The best single item I've seen on the healthcare debate

[mattpegher]

Your two above post are contradictory,

 

[sandorski]

Originally posted by: mattpegher
Your two above post are contradictory,

Really? hmmm, I think you need a Dictionary.

 

[Phokus]

Originally posted by: Jmman
I am not going to delve into this health care debate because truthfully I don't care. The one thing that amazes me though is how so many people are adamant that government run healthcare is going to be better then what we have now. Its like these people have never been to the DMV, the post office, or any other government run agency. Customer service is nonexistent because that simply is not part of the equation when goverment is involved. And to think that somehow it is going to be more monetarily efficient than the current system is also laughable as well. Leave to the goverment to run it into the ground like they did the post office, even though I will admit that there were external factors that helped the demise of the PO (like email for example). And yes, I spent 4 years working for the government, so I have some experience in this respect.

My post office has always delivered my packages without destroying them (unlike UPS, who apparently love treating my packages like soccer balls before delivering them).

My local DMV is actually pretty fast and efficient.

if government UHC is anything like that, i'll be happy

 

[colossus]

Originally posted by: sandorski

Originally posted by: colossus

Originally posted by: sandorski

Originally posted by: Hayabusa Rider

Originally posted by: mattpegher
To clear up a bit of the above, I will continue to argue with sandorski, that health policy cannot be narrowed down to a number of statistical charts and accountants estimations of what facets of spending have impact. I have been in the practice of the analysis and application of scientific data for 20 years now and I will assure you that any study can be biased especially those dealing with public health. I have seen many double blind randomized control studies that contradict prior studies of equal strength. I certainly am not going to want to believe every study out there about how americans should follow the paths of other nations.
We live in a different environment than other countries. We Americans wish to retain many rights that are foriegn to other countries. And to be honest, a great deal of the dollars spent by me in the evaluation of a patient are on tests designed to prove to the patients and lawyers that my clinical assessment is correct. Americans demand a certain type of care that includes many expensive diagnostic test and I don't see that changing in my lifetime. They demand the newest drugs and the newest tests even when there may be no proven benefit. They cannot tolerate even the smallest period of illness, demanding that whatever measures needed to make them well as fast as possible be utilized. They even refuse to accept that often no medication is necessary (ie antibiotics for viral illnesses)and that the course of illness cannot be changed. All this costs money.
Lastly to clear up Sandorski's portayal of my credentials, I have been practicing internal medicine and emergency medicine for 12 years, following 4 years of residency and 4 of medical school. I have worked in many different facilities, from level 1 trauma center to rural emergency rooms to private offices and Urgent care centers. I am currently on staff at 3 facilities, hospital ER and 2 urgent care centers and am intimately intouch with the revenues that each facilities bill out and recieve. I have taught residents and students and believe that I can see trends in healthcare quite well.
Although I welcome some reform, I will continue to beleive that this reform must consider one undeniable fact: Hospitals are losing money, physician are losing money and seeing more patients less well to maintain their incomes, and Insurance companies are making huge profits and becoming bigger and bigger. All the factors that may be affected by goverment control of health care must be considered and no matter what system we choose the forces of a capitalism and human nature cannot be easily changed.
I believe that blindly approaching a complex system as health care is foolish. And ignoring the fact that we are attempting to socialize a part of our society while leaving the remainder free to follow capitalist pressures cannot be approached without serious scientificly derived predictions. And Sandorski- your data is neither scientific or unbiased. And a good scientist always recognizes the biases that effect his position.

Welcome to the debate, however your experience and knowledge of health care count for nothing when put up against the formidable wisdom of those who may have stayed at a Holiday Inn Express. As I've said in the past, no one knows your job better than someone who's never done it, and judging from what we've heard there's a lot of that out around. Never ask to see details. It's too tedious.

Rubbish. His Experience, as I've stated repeatedly, is only a small part of the much larger System. I really don't understand how you guys can't comprehend this.

I actually forced myself to watch the video on KCET last week (before this posting). The bias in the interview was obvious (almost like leading a juror) but the points the guest wanted to make were clear and not coerced. What wasn't discussed was who would pay for UHC - but that's another issue I guess.

Not all docs practice the same way. Some docs can go through 40 years working for Kaiser or an HMO/IPA and not have a clue where the money trail is. I'm guessing Matt is an ER doc. ER docs (especially if they've worked in a trauma center) usually know more about health care costs and how the system works better than most docs - they are the gatekeepers to acute hospital stays. So I will back up Matt's small "niche" experience with my own experience as a family practice doc who does almost all Internal Medicine (in-house). I DO KNOW what each procedure gets reimbursed for and how hospitals and physicians get reimbursed. I have to say I agree 100% with what Matt is saying.

There was a previous post about UHC where I made a good rant about about it (pro and con). I won't rehash it - but basically until America improves its primary care infrastructure the notion of UHC is laughable. You can't just push an extra 50 million people into the offices of primary care docs and not have the infrastructure for it. I'm surprised not one politician has mentioned this (although I've seen enough MPHs say the same thing).

I personally feel Americans are not ready for the lower level of care that UHC will provide (well lower for those who are supporting the system currently). My income would actually go up quite a bit and I wouldn't never have to worry about chasing after bills on my own (I don't even bother billing uninsured people now since I never receive a single response) but I can just imagine all the uproar in the waiting rooms.

Long before this country can talk about UHC it needs to implement a standardized electronic medical record and pump out enough primary care docs/nurses/PAs (even if it means subsidizing their education by the gov) to support those people.

