This post was written by Niko Karvounis and Maggie Mahar

It’s no secret that the wars in Iraq and Afghanistan have stretched the military thin. Indeed, the past few years have seen a steady flow of news stories depicting just how desperate our armed forces are for warm bodies—including reports that the military is “at its breaking point” and has considered non-citizens for service; that states are seeing their largest mobilization of reservists since World War II; and that the army has abandoned the 24-month limit on time that reservists must serve.

Meanwhile, in November, Stars and Stripes reported that the Pentagon was quietly looking for ways to make it easier for people with “minor” criminal records to join the military. In 2007, the share of Army recruits needing waivers for infractions that included stealing, carrying weapons on schools grounds, and fighting rose to 18 percent –up from 15 percent a year earlier.

There’s no shortage of political objections one can level against the military’s never-ending need for manpower, but there are also some profoundly personal issues to consider when reflecting on just how dangerous it is for our military to deploy—and redeploy—so many soldiers. More than 100,000 American veterans have been sent back to Afghanistan and Iraq despite finishing the terms of their enlistment. Imagine what it means to think that you have fulfilled  your duty—and then to find yourself on the way back to hell.

Imagine being told that you will have a year at home before going back to Iraq—and then being ordered back, as the 4th Infantry Division from Fort Hood, Texas  was after a break of only seven months. “It just plays with your head," says one soldier. “The people in Washington think that this is a board game."

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Did you know that three-quarters of the 40 million sightless people in the world don’t have to be blind? According to ORBIS International, a global nonprofit organization, most of the world’s blind population owes its lack of sight to a lack of access to care.

ORBIS’ mission is to eliminate avoidable blindness by "strengthening the capacity of local eye health partners in their efforts to prevent and treat blindness." Through a process that ORBIS calls capacity building, local partners gain "self-sufficiency in eye health care and residents enjoy quality eye health services that are affordable, accessible and sustainable."

As part of ORBIS’s broad-based capacity building program, the organization works with carefully selected local partners on projects typically lasting at least three years. ORBIS has about 100 of these active partners, which include hospitals, health centers, universities and training centers, local non-governmental organizations (NGOs), eye banks and government health departments.

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When Medicare first created a fee schedule, critics suggested that it was a Marxist invention. Nevertheless, the schedule, which lists what Medicare is willing to pay for some 7,000 procedures, has become the master list for physician reimbursement in our health care system:  most private insurers peg their payments to the Medicare schedule.

The notion of deciding the precise worth of some 7,000 diagnostic and therapeutic procedures is mind-boggling. How exactly does Medicare do it?

The process began in the late 1980s when officials at the Department of Health and Human Services decided that the way Medicare paid doctors should be overhauled. At the time, Medicare was reimbursing physicians  based on what was considered “customary, prevailing and reasonable” in a particular market —in other words the “market value” of the service in that region.

Instead, reformers urged Congress to begin paying doctors in a way that reflected the real cost, to the doctor, of providing the service. (This is where Marx comes in: rather than letting the local market decide what a service is worth “the system appears to be based on the Marxist ‘labor theory of value,’” sputtered Susan Mandel in a 1990 piece in the National Review.) 

But to many in Congress, the notion that physicians should be reimbursed for what it costs them to do what they do—plus a reasonable profit—seemed on the face of it, a sound proposal. The problem, of course, lies in determining what the true “cost” to the physician is.

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Did you ever wonder why hospitals run those radio ads?  In the U.S., hospitals are always trawling for well-heeled, well-insured patients—and the doctors who bring those patients through the door.  And now, the Columbia Journalism Review reveals, some TV stations and newspapers have taken the hype one step further, by forming “Unhealthy Alliances” with individual hospitals.

But first consider the larger picture.

In the U.S. hospital advertising began in the 1970s, when the money really began streaming into the health care industry.  Meanwhile, other countries did not allow medical centers to peddle their services to the public. 

Indeed, in the U.K. the National Health Service decreed that hospitals could promote  themselves “direct-to-consumers” just a few months ago, bringing an end to what had been a fairly acrimonious debate.  Dr Laurence Buckman, a leading member of the British Medical Association’s (BMA’s) General Practitioners’ committee, was an early critic of the idea: "Patients want money to be spent on their healthcare, not spent on advertising to doctors so the hospital makes more money. The health service is not about making money, it is about delivering care for patients."

Dr Jonathan Fielden, chairman of the BMA’s consultants’ committee, told the BBC: "It is a sad indictment of government policy to consider spending public money on advertising NHS services when hospitals are having to make cutbacks in patient care…in order to save money."

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You’ve probably heard about “medical tourism,” the traveling of patients to foreign countries in order to receive care. But what you may not know is just how popular medical tourism has become: according to Deloitte LLP, an international consulting firm, an estimated 750,000 Americans traveled abroad for medical care in 2007. Aggressive projections put this number somewhere around 6 million by 2010.

As interest in medical tourism increases it’s important to understand the nuts and bolts behind its allure, and the risks that it poses—both for patients and health care systems at home and abroad.

Saving Money

Over the past few years insurers and employers have warmed up to medical tourism as a way to save money: its cheaper for insurance plans to help fund patients’ trips to foreign doctors who charge much less for procedures than their U.S. counterparts.

