The Government Debt Train Nudges Closer To Collision

[GGT]

Actually, the Freeee Market reaction should be physicians and hospitals refusing to play this Insurance game as it's currently being played. It's starting, but slowly....they should refuse to participate in the schemes, not just by refusing to accept Medicaid and Medicare patients as they are now, but anyone in a large employer group insured plan.

[EyeKhan]

The great cost of medicare certainly has a lot to do with the number of patients it covers as well as with the type of patients it covers, but much of the cost can be attributed to waste.

What portion is waste? What does waste mean? Procedures that shouldn't be done or do you mean fraud?

[Aimless]

http://www.pwc.com/us/en/healthcare/...f-excess.jhtml

[EyeKhan]

That's interesting. I wonder how much of Defensive health care is really a way to rack up income in a fee-for-service environment. It's typically blamed on 'frivilous' lawsuits, but I'm skeptical of that characterization.

[GGT]

That's interesting. I wonder how much of Defensive health care is really a way to rack up income in a fee-for-service environment. It's typically blamed on 'frivilous' lawsuits, but I'm skeptical of that characterization.

Fee-for-service is a flawed incentive. But so is hugely distorted profit for providing care.

It used to be much worse when physicians groups were legally allowed to own partnerships in imaging facilities; the revolving door---order a scan or x-ray, refer patient to their site, get a cut of the profit. Gee, no wonder there were so many scans and x-rays ordered.

Now the off-site labs and test centers are owned by large Health Networks (aka for-profit hospitals) in cooperation with insurers that give preferred rate reimbursements. Same revolving door, different pockets.

They have no incentive to NOT be redundant, or streamline medical records so they don't duplicate a service. They have a network but function as independent pieces. That's why granny will keep getting the same blood tests, scans and scopes, with crazy dangerous Rx orders. Or every new diagnosis will mean a new referral, with same diagnostic tests repeated. Rinse, repeat.

[EyeKhan]

Fee-for-service is a flawed incentive. But so is hugely distorted profit for providing care.

It used to be much worse when physicians groups were legally allowed to own partnerships in imaging facilities; the revolving door---order a scan or x-ray, refer patient to their site, get a cut of the profit. Gee, no wonder there were so many scans and x-rays ordered.

Now the off-site labs and test centers are owned by large Health Networks (aka for-profit hospitals) in cooperation with insurers that give preferred rate reimbursements. Same revolving door, different pockets.

They have no incentive to NOT be redundant, or streamline medical records so they don't duplicate a service. They have a network but function as independent pieces. That's why granny will keep getting the same blood tests, scans and scopes, with crazy dangerous Rx orders. Or every new diagnosis will mean a new referral, with same diagnostic tests repeated. Rinse, repeat.

Salaried doctors would be a nice start.

The real problem with health care reform is that the current gigantically expensive system is paying money into lots of people's pockets who are organized into very politically influential groups. And none of them want to give up any of their money. The solution to Dreads' problem of too much cost is to take the cost out of the system but that means everyone, or at least very many, have to take a hair cut. And because of the way our fucked up political system works, that means all the interest groups and corporate giants will have to take that hair cut more or less voluntarily. Good luck with that. Instead we do nothing because we "just can't afford to fix it." We can't fix it because the Powers that like that money won't let us and our political system is structured to, effectively, give them the Power to say no.

[GGT]

Salaried physicians would be great! The new Boutique providers are starting that model (one I found is called VIPmd), but it's mostly designed for wealthier people with extra discretionary income. Unless big employers (with employees in all income levels) disengage from big insurance, we'll keep going in circles.

Options would still exist.

1) See the plant/corporate MDs or nurse practitioners on staff, on-site during work. Could offer mini-clinics off site for spouses and children. Well checks, physicals, vaccinations, birth control, Rx refills. Also treating mild-moderate illness like flu or ear infections. Complicated diseases move to next tier of provider, also salaried as consultants, keeping primary care in place as case managers. Even home visits and house calls could be part of the plan.

