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

Jonathan Duncan jonathan at bluesunhosting.com
Fri Apr 18 17:43:28 MDT 2008

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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