The price differentials  are stunning. According to a recent Deloitte report, Thailand, the world’s leading medical tourism hub, saw 1.2 million medical tourists from around the world in 2006. On average, medical procedures in Thailand cost a mere 30 percent of American prices. India, another destination that sees more than 400,000 medical tourists each year, charges just an average of just 20 percent as much as the U.S. Thousands of Americans also flock to Mexico and South America every year for cosmetic and dental surgery, where procedures cost anywhere from 75 to 50 percent less than they do in the U.S.

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Commenting on “Surgeons and Other Physicians: A Cultural Divide,” a reader who recently found himself in an OR with his wife offers his perspective.  This is not meant as a rebuttal to Dr. Cohn’s post. I think that the two perspectives are both equally true—and that OR cultures may vary widely, from one hospital to another.  I would also like to hear some surgical nurses weigh in.

“jd” writes:

“The domination exhibited by physicians, particularly surgeons, is about far more than verbal abuse and yelling. I don’t doubt those defending their experience who say that they haven’t seen many angry tantrums by surgeons. But I think we’re getting distracted by the most extreme displays so that we miss the very real and dangerous power dynamics here.

“I happen to have just been in the OR a couple of weeks ago with my wife, who was undergoing an emergency C-section. It was performed by obstetricians, as most are. There was one attending and one (I’m guessing) resident who was being trained during the operation. Their tone of voice and demeanor was perfectly pleasant throughout.

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Dr.  Kenneth Cohn, a surgeon and blogger, offered a particularly thoughtful response to my post “Surgeons and Other Physicians: The Cultural Divide.” First, let me introduce him.

On his blog, Cohn describes himself as a “board-certified general surgeon currently splitting time between providing locum tenens surgical coverage in New Hampshire and Vermont and working as a consultant at Cambridge Management Group, which specializes in physician-physician and physician-administrator communication issues. I am a recovering academic surgeon who is passionate about helping physicians, nurses, hospital leaders, and board members work together.”

Let me add that I’m impressed by his blog, Collaborative Confession, and that we’re adding it to our blogroll.

In his comment here on Health Beat, Cohn explained that his training was very different from the surgical training I described in the post:

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Over at TPM Café (www.tpmcafe.com) I’ve posted a review of James Galbraith’s witty, insightful book, The Predator State, which some readers may find of interest.

What is delightful about James Galbraith’s The Predator State is that he says things that are, at once, outrageous– and completely true. Because he shows so little concern for what one "can" and one "cannot" say in a polite capitalist society, one might call him an idealist. But Galbraith is not tilting at windmills; he is simply toppling the conventional wisdom of the past 28 years.

Begin with "the market." When you come down to it, Galbraith explains, "the market" is a fiction. In theory, "it is the broker, the means of detached and dispassionate interaction between parties with opposed interests…Buyers want a low price, sellers wants a high price. The market works out the price that exactly balances these desires, a price that is fair because it is the market price." Even liberals believe in this mythical "market"–a higher intelligence that hovers over transactions ensuring that, as long as you let "the market" work its magic, everything will work out for the best…

To read the whole review, click here.

In a 2006 New York Times article, Dr. Amit Shah, a physician at Johns Hopkins, recalled how other doctors looked down on him during his residency because of his chosen field. “The most memorable discouragement came during his residency, from a pulmonologist,” notes the Times. ‘When I passed him in the hall, [the pulmonologist] would shake his head and mutter, ‘waste of a mind,’” Shah said.

Dr. Shah’s sin? He had chosen to become a geriatrician.

You’d think that Shah would be applauded by his colleagues for choosing geriatrics, given that the U.S. is in the throes of a major geriatrician shortage: Since 2000, the number of geriatricians in the U.S. has fallen by a whopping 22 percent to a mere 7,100. According to a May Institutes of Medicine report, the outlook for the future isn’t much better: by 2030, there will be just 8,000 geriatricians, despite the fact that the U.S. will need about 36,000 to cover the workload as the number of Americans 65 years and older mushrooms.

Clearly, the U.S. needs more geriatricians. Yet the reason we don’t have more stems from the mindset of the pulmonolgist that scoffed at Dr. Shah: both our health care system and our medical schools devalue the kind of care that geriatricians provide.

Geriatricians are family or internal medicine physicians who have taken extra training in the area of aging and the special needs of seniors. In the words of Cheryl Phillips MD, a Sacramento geriatrician, “the particular focus of geriatrics training is the care of frail elders—where understanding how to assess and determine the individual’s ability to function is oftentimes every bit as important as understanding their diseases.” Thus geriatrics deals with coordinating long-term care for chronic conditions or helping seniors to manage their day-to-day life. Geriatricians tackle issues like confusion, dementia, incontinence, falls, depression, and the special effects that medications can have on the elderly. As the New York Times explains, “caring for frail older people is about managing, not curing, a collection of overlapping chronic conditions, like osteoporosis, diabetes and dementia. It is about balancing the risks and benefits of multiple medications, which often cause more problems than they solve. And it is about trying non-medical solutions, like timed trips to the bathroom to improve bladder control.”

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Are there intrinsic differences between how surgeons and physicians who are not surgeons see the medical world?  A pediatrician who reads this blog thinks so, and he e-mailed me to suggest that “The distinction matters because the dichotomy between doctors who perform procedures and those who practice ‘cognitive medicine’ [listening to and talking to the patient] is a major culprit in driving up the cost of American medicine.”

His grandfather was a physician and his father was a surgeon, which puts him in a unique position to muse over “the cultural divide between surgeons and non-surgeons.” I’ll call him Dr. Y

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