2) Use your extra income (that used to be taken from paycheck for insurance premiums) to pay any other doctor you choose. *Perfect for the physician who wants a private practice, not affiliated with a big employer or hinged to their business*

3) Non-employees (people whose employer is small, self-employed) could purchase into those mini-clinics, either walk-in one time or annual membership plans.

4) Insurers would be limited to selling catastrophic plans, for things like organ transplants, premie care, dialysis, disability and long term care. Assumption made that the market would be open inter-state, with transparency at every step.

5) People previously employed by big insurance (or corporate internal Human Resources) could now work as cost-containment managers, utilization reviewers, or quality control assessors. New niches would open up---Health Advocates, Medical Shoppers, Angie's List for Patients....people who want an Easy Button could pay a small fee for someone to do the cost/benefit analysis and make recommendations.


That continues the private/business model, so capitalists should froth at the mouth for that kind of thing. Innovators should want to get on the ball, if they want to start over from scratch, come to the table with ideas and plans instead of just saying NO to everything.

The public option could exist as competition with open clinics charging by means, prorated by income. Rolling mobile wellness vans, visiting nurses, etc. Or providing vouchers for use at the private clinics, full reimbursement. Everyone has access to the same high quality care.

[Loki]

Someone gets paid too much money. I'm jealous. What should I do? Oh, I know, I'll lobby the government to nationalize that person's industry and set the person's salary.

[GGT]

Someone gets paid too much money. I'm jealous. What should I do? Oh, I know, I'll lobby the government to nationalize that person's industry and set the person's salary.

What?

[Aimless]

I don't think he understands what the consequences are of the fee-for-service types of payment models. There's at least one good reason why eg. the Mayo Clinic prefers to pay their doctors fixed salaries.

[Loki]

I'd say you don't understand the consequence of having the government set the salaries of private sector workers, but that would be a lie: you actually want the government to control every aspect of our lives. After all, if something is done in Sweden, it must be right by definition.

[wiggin]

Private bureaucracies (in the form of huge for-profit insurance companies) are already gobbling up our resources. Why shouldn't they--their goal is to take our money for providing us their administration "service". Usually people here dislike unions pushing companies around, or forced worker participation in unions....but when it comes to insurance everyone's blinded by the similarities. They wield their price bargaining clout around to providers, collude with congress for more control, have near total market monopoly, and anyone not participating in their scheme gets shat on. Mostly the consumer but also the doctors and hospitals.

That's because the insurance market isn't particularly efficient, not because it's private. In theory, if people could easily choose between providers, if insurance company X was wasting money on overhead, they would have less profit. Thus, insurance company Y could offer the same product as insurance company X but without the inefficiencies. Even with the same profit margin as company X, they'd be cheaper, and thus would get more customers. It's called the free market.

The only issue is that there are regional monopolies and the like, and major employers are very leery about switching insurance providers. Take down the barrier to entry in the market, improve transparency in pricing and the difficulties in switching, and competition will increase.

It's almost offensive that their ad campaigns suggest they're partners in our healthcare, they're on our side, even part of our family. Wake up people! All the billions of dollars funneled to these middle managers could have been used to actually provide care.

You don't think CMS has middle managers? I live in Baltimore and know a lot of people who work for CMS. They are well-intentioned but hardly efficient workers. It's a huge bureaucracy that wastes a lot of the money ostensibly earmarked to provide care.

If wasteful spending constitutes 1 trillion dollars of the US annual healthcare expenditure, and you manage to cut 90% of that waste, how many more people can you cover?

Aside from pulling random numbers out of your ass, the answer is zero. The federal government is borrowing about a trillion dollars a year to pay for current programs, so cutting out a trillion would just make us break even.


As for fixed salaries, plenty of hospitals and such pay their employees fixed salaries, but somehow they still are charging high prices for healthcare. For that matter, depending on the specialty, private practitioners who own their businesses may not exactly be rolling in dough. This applies to most primary care physicians, pediatricians, etc. Somehow they still have high costs.

