OT: health care was: (UTOPIA) Tax Alert : Stop 150% tax pledge increase

[Nicholas Leippe]

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.