors? Of course, they wouldn't, except that user fees would reduce the number of people wanting to go into clinics and emergency wards and that would cut into the patients they see and therefore the money they make.

So that's the discussion in a...wait, hold on, what's this I just said here?
user fees would reduce the number of people wanting to go into clinics and emergency wards and that would cut into the patients they see and therefore the money they make
Yes, that's right, doctors are paid in based on the number of patients they see. That may explain this scenario.

You've suddenly woken up to discover that every time you move a muscle on the right side of your body, your chest aches. Nothing heart attackish, just aches. Yet you can do Rockettes routines on your left side with nary a problem. And, come to think of it, the muscles on the right side of your body that aren't on your limbs feel fine, but little blossoms of pain come when you touch them with your left hand. You call Alberta Health Link (an actual innovation that helps) and are told its not immediately serious and time to see your doctor. Once you get there, you're in a waiting room for hours on end admiring how many people have managed to get past Jason Kenny's immigrant screening process without the ability to speak either official language or have bothered to teach their child the word for "shut up" in their native tongue as well. You are watching roughly 5 patients per hour get shuffled in to see the doctor. With 11 people in front of you, you realize its roughly a 2 1/4 hour wait. So three hours and twenty-six minutes later (noticing some people who got here after you and aren't walking like Frankenstein jumped queue ahead of you, possibly because they're Alison Redford's long lost Chinese cousin) your name is called to see the doctor. So in you go, where you sit in a waiting room to see the doctor another 12 minutes before he strolls in and asks what's wrong. Halfway through your explanation (just as you're getting to the "touching your muscles with your hands" bit, an unreasonably long 35 seconds after you started speaking), he suddenly explains what you have, seemingly writes instructions for the 20th WTC terrorist on a notepad, and mispronounces a medication that you can't pronounce either with the declaration that the attached pharmacy can take care of you from here. As you're walking out the door you notice that your interaction with the doctor took less than 3 minutes. Even doubling that for paperwork and breaks, that's a patient every 6 minutes. That's 10 patients per hour. So why did you wait that long to see him so little to just give you a slip for a pill? And why doesn't that pill do anything in the 6 days you're taking it other than slowly reduce the pain day-to-day as you suspect would have happened normally? And more importantly to the point of this scenario...

How much value would you have put into that visit? If the Feynman and Coulter's Love Childs of this word got our wish and public healthcare was abolished tomorrow, how much money could he have charged you for that experience with you walking away thinking "that seemed reasonable enough that I'll do this again?" $12? $60? $2.14?

Half of this problem is being fixed by @KikkiPlanet's user fees. If there was a cost to this visit to you automatically of, say, $20, there's a pretty good chance you'd say yes to the spiking pain and no to the funny rash that's been getting better since you first noticed it at 8:00pm on Sunday. The problem is that this $20 is artificial, and doesn't impact how much this cost the healthcare system (one problem may be cheaper than the other).

But wait, how much does this cost the healthcare system? The problem with government healthcare is that nobody knows what the actual value is (only a free market can decide that) and almost never do you know what the monetary cost is (and if you do, its interesting trivia that barely affects you). What does your doctor bill the government for your visit? When you add up all those patients he sees, the government tallies them and cuts him a cheque. At no point does the Accounts Payable department over at Alberta Health look at your line on his bill and call you up to ask "did he really do much of anything?" Now granted, identifying medication to help you is a useful skill: but surely less valuable than a small procedure done at the clinic to solve your problem right away. Are they billed accordingly? And accordingly to whom?

This is the healthcare crux that addresses all three points: the reason there are inefficiencies in the system is the system itself! As long as you have fat Walmart employees who aren't put out-of-pocket for the cost of giving them ultimately unnecessary healthcare then they won't have the incentive to waste the doctor's time less than they do now. The Raj Shermans in the industry will continue to pump as many people in and out as they can with no regard for the quality of their care, as long as they receive some care and it doesn't kill you. A twenty minute process that cures what ails you is less in his interest than a 3 minute prescription writeup that will shut you up until your body cures itself with possible assistance from the drug. The latter frees up 18 minutes for him to see other patients, each of which puts more money in his pocket. At the same time, the Suncor executive gets less value out of this waste of his time than anybody else, so he just doesn't go and gets an inefficiency in healthcare in another way -- his ounce of prevention costs him so much he might as well wait for the pound of cure. The adding up of these various incentives is what inevitably leads to a healthcare crisis (regardless of where its tried.

You won't solve the inherent inefficiencies with a top-down strategy (how many unionized bureaucrats costing $110,000/yr would be needed for an overview of what doctors are charging?), though to be fair some of the low-hanging and well publicized fruit will go away. The death-of-a-thousand-cuts-funding increases will continue. Those hidden costs are impossible to get rid of in such a system. You may deal with a part of the problem with user fees, but your user fee system will be a weird hybrid of both too high for some visits and too low for others. You certainly can try administrative or legislative efforts to minimize unnecessary use of the healthcare system, but this too ultimately smacks of totalitarianism.

Quite rightfully, patients have a pretty wide view of what a necessary healthcare cost is. Taxpayers (always marginalized or forgotten in these discussions) quite rightfully have the opposite view. I don't want a single penny of my money going to Glenn Taylor's healthcare, yet he'd be okay with spending the entire budget on him alone. The only way for people to police the complex calculus of how much they perceive (there's that word again) the healthcare to be worth and how much money the healthcare system charges is for the actual patient to actually be the sugar daddy.

Anything else will just lead to wasted emergency room visits, inefficiencies, service cuts, and spending increases (user fee or tax based).