[Hazir]

Uhm, you're assuming that the incentive to profit and resulting competition doesn't result in any reduction in overhead. Government bureaucracies have no reason to be efficient in their use of funds or administration thereof; in fact, bureaucracies left on their own will grow to consume all of the resources available to them.

I didn't forget about that. You are forgetting that I am from the Netherlands where the one doesn't exclude the other. The very place where I work is proof of that. We are charged with the execution of the workers benefits legislation by the state, yet are not an arm of the state. And I can assure you that we have a very keen interest in keeping costs down.

People in similar jobs in other countries would be certain they'd keep it untill they retire or decide to leave. My job security horizon is on average one year. As a matter or fact, I have come back from a couple of christmas holidays surprised to hear that I would still have a job in april. I think this time was the first time in at least 4 years that I didn't really think I'd be out of a job by april 1st on return after New Year's. And that was because the economy tanked which simply meant there had to be more work for us.

However, that doesn't change the underlying fact that profit based insurance defies the principle of insurance.

[GGT]

That's because the insurance market isn't particularly efficient, not because it's private.

Agreed.

The only issue is that there are regional monopolies and the like, and major employers are very leery about switching insurance providers. Take down the barrier to entry in the market, improve transparency in pricing and the difficulties in switching, and competition will increase.

Agreed on the monopoly part. Remove the insurance company middle-men with their overhead costs that are ONLY administrative; that's the real barrier to cost containment. If they could have done it, it would have been done by now. Instead, it's been viewed by employers as a necessary cost of doing business (providing the perk for employees) and physicians have been sucked into the vortex.

[EyeKhan]

Someone gets paid too much money. I'm jealous. What should I do? Oh, I know, I'll lobby the government to nationalize that person's industry and set the person's salary.

I don't think he understands what the consequences are of the fee-for-service types of payment models. There's at least one good reason why eg. the Mayo Clinic prefers to pay their doctors fixed salaries.

I'd say you don't understand the consequence of having the government set the salaries of private sector workers, but that would be a lie: you actually want the government to control every aspect of our lives. After all, if something is done in Sweden, it must be right by definition.

If a large chunk of the problem is unnecessary medical services, and if that part of the problem is incentivised by the fee-for-service payment model, then the logical solution is change that incentive structure. Doctors need not get paid less under a salaried model. However, all the folks that administer the unnecessary procedures, staff the facilities, maintain the equipment, and do all the underlying administrative work will be paid less. In fact, there will likely be fewer jobs.

But you have to expect this, right? Nobody wants to lose their job or get a pay cut, but if too much money is being spent in the health care system, and if no further revenue can be put toward it, then the only solution, outside leaving the status quo per Dread's "we give up non-plan" is to take the waste out. If there is no actual waste as outlined in that link Aimless posted, then that's another story. But if you accept the premise that there is that level of waste in the system, how in the world can you oppose changing fee-for-service or some other plan to reduce the unnecessary testing?

[Aimless]

Aside from pulling random numbers out of your ass, the answer is zero.

I didn't pull the 1 trillion number out of my ass, I pulled it from the report I linked to. I just rounded down from 1.2 trillion.

As for fixed salaries, plenty of hospitals and such pay their employees fixed salaries, but somehow they still are charging high prices for healthcare.

Uh, who said that giving hospital doctors a fixed salary would necessarily reduce the costs for the patient? Doctors' salaries are only a part of the cost of healthcare.

Giving doctors a fairly fixed salary is a way to diminish the incentives for making more money simply by seeing more patients. While I brought up the Mayo Clinic the problem is esp. great in primary care, where ways to make money are: see LOTS of patients; perform LOTS of services; refer LOTS of patients to a hospital that'll pay you a cut. Very nice for a primary care physician with a private practice who loses lots of money to overhead. Well, they're often quite miserable, but whatcha gonna do.

Hospitals can continue to make money from services such as unnecessarily expensive diagnostics.

