Herr Doktor Doc,
The problems we face are insurmountable . . . and I'm an optimist.
Your post is encouraging! The physician who continues to climb the never ending climb in search of the non existing cure gets my vote and applause for the effort.
Hospital care is probably the largest single expense but the majority of centers in the US are now for-profit organizations. They must compete for full-price patients (wealthy from Arab sheiks to American CEOs) by having spacious private rooms with hardwood floors, marble-tiled baths, and amenities that might shame a luxury hotel. The typical bed bill is $800-$1000 per night . . . and that's without actual care . . . that's the cost of occupying the bed. The waste in billing and overcharges will not stop until rigid price controls are established.
This is my gripe about the Charter for the HC Industry. What and who are you folks suppose to staff to? How many luxury suites and how many steerage suites and where? All should be able to have steerage suites of six per room. Rich folks can pay for the right to be in luxuary by dues to the club. Maybe even another tier... second class where there are only two per room.
#2 on the expense list is medications. Even if it hasn't overtaken doctor salaries it's only a matter of time before drug costs alone will be the single most expensive aspect of our system. This again is indicative of how market forces AND government regulation has warped the system. Contrary to the BS in the multibillion dollar per year Big Pharma enterprise advertising . . . most "new" drugs in the past decade are neither lifesavers or revolutionary. The majority have been lifestyle meds (sildenafil) or reformulations (desloratidine). Granted, I don't have a better solution for erectile dysfunction but the $1.5B funneled to Pfizer could certainly be better spent. Clarinex (desloratidine) is no more effective than its generic sibling (loratidine) and neither surpasses the efficacy of good ol' diphenhydramine (Benadryl). The primary killers in America (hypertension, diabetes) are not only effectively treated and prevented by lifestyle interventions and preventative healthcare guidance . . . but many non-patented therapies . . . fish oil, aspirin, multi-vitamins, generic statins, generic diuretics, generic beta blockers . . . are as effective and dramatically cheaper than the "new" therapies being pushed by Big Pharma . . . and unfortunately . . . physicians.
I read your post and looked up one of the meds the VA provides free to me. They list it on the bottle as Lansoprazol but the little capsules say Prevacid 30mg and I take two a day. I found them listed as $3 and change a unit. I then almost had a heart attack! 
I can't imagine anything costing that much. I seem to remember lots of TV adds on the product. So the VA pays for the manufacturer to advertise. I wonder how much the VA pays for them?
I sorta view the Rx industry in a manner akin to the utilities... I did a case study on Pfizer a century ago and forgot what I concluded but remember their structure was out of sync with their product development. I also remember something about Elavil (aka) Amitrytaline (sp?) at 25mg being as effective as aspirin for pain control but, marketed, at that dose, as an ineffective anti depressant or something but, MD's wanted that dose for some reason. (Might not have been Pfizer)
I think there should be a right to profit from the development as long as 'orphan' drugs are held low in price. On second thought, I haven't a clue how to deal with the Med issue.
#3 is probably physicians but hey unless you plan to make medical education free . . . you gotta provide decent cheddar. On the otherhand, physician fee schedules for procedures need reform. If you visit the typical primary care doctor, he isn't paid jack for telling you to stay out of the sun, wear a hat, and use sunscreen liberally. If you come in the office with an atypical nevi, he gets paid $120 to remove it . . . which costs $5 (rubber gloves, alcohol swab, lidocaine, syringe, needle, disposal blade, and a Band-Aid . . . we can splurge and give you a name brand . . . but if I'm a cheapskate I will fold some gauze and tape it on). If that sample is sent for pathology . . . even if I think it's not cancerous . . . the fee doubles. Medicare, Medicaid, and private insurance all have a similar schedule for this type of procedure.
I'm all for free ride for the Med School. Associate it with local hospitals. As long as there is a committment to providing Pro Bono care in one of the 'steerage' clinics on Wedensday for a time Medicine should be provided without the need to be sure to be sure to avoid a law suit. In a hospital it is rather easy to weed out the incompetent. Therefore, if a MD screws up because she is incompetent then Au Revoir.
#4 Insurance: Health insurance is the biggest crock of poo. It is nothing but a drag on the system. Companies are just skimming one-tenth of all healthcare dollars to provide superfluous employment (if you don't take care of people . . . you are not a healthcare provider) and dividends to investors. The only reason health insurance isn't higher on the list is b/c government is the primary insurer/payer for Medicare/Medicaid recipients. These programs typically require half the administrative costs of comparable private plans. Unfortunately, all third payer systems exact a bureaucratic expense on providers.
I vote we all have health care available. Eliminate the Insurance Industry. Establish a general fee schedule and give the MD the right to determine needed care. Each is paid for her service with no change based on sending off to pathology other that shipping costs. The payment for this comes from the general fund which gets its $ from general revenue. Yup.. everyone is taxed but, the healthy get recognized in some TBD fashion. I don't want folks not going for preventive care to get a refund.
#5 tort : Lawsuits do affect the expense of our system. The lawyers are lying when they say they are not responsible for some healthcare inflation. The doctors, hospitals, insurers, and politicians are lying when they imply tort reform will help significantly. The truth is that bad doctors exist in America. Neither the profession nor the government have done much to cull the herd. Regarldess of what their motivation may be . . . umm money . . . arguably lawyers have been the most effective at highlighting the inadequacies of hospitals and physicians. Defensive medicine is only used by doctors that don't know what they are doing. Sometimes that's the unavoidable diagnostic uncertainty that comes with an uncertain science. Sometimes that's incompetence. People deserve fair compensation for the latter.
Standard fee schedule for incompetent care. The coverage is paid by the hospital and or physician and each is evaluated and charged accordingly. Causes the hospital to weed out the potential problem MD's
In the end, no one wants to acknowledge they are part of the problem. No one wants to tell healthcare consumers that their expectations are unrealistic (when it comes to care and costs). And no one wants to be held responsible when practical reform fails. Reform will fail b/c everyone in the society (except for possibly the working uninsured) is reasonably satisfied with the dysfunctional status quo
I know two things for sure. First) The problem is massive and Second) We need to start somewhere to fix it and I suggest at the top... Develop a Charter and determine the scope of who ought to be covered. If everyone, fine. Then we know where to start. If only those who can afford it, fine (not really) but, then we also know where to start. No solution will fit both philosophies so why start till we know which is the way to go... aside from MED/MAL which is not really health care and can be fixed by keeping the lawyer and court out of it... unless a real dispute exists.. like ineffective erectile dysfunction care..
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