Personal Responsibility verses Group Responsibility
Skimmer Version—Just the main points for those who won’t take the time to read the full article
• In general individuals will not knowingly harm or take from other individuals.
• Persons easily rationalize harming or taking from groups of people when they are in the form of companies, institutions or the government.
• Persons also rationalize harming or taking from individuals as long as they are acting through a group, company, institution or the government and are detached from the person being harmed.
• A little harm done to a lot of persons or major harm done to one person is still the same amount of harm. The detachment felt by the group makes it easier to rationalize.
• Group responsibility means no responsibility. IF EVERYONE IS RESPONSIBLE, THEN NO ONE IS RESPONSIBLE.
• Our current medical system works through groups rather than individuals, especially in the area of billing. There is waste, overcharging and fraud and no one cares because these actions are taken against groups rather than individuals.
The Full Article
Years ago I was driving and I needed to stop for gas. I pulled into a rather large and busy, self-serve, gas station. In those days you could pump your gas first and then go up to the window to pay. So I filled up my tank and walked up toward the window. There was another customer in front of me. He looked into the attendant’s booth. Then he shaded his eyes with his hand to see in better. He turned around, looked at me with a puzzled expression and said, “There’s no one in there”. Then he walked back to his car. I walked up to the window and sure enough, no one was there. I tried to see in the building but there was no sign of an attendant. I walked a little way down the front of the building to see if the attendant was in another section. People behind me were walking up to the window and then back to their cars and driving away. As I made it in front of the garage section I heard a voice yelling for help. I called back. It was the attendant. He said, he had been robbed and locked in the bathroom, but he was alright. He asked me to find the emergency shut-off switch and shut down the pumps. By this time news of the unattended gas station had made its way to the pump islands. People were no longer coming to the window. They were just filling up their tanks and driving away. I found the switch and shut down the pumps.
My guess is that a hand full of people got to work and told the story about the unattended gas station where they filled up for free. I don’t know if the report of the robbery made in on the news or into the newspaper the next day; but my guess is that the same people who were happy at their good fortune to get free gas were horrified that some low-life would rob a gas station at gun point.
How is it that we can condemn someone for robbery and yet justify our own actions of stealing a tank full of gas? You see one action is violent and directed toward an individual. The other is detached, almost unintentional and directed toward a company. Somehow we have little problem rationalizing negative actions against a group or an institution. It is easy to say “Exxon is this huge company. They make tons of money—huge profits. They won’t miss a tank of gas. That’s not going to hurt them.”
Exxon is a company, but that company is made up of thousands of people. Individuals that have families and responsibilities and bills, just like everyone else. What if Exxon took the losses that they experienced that day and said, “Rather than spreading the loss across the whole company, we will deduct it all from one person’s pay check.” Suddenly that gives it a different perspective. For some reason we think it is OK to hurt a lot of people just a little bit, but it is not OK to hurt one person a lot. Funny, it is the same amount of hurt; just one is distributed and one is concentrated.
What about when it is the other way around? Will a group of people combine their efforts to do major harm to an individual and not feel personally responsible? Of course they can and do. This is the basis of a firing squad. One man can execute another, but when he does, he often feels great guilt and personal responsibility. So the solution is to have a firing squad. In this way the execution will be quicker. We don’t have to watch the person suffer. No one bullet or person killed him. The responsibility is distributed among multiple people. It becomes easier for a person to justify or rationalize their action. “I didn’t kill him. I was just following orders. Someone else convicted him; they are responsible for his death.” I am not against executions or firing squads. I am just using it to illustrate in a dramatic way how we rationalize our individual actions when we act in a group.
By this time you should be asking yourself, “What does this have to do with medicine?” It has a lot to do with our current medical system. Notice that we no longer talk about health care in terms of doctors and patients; it is now the “health care industry” or our “medical system”. In Medical Part Four I talked about how medicine has moved from being a ministry to being a business. It has also moved from individuals dealing with each other to, groups, institutions, and companies dealing with each other and with individuals.
Let me give a few examples.
When dealing with a family physician, the exam is done face to face after you talk to the receptionist, filled out paper, been weighed and vital signs taken. When it is all over the billing is between institutions. The doctor’s billing department contacts the insurance company for payment.