Eg:

WELCOME TO OUR HOSPITAL
WE TAKE FEWER PATIENTS AND GIVE YOU MORE SCANS

I'd say you don't understand the consequence of having the government set the salaries of private sector workers, but that would be a lie: you actually want the government to control every aspect of our lives. After all, if something is done in Sweden, it must be right by definition.

Aren't you the guy who recently said we need more science and less intuition in medicine? It's not exactly breaking news that giving primary care physicians strong financial incentives to see more and more patients; to perform as many services as possible; to refer as many as possible to specialists at partner hospitals... is going to have consequences on the way they practice medicine.













EDIT: No, forcing physicians to work for fixed salaries isn't the solution to all your problems, and no-one suggested that it is, you twits.

[Aimless]

But if you accept the premise that there is that level of waste in the system, how in the world can you oppose changing fee-for-service or some other plan to reduce the unnecessary testing?

Let's not forget tort reform

[EyeKhan]

Let's not forget tort reform

wiggin didn't say that, I did.

About tort reform - If it is a problem, and I'm not so sure its as big a problem as some claim, then I'm fine with reforming it. I hate the idea of using a broad brush to limit damages to some arbitrary amount regardless of how egregess the negligence was. Sounds like a formula for hobbling justice.

On the other hand, IMHO, nobody should get rich because some dumbass doctor botched up a procedure. If you were harmed, you should be compensated according to the harm. (even down to replacing lost income for life if you can't work anymore, etc) The doctor, on the other hand, should be dealt with accordingly as well. On the scale of - if there is real negligence and real harm involved, then the doctor ought to be looking for another career. Same goes for the hospital - if policy contributed to the negligence, then hospital staff and administrators need to be held accountable.

[GGT]

I was going to say, no one mentioned FORCED salaries set by the government. Where the hell did that come from?

As it stands currently, there is a quasi-forced reimbursement to physicians and hospitals, from Medicaid/Medicare caps. But also from private insurance networks caps. There's a ton of money moving around, changing hands, cost-shifting. Waste, redundancy, and fraud are not really being addressed, it's just being moved around to those WasteBaskets.

[Aimless]

About tort reform - If it is a problem, and I'm not so sure its as big a problem as some claim, then I'm fine with reforming it. I hate the idea of using a broad brush to limit damages to some arbitrary amount regardless of how egregess the negligence was. Sounds like a formula for hobbling justice.

The threat of frivolous lawsuits doesn't just drive up insurance costs, it's also another strong incentive for practising defensive medicine. I've read at least one fairly good study that's investigated the association between lawsuits and defensive medicine, but I can't find the links right now as it's a pain to slog through the old threads on CC. I also think there were some good references from that lovely essay by Atul Gawande in... er, the New Yorker or something.

[GGT]

The malpractice side is another odd "invisible hand". Especially for those in areas like obstetrics or surgery. Physicians are scared out of their wits they might be sued, because a few law suits awarded insanely large damages for "pain and suffering". This lets the insurance companies sell their malpractice product very easily, and the premiums are HUGE.

<One of my neighbors is a plastic surgeon who pays $500,000 for his policy>

Then, by contract, the physician is forced to cover his ass with all sorts of testing and consultation, to keep the terms of the insurance policy. Simple sutures to repair a facial laceration turns into a complete work-up to rule out every possible undiagnosed condition, from diabetes (which inhibits healing) to liver disease (drug screen and liver enzymes pre-anesthesia).

[EyeKhan]

The threat of frivolous lawsuits doesn't just drive up insurance costs, it's also another strong incentive for practising defensive medicine. I've read at least one fairly good study that's investigated the association between lawsuits and defensive medicine, but I can't find the links right now as it's a pain to slog through the old threads on CC. I also think there were some good references from that lovely essay by Atul Gawande in... er, the New Yorker or something.

