On 18 Apr 2008, at 15:00, Nicholas Leippe wrote:
Many good points...
<rather long, rambling post>
IMO, one of the reasons our health care system is broken is that it
is not an
open/free market. Let me explain:
You go to your doctor for a visit. He performs an exam, orders a few
tests,
and prescribes some medication, whatever.
Then, his office sends a bill to your health insurance provider.
Here is one
place where it falls apart. Your doctor does not know what your
coverage plan
will pay for the services, procedures, and tests. So, he bills as
high an
amount as he thinks he can. Your insurance responds to him that they
only
cover up to $x for an item. They send you an "explanation of
benefits" report
that shows this, and then it usually says "provider has accepted
this as
payment in full". Why not? Why wouldn't the doctor accept it? He
just milked
the maximum amount possible from your health plan--which is
undoubtedly well
over what it cost him (otherwise he'd still charge you the
difference and
pass it on to you to ensure a profit).
So in short, every time your plan is billed, it pays out the maximum
amount
for that item. There is no price competition in this.
Have you ever seen a price sheet at your doctor's office? Have you
ever been
able to compare price sheets from different doctors? When was the
last time
your doctor even told you how much he would bill your insurance for
a test
and then asked you first? This, IMO, is one of the primary reasons
the costs
will only continue to rise. People just trust doctors to do what is
necessary
for their care. Since most people are ignorant about medicine, just
like they
are about cars, doctors have become very much like mechanics--people
are
largely at their mercy.
Personally, I wish there were more private doctors like in the days of
old--you could shop around (how much for a visit?, how much to
deliver a
baby?, etc). Quality of service would determine demand--doctors
would be
immediately liable for their own success according to their
competence,
practices (do follow-ups cost the same as an initial visit?), and
price. A
really good doctor could charge more, and expect it. A new or doctor
w/complaints would have to charge less while they (re)establish
themselves.
IMO this is another place where the current model falls short.
Right now, is there any visibility to how good a doctor is? Is there
any
visibility to their prices/compensation? There certainly is very
little
recourse available for bad doctors--they tend to band together and
watch each
other's backs--a "good-old boys club". Nurses are forbidden to warn
patients
about bad doctors (they lose their jobs if caught, and if I am not
mistaken
can become black listed, keeping them from finding employment in
related
network facilities). A doctor can put an opinion as fact in your
medical file
and you can do nothing about it. You can't get it stricken, even if
it is
proved to be false or was just an opinion. You can't hardly even get
access
to your own file. Doctors tend to believe what other doctors have
written
over what a patient says--of which there are many stories (I know some
first-hand) where this goes disastrously wrong. And what do doctors
get when
they screw up? Protected by their fellow doctors. There is no
competition or
open market in this model either. In an open market, such doctors
would have
a publically accessible "bad rap" and have to lower their prices or
find a
new career.
Now, as for the topic of privatization vs UHC, I don't know if
either is ever
a perfect solution, but I do believe competition is possible in both
models.
I think "it would be nice" if there was at least a mandatory minimum
level of
care for acute trauma--a guy shouldn't have to decide which of two
fingers he
cut off to stitch back on. Have some decency and just put the poor
guys
fingers back on... I honestly don't believe people are going to look
for ways
to abuse acute trauma care in any system. (Who's gonna go cut off an
arm and
a leg just to see if they'll reattach both?) But, this thinking kind
of runs
against what I said above about having an open market and competition.
Someone still needs to pay for performing the service, but I would
think acute
trauma care could be fairly easily enumerated, analyzed and divided
up. I
think perhaps having a UHC model for just acute trauma care could be
manageable. I wouldn't mind paying into it--and never having to
worry about
deciding how many limbs to reattach if I ever got into an accident.
I would
feel happy paying so that someone else also doesn't ever have to
face that
decision either. That's just being a good fellow human being IMO.
I think this could cost a lot less than the current HMO and UHC
models--slicing out the acute trauma costs from the rest of medical
care.
Managing the aftermath of an acute trauma beyond a fixed time period
falls
under chronic care. But the initial fix, a week or two of
antibiotics and
pain killers, a loan of some crutches or a wheel chair, sure, cover
that.
That's all very enumerable.
I agree that for routine and chronic medical care, abuse is easy in
some
systems and thus (as in the cases in California) often exploited.
This is
where the system just has to be well defined. Bleeding, broken,
suffocating,
and/or dying--it's acute trauma. Unsure? Then once you find out, if
it's not
acute trauma, bill at the standard rates--this will encourage people
to be
reasonably sure they need it before they go in--and make them shop
around
first if they can, just in case they do wind up paying for it. And
start out
fair by charging a fixed amount for the triage--another reason to
make people
be reasonably sure they need it before seeking care--if it's not
trauma,
they'll just go to a doctor for care first and avoid the triage
charge,
however small the charge might be.
Provide incentives to people to reduce costs (not that would
decrease quality
of care), such as bonuses for helping people to quit smoking, or to
not waste
supplies (if a nurse drops a pick line on the floor, who pays for
it? you do,
or the hospital does--but the nurse is the one that wasted it, so
why don't
_they_ have pay for it?).
Also, lower cost alternatives could become more abundant. Do you
really need a
doctor to stitch a cut? Quite often a nurse could do it just fine.
If they
think they can't, they refer you to a doctor. Why pay a premium for
a service
simply because it's performed by someone significantly overqualified
for the
task? Those little medical clinics/instacares could become quite
handy and
flourish.
<end rambling>
There are many different possible approaches to improving (or just
changing)
the system. None, IMO, are perfect. There are potential flaws in all
of my
ideas above. If it were so obvious what the perfect solution was,
there
would be less resistance to get us there. Because of that, just
because some
things may be obviously imperfect, it isn't clear how best to remedy
them--and there's a lot of momentum to change directions making any
change
even more difficult.
Wow, that read like an editorial. You should send those thoughts in
to some medical magazines. If you do not mind, I am going to pass
your comments on to my brother who is a medical professional.
One question all of this brings up is, where does the change start?
The end users, health care providers, or insurance companies? The
answer seems to be all three would need to start making some changes.
I see the insurance companies being the least likely to be interested
in change. My perspective is most assuredly narrow but it seems like
the insurance companies are the ones making bank off of health care
professionals and health care users. Seems like doctors should take a
stand and start offering two options. The first option being to let
insurance pay have the users deal with co-pays and premiums. The
second option being some sort of payment system like in the old days
where you pay for the services you use directly to the doctor at
reasonable doctor rates and move on with your life.
Great comments. Thanks!
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