If you belong to an HMO, you go to the office and you may see your doctor or another doctor on the schedule. I had a doctor for about 8 years that I never met. The routine is much the same as seeing a family doctor, but much less personal. You move from line to line and room to room receiving and returning forms until you see the doctor. Once again the billing is handled by institutions and departments.
Hospitals are even worse. Now when you go to a hospital you may be assigned to a team of doctors. So who is really responsible for you? The hospitals have realized that this is a problem. They understand that if everyone is responsible then in reality, no one is responsible. Now they will designate someone on the medical team as the responsible physician. In some cases a hospital will assign a patient advocate. This is an additional person, paid by the hospital, to assist the patient in navigating through all of the complex hospital procedures and personnel. It gives the patient one person that they can deal with and is responsible to see that the patient gets proper care.
The big problem here is:
IF EVERYONE IS RESPONSIBLE, THEN NO ONE IS RESPONSIBLE
If I go to my HMO and see a doctor, then later go back and see another doctor, and he sends me to a specialist, who is responsible for my healthcare? The answer is everyone and no one. If I would die the chances are that my primary care physician would never know. He would only see that I was dropped from his list.
What about billing? If the doctor or hospital over bills, who will hold them accountable? I most likely will not check the bill closely. Even if I do, I have little recourse to have it corrected. Besides what do I care? If I have it corrected then I get no benefit. The insurance company is the one that saves money. That will never trickle down to me.
This concept is so obvious. Everyone knows it and experiences it in their daily lives. Are you more careful when spending your own money or someone else’s money? I think most of us, if we are honest, would say we are more careful when spending our own money.
Normally when I buy my lunch I try to average about $5 a meal. On a rare occasion I go on a business trip. They give me an expense account that may allow me to spend up to $25 per meal. I will feel free to spend it all. Why? Because the money comes from a group, a company, not an individual.
My brother, Dave, related to me a personal experience as to how this plays out in the world of medicine. He was without medical insurance but he did have a medical savings account. A situation came up where he needed to have an MRI. He called the place referred by his doctor. They quoted him a price somewhere around $3000. That seemed rather expensive so he decided to shop around. He called another place and received a price of about $1,200. After calling some more places and he found one that would do it for only $800. That was quite a savings. As he was talking to the receptionist, to book the appointment, he related to her his experience calling various places. He told her that he needed a good price because he didn’t have insurance and would be paying for it out of his medical savings account. Her reaction was “Oh I didn’t know you would be paying for this yourself. In that case it is a different price, only $385, we save a lot by not needing to bill an insurance company.”
There was a price range from $3,000 to $385. How can that be? There are really three factors coming into play here. One of them is what she mentioned, billing an insurance company. Many times insurance companies will delay payments as much as 120 days. That means repeated billings, which cost. They will also negotiate the price based on their own rules. Sometimes companies will borrow money from a bank based on accounts payable resulting in more paper work and interest payments. All of this adds up. With a simple cash payment from an individual all of this goes away.
The second factor is that dealing with an individual allows the market economy to function. Dave shopped around for the best price and they know if they want to get Dave’s business they are going to need to provide reasonably good service at the best price. That is not so with our current medical system. Often the patient gets to decide where he will get the best service base on a doctor’s recommendation. Then the insurance company must pay for it. Sometimes the insurance company will set limits on what they will pay or they will negotiate the price after the fact. A related market factor is supply and demand. People will pay more for a product if they have a lot of money available. Dave had limited funds available; whereas the insurance company has very deep pockets.
The final factor, and I think the most significant, is the aspect of dealing with a company rather than an individual. The woman that Dave was dealing with realized that to charge him even the $800 would create a financial hardship for him and she offered him the $400 price. That doesn’t happen when dealing with insurance companies. Rather they are viewed as cold institutions loaded with money. The game of business come into play. Now it is a strategic contest to see how to move as much money as possible from their company to ours. Individuals and the impact on their lives is no longer a factor.
In order to fix our current medical system we need to move the payment system back to the individual as much as is reasonably possible. Medicine happens with individual doctors and surgeons treating individual patients. The payments for such services should happen in the same way. We will explore some ideas on how to make that happen in next week’s article, Medical Part Seven.