The cynical side of me says that frivolous lawsuits are fewer than most think and are being used as a skapegoat to hide the fee for service brand of income pumping. I freely admit its just cynical musings, but before tort reform is undertaken, I'd like someone to take an honest look at the problem and determine if its indeed as bad as the propaganda claims. With the risk of hobbling justice for people with real and serious injuries, I think any reform should proceed with extreme caution.

[Hazir]

Wow, those PWC figures are pretty horrible. To me it seems that the problem isn't that the US can't afford to reform health care, but that it can't afford not to.

Anybody can tell me what a tube of Zovirax costs in the US today?

[Aimless]

Re. the influence of insecurity, this is one of the articles I was thinking of:

http://jama.ama-assn.org/cgi/content/full/293/21/2609

Table 5 shows all statistically significant predictors of the defensive practices identified in the adjusted analyses. Two subjective measures of liability experience—specialist physicians’ confidence in the adequacy of their liability coverage and their perceptions of premium burdens—were the strongest predictors across all types of defensive practice. Specialist physicians who lacked confidence in their coverage were more than twice as likely as other specialists to order unnecessary diagnostic tests (OR, 2.48; 95% confidence interval [CI], 1.75-3.51), refer patients to other physicians unnecessarily (OR, 2.25; 95% CI, 1.52-3.05), suggest invasive procedures that in their clinical judgment were not needed (OR, 2.12; 95% CI, 1.48-3.04), and avoid risky procedures (OR, 2.26; 95% CI, 1.57-3.26) and high-risk patients (OR, 2.47; 95% CI, 1.72-3.56). Specialist physicians who perceived their premium burden as extreme were more than 11/2 times as likely as other specialists to overprescribe medication (OR, 1.88; 95% CI, 1.27-2.80), refer patients to other physicians unnecessarily (OR, 1.71; 95% CI, 1.53-2.88), and order unnecessary diagnostic tests (OR, 1.51; 95% CI, 1.02-2.22).

It's a good read in general, although the results should be interpreted with caution

[Dreadnaught]

I don't understand what you are trying to say in this paragraph.

I'm not prtending. Please explain one of these ways to cover everyone and replace Medicare for less cost. I'm assuming the solution means more choices for consumers and profitablity for insurance and care providers too? I'm really interested in how that can be accomplished.

So you are seriously advocating the US to end Medicare (and Medicaid, I assume) and abandon any attempt to make health care universal? Your conclusion, even in the face of the fact that every other industrial nation in the world is able to do it without destroying their economy, your conclusion is this is nevertheless impossible for the US to do? Wow.

I've made suggestions clear in the past in threads that you posted in. But my larger point is we should abandon universal health care and stop thinking that it works in budget terms. We should strive for policy solutions make health care affordable in most circumstances to most people without nationalizing the whole damn thing.

But more importantly, didn't you notice in the opening post that Germany also got a debt warning? Pretty much all of the major industrialized nations except Japan and Australia are overleveraged. I was reading a copy of Institutional Investor on the subway yesterday and saw a full page ad for French debt. Seriously, our budgets have been blown out of whack.

The amazing thing is people don't seem to be able to accept this. We don't have the income, and we don't have the capacity for another trillion dollars of debt.

Actually, the Freeee Market reaction should be physicians and hospitals refusing to play this Insurance game as it's currently being played. It's starting, but slowly....they should refuse to participate in the schemes, not just by refusing to accept Medicaid and Medicare patients as they are now, but anyone in a large employer group insured plan.

Some doctors are refusing to participate in Medicaid. Surely you read this one from yesterday...

March 15, 2010
As Medicaid Payments Shrink, Patients Are Abandoned
By KEVIN SACK

FLINT, Mich. — Carol Y. Vliet’s cancer returned with a fury last summer, the tumors metastasizing to her brain, liver, kidneys and throat.

As she began a punishing regimen of chemotherapy and radiation, Mrs. Vliet found a measure of comfort in her monthly appointments with her primary care physician, Dr. Saed J. Sahouri, who had been monitoring her health for nearly two years.

