Candide and health care

Candide was famous for saying 'all is for the best in this best of all possible worlds.' Megan McArdle has a blogpost which has devolved into 'efficiencies' and 'minimum standards.' This puts me in mind of a patient who was happy with what we did. It developed that he 'had an income of $24,000' a year. Though he said 'he needed to get cheaper medicines, his previous psychiatrist had continued to prescribe him Risperdal.. which had cost him $700 a month.' I was prescribing him perphenazine and lithium and 'he was now able to afford a car.' He also appreciated that I charged him $60 a visit; most doctors would have charged him more (though insurances wouldn't pay more). I added cyproheptadine which because of its serotonin 2 receptor blocking action will, in combination with the perphenazine, make this Rx set like Risperdal. The same day I wrote a prescription for Abilify, the most expensive antipsychotic, for a Medicaid patient. I had sent this prescription in electronically with a refill some 3 months ago but the state makes you write it out. He has a developmental propfschizophrenia and his mood and interest are better on this than cheaper antipsychotics. The state tries to discourage me from writing it by insisting that I literally write it each time rather than provide it any other way. I was thinking today, well was this unfair that the man with the limited income had less expensive medicine than the person totally dependent on the state. Overall I don't think so because both are getting a very satisfactory treatment. If the state were paying for both though, I think some further way would be found, as hinted at in my second patient, to degrade the potential treatment of them and others.