She was devastated, therefore, when Dr. Sahouri informed her a few months later that he could no longer see her because, like a growing number of doctors, he had stopped taking patients with Medicaid.

Dr. Sahouri said that his reimbursements from Medicaid were so low — often no more than $25 per office visit — that he was losing money every time a patient walked in his exam room.

The final insult, he said, came when Michigan cut those payments by 8 percent last year to help close a gaping budget shortfall.

“My office manager was telling me to do this for a long time, and I resisted,” Dr. Sahouri said. “But after a while you realize that we’re really losing money on seeing those patients, not even breaking even. We were starting to lose more and more money, month after month.”

It has not taken long for communities like Flint to feel the downstream effects of a nationwide torrent of state cuts to Medicaid, the government insurance program for the poor and disabled. With states squeezing payments to providers even as the economy fuels explosive growth in enrollment, patients are finding it increasingly difficult to locate doctors and dentists who will accept their coverage. Inevitably, many defer care or wind up in hospital emergency rooms, which are required to take anyone in an urgent condition.

Mrs. Vliet, 53, who lives just outside Flint, has yet to find a replacement for Dr. Sahouri. “When you build a relationship, you want to stay with that doctor,” she said recently, her face gaunt from disease, and her head wrapped in a floral bandanna. “You don’t want to go from doctor to doctor to doctor and have strangers looking at you that don’t have a clue who you are.”

The inadequacy of Medicaid payments is severe enough that it has become a rare point of agreement in the health care debate between President Obama and Congressional Republicans. In a letter to Congress after their February health care meeting, Mr. Obama wrote that rates might need to rise if Democrats achieved their goal of extending Medicaid eligibility to 15 million uninsured Americans.

In 2008, Medicaid reimbursements averaged only 72 percent of the rates paid by Medicare, which are themselves typically well below those of commercial insurers, according to the Urban Institute, a research group. At 63 percent, Michigan had the sixth-lowest rate in the country, even before the recent cuts.

In Flint, Dr. Nita M. Kulkarni, an obstetrician, receives $29.42 from Medicaid for a visit that would bill $69.63 from Blue Cross Blue Shield of Michigan. She receives $842.16 from Medicaid for a Caesarean delivery, compared with $1,393.31 from Blue Cross.

If she takes too many Medicaid patients, she said, she cannot afford overhead expenses like staff salaries, the office mortgage and malpractice insurance that will run $42,800 this year. She also said she feared being sued by Medicaid patients because they might be at higher risk for problem pregnancies, because of underlying health problems.

As a result, she takes new Medicaid patients only if they are relatives or friends of existing patients. But her guilt is assuaged somewhat, she said, because her husband, who is also her office mate, Dr. Bobby B. Mukkamala, an ear, nose and throat specialist, is able to take Medicaid. She said he is able to do so because only a modest share of his patients have it.

The states and the federal government share the cost of Medicaid, which saw a record enrollment increase of 3.3 million people last year. The program now benefits 47 million people, primarily children, pregnant women, disabled adults and nursing home residents. It falls to the states to control spending by setting limits on eligibility, benefits and provider payments within broad federal guidelines.

Michigan, like many other states, did just that last year, packaging the 8 percent reimbursement cut with the elimination of dental, vision, podiatry, hearing and chiropractic services for adults.

When Randy C. Smith showed up recently at a Hamilton Community Health Network clinic near Flint, complaining of a throbbing molar, Dr. Miriam L. Parker had to inform him that Medicaid no longer covered the root canal and crown he needed.

A landscaper who has been without work for 15 months, Mr. Smith, 46, said he could not afford the $2,000 cost. “I guess I’ll just take Tylenol or Motrin,” he said before leaving.

This year, Gov. Jennifer M. Granholm, a Democrat, has revived a proposal to impose a 3 percent tax on physician revenues. Without the tax, she has warned, the state may have to reduce payments to health care providers by 11 percent.

In Flint, the birthplace of General Motors, the collapse of automobile manufacturing has melded with the recession to drive unemployment to a staggering 27 percent. About one in four non-elderly residents of Genesee County are uninsured, and one in five depends on Medicaid. The county’s Medicaid rolls have grown by 37 percent since 2001, and the program now pays for half of all childbirths.

But surveys show the share of doctors accepting new Medicaid patients is declining. Waits for an appointment at the city’s federally subsidized health clinic, where most patients have Medicaid, have lengthened to four months from six weeks in 2008. Parents like Rebecca and Jeoffrey Curtis, who had brought their 2-year-old son, Brian, to the clinic, say they have struggled to find a pediatrician.

“I called four or five doctors and asked if they accepted our Medicaid plan,” said Ms. Curtis, a 21-year-old waitress. “It would always be, ‘No, I’m sorry.’ It kind of makes us feel like second-class citizens.”

As physicians limit their Medicaid practices, emergency rooms are seeing more patients who do not need acute care.

At Genesys Regional Medical Center, one of three area hospitals, Medicaid volume is up 14 percent over last year. At Hurley Medical Center, the city’s safety net hospital, Dr. Michael Jaggi detects the difference when advising emergency room patients to seek follow-up treatment.

“We get met with the blank stare of ‘Where do I go from here?’ ” said Dr. Jaggi, the chief of emergency medicine.

New doctors, with their mountains of medical school debt, are fleeing the state because of payment cuts and proposed taxes. Dr. Kiet A. Doan, a surgeon in Flint, said that of 72 residents he had trained at local hospitals only two had stayed in the area, and both are natives.

Access to care can be even more challenging in remote parts of the state. The MidMichigan Medical Center in Clare, about 90 miles northwest of Flint, closed its obstetrics unit last year because Medicaid reimbursements covered only 65 percent of actual costs. Two other hospitals in the region might follow suit, potentially leaving 16 contiguous counties without obstetrics.

Medicaid enrollees in Michigan’s midsection have grown accustomed to long journeys for care. This month, Shannon M. Brown of Winn skipped work to drive her 8-year-old son more than two hours for a five-minute consultation with Dr. Mukkamala. Her pediatrician could not find a specialist any closer who would take Medicaid, she said.

Later this month, she will take the predawn drive again so Dr. Mukkamala can remove her son’s tonsils and adenoids. “He’s going to have to sit in the car for three hours after his surgery,” Mrs. Brown said. “I’m not looking forward to that one.”

This article has been revised to reflect the following correction:

http://www.nytimes.com/2010/03/16/he...6medicaid.html

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For the record (and so that I don't have to go back to that place), here was my rough scribbling of thoughts on possible reform.

Very few people think our current system is working well. Costs are out of control, there is an unclear system of regulations and Medicare distorts pricing by guaranteeing coverage for older people (while also fixing prices for doctors, which is why many hospitals in Eastern Florida suck-- there's lots of retirees there and few doctors want to work there).

There are several ideas floating around, many of them what I've posted. But they include:

1) Allowing competition across state lines--*right now most insurance companies operate under narrow state regulations with varying requirements for what they can cover. It's led to insurance oligopolies in each state, which in turn has led to bad, overpriced health care plans.

Setting a reasonable federal standard for insurance coverage and allowing insurance companies to compete nationally would help restore balance to the market and give people real choices.

2) Changing the tax structure-- Companies deduct employee health insurance costs. But if you are a freelancer of some sort, you can't really make those kinds of deductions. Plus the lack of competition (see above) means your plans are so expensive only a large corporation can afford to insure anyone without breaking the bank.

3) Allowing/changing item-by-item medical expense deductions-- Allow people to deduct individual medical expenses. I don't think this is a super-useful idea, but it's an idea.

4) Encourage the use of pre-tax health savings accounts-- This would encourage people to follow and pay attention to their medical expenses. But of course it would need to be under a system where doctors weren't billing each patient for a whole mortgage payment.

***

This is just me barfing out a bunch of ideas that I've seen tossed around. The point is that (again) we have a complicated system that needs a refresh. That doesn't mean it should be socialized. The US can't afford it, and it may stymie medical innovation, as our system's lack of price fixing in many areas has allowed a lot of medical innovation to take place.

http://www.ataricommunity.com/forums...&postcount=124

************************************************** ************************************************** ********************

Big picture: we can't afford it.

[Hazir]

No, the big picture is that you can't afford your present system, because it's wasteful and ineffective.

[Aimless]

Look, I get that more competition can in many instances lead to greater efficiency, which can, in turn, lead to savings for the consumer. But why are you so convinced that that will be the case with healthcare in the US? Why would more competition between eg. providers of healthcare lead to more cost-effective healthcare if that would also mean less $$$ for those who profit from selling as many services as possible at as great a cost as possible??

Why would more competition between insurance companies lead to significantly lower healthcare costs? Would it somehow magically make physicians less inclined (or less pressured) to practice defensive medicine? Would it magically reduce administrative costs??

An example from the PWC report:

Operational: Complexity adds costs

About 700 different organizations, health plans, and employers pay the bills at
Johns Hopkins Health System in Baltimore. Each one has different rules about
what’s eligible for payment, how much to pay and when to pay. As one of
4,500 hospitals in the U.S., it’s a microcosm of the complexities that add costs
to the health system. An in-house study found that potential administrative
complexity fuels expenses in scheduling, registration, fnancial clearance,
coding, claims processing, credentialing and utilization management for
inpatient, outpatient and home care services. 25
Reducing the redundancies could save the hospital more than $40 million annually, and that’s only
“numbers we could identify if we could just get computers talking to each
other,” said Richard Davis, vice president of innovation and patient safety at
Johns Hopkins. Hopkins is “trying to focus on the front-end administrative
tasks that are just required to get the patient in the door and receive a payment
from a payer,” but larger savings could result from cross-sector collaboration.

Administering treatment is expensive, estimated at between 15% and 30%
of all health spending. That cost is shared among purchasers and providers.

The article by Atul Gawande that I keep mentioning brings up a point that I think is very important. It's a point that often gets overlooked in these discussions that tend to focus on payment schemes:

The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care.

The high-quality/low-cost communities:

The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.

Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

The pedagogical metaphor:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

And, because we've all agreed that comparing interventions is a good thing:

We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions.

[Dreadnaught]

And the plan that is being rammed through Congress (again in an arguably unconstitutional or at least unethical way, we'll have to see) does nothing to solve any of this. At all. In fact, it makes it worse by entrenching and subsidizing current bureaucracies/systems that we already can't afford.

[Aimless]

I haven't kept up with the Plan. My interest in this matter is rooted more in principles and in ideology wrt healthcare than it is in any compulsion to undermine or to glorify Obama

[GGT]

And the plan that is being rammed through Congress (again in an arguably unconstitutional or at least unethical way, we'll have to see) does nothing to solve any of this. At all. In fact, it makes it worse by entrenching and subsidizing current bureaucracies/systems that we already can't afford.

Asking again how it's "unconstitutional"? Are you referring to the states scurrying to make new laws for state rights, so they don't have to follow federal mandates? And yes, I've read and linked to news that providers refusing to accept M/M, begun before the reform bill.

I still don't see how you can call this any type of universal care, or 'nationalizing the whole damn thing'.


The deficits are big for all countries, everyone is scrambling to figure this out. It's unfortunate that it took a global crisis and near meltdown for everyone to finally DO something. Austerity in the eu, deficit hawks, all the economists and politicians worming around....

A huge chunk of our problem is interest on our debt. Instead of tax and spend it was borrow and spend. We'll need to raise taxes AND cut spending. How dumb to cut taxes and have 2 unfunded wars. That's just a fact. Let's grow up already and stop acting like immature teenagers, wanting a champagne lifestyle on a beer budget. As we become bigger and 'better' we expect certain services, but no one wants to pay for it? oy