What's there to understand here? There isn't one Doctor working in a Hospital , or a Hospital Administrator, or even Insurance/Pharma Exec/Worker who knows the System with complete Authority. They all know Parts of it, but not the whole.

What is there to understand? - I have no way of making this point to you. If it hasn't come across yet, nothing anybody says will get that point across.

It is true there is no all-knowing person in health care. In fact I'm often disappointed with every physician who enters Public Service since they seem to forget how bad the current system sucks. I can't speak for Matt, but I know I do not know it all. I know a part - being out in practice only 4 years I can say I know some. I was trained by a few physicians who worked in other countries with UHC so I have a vague idea of what those function like (by vague I do, however, mean far more intricate knowledge than any suit wearing Senator could ever imagine). I fully know the reimbursement system for Medicare/MediCal. I do know where the funds are allocated and roughly what percentage go to outpatient vs inpatient care and what percentage go to end of life care. Sure there are local experts as USC/UCLA who know this stuff better than I do but they given up talking directly to patients to get this knowledge (you can't be everywhere at the same time).

IMHO, if the people in the rest of the US are like the middle class in SoCal they will grumble within 2 years of getting UHC.

It would create a level playing field and actually make it a lot easier for physicians to do their work (often times most of the staff in an outpatient setting is doing some form of clerical crap unless they have a really good EMR and trained staff to go with that). That being said, the underlaying problems in the health care system need to be addressed. As it stands Medicare pays a measly 2% for quality innitiatives by physicians. We all know in the private sector the "kiss-ass" employee will make more than 2% than his lazy counterpart. Like I said my income would go up significantly if not double and I wouldn't have to worry about chasing $ (at least until they start reducing reimbursement once they figure out they can't afford the current level of care).


Phokus - I'm happy for you that you have short DMV lines. I wish I had those here in SoCal (not that I need them since it's a rarity I ever go in there). Answer me this - would there be a line in a cardiac suite in a hospital if there were no stents available for angioplasty? If the government says there is too much intervention (PCI) and we'll no longer reimburse the stents but we'll reimburse the procedure (BTW cardiologists make about $250 per deployed stent - about 15-20 min if you're very experienced. A plumber can make that and more snaking 2 drains in the same time). If the hospital says we can do the procedure but you need to bring your own stents since Medicare no longer covers that for this fiscal year... how would people react? I'm pretty sure most people won't bother waiting in the hospital. Hence no lines - this references the video from OP.

Of course a wealthy middle class or rich person would be able to get those treatments (would probably end up flying out of the country lol).

UHC would eventually level the playing field. The hospital won't have to do a CT for every pt that comes in complaining about headaches - why - the gov doesn't pay for it. The gov would say that CTs are only indicated for people with obvious clinical manifesations of a stroke - not an educated guess by an experienced clinician or worse a defensive newbie doc. Then care in Mississippi would the same as in Manhattan. Makes it a lot easier for the doc to not worry about doing a test if he doesn't have access to it.

Then problem then arises - the current crop of medical grads (guess you can lump me in there) do not have the skills to do physicals as most docs who have practiced for say - 20 years. They depend on tests too much.

You can have UHC - but know what you will be getting into and know that the infrastructure is not there at present. If the goverment wants to put up a house w/o laying a foundation....well I guess there's no stopping lunacy.

 

[mattpegher]

Boberfett -And just so we're clear, your authority is zero
Sandorski-Not Zero, just from the same sources...
Snadorski-That's a stretch. I haven't been making Appeals to Authority

mattpegher-Your two above posts are contradictory


and how is it that I need a dictionary?

 

[sandorski]

Originally posted by: mattpegher
Boberfett -And just so we're clear, your authority is zero
Sandorski-Not Zero, just from the same sources...
Snadorski-That's a stretch. I haven't been making Appeals to Authority

mattpegher-Your two above posts are contradictory


and how is it that I need a dictionary?

oh yes you were.

 

[theeedude]

Matt, maybe you can extrapolate for us what will happen under current system if there are no reforms? Just your educated guess would be good, since you are on the front lines so to speak, what trends are you seeing and where are we headed?

 

[mattpegher]

I fully recognize the need for reform. I fully support the idea that we need enough medical schools and enough residents to fill the deficits.

That said turning physicians into government employees such as postal workers and pushing their incomes down is not the answer, and using the force of the goverment to pressure providers to lower prices is also not the answer. I am unsure that the current plan will place any pressure on private insurance to change.

The insurance companies are unregulated and it is not within the power of any consumer to change their supplier or have companies compete for our business. This leads to little regional monoplies.

I work primarily in an ER. I see all patients regardless of coverage or income and treat everyone with the same care. The cost of doing business is therefore spread amoungst all patients so those that can pay, pay more, especially if you are not covered by the contracted discounts that insurance companies shove down our throats. The tests that I order are expensive but the nurses and techs make very little. I find these tests invaluable in determining the cause and severity of your illnesses. Although some tests are often used when the physician is reasonable sure they will be negative, I am not so ignorant of the degree of error in my clinical assessment to gamble with peoples lives.

We can either follow the path of other nations, or we can attempt to improve upon these models. I for one do not think that any of the other systems is near perfect enough to emulate so believe that we should seriously look at where our systems spends money wisely and where it wastes it. And we should design our own system that delivers good care to all, but allows for many of the freedoms that we americans have and desire to keep.

 

[theeedude]

But from business point of view, does that not force employers who provide health care to pick up tab for those who don't by passing on the cost of those who don't pay to those who do?

I see this feedback cycle:
1. Employers drop coverage due to increasing premiums, increase number of uninsured.
2. Uninsured get care in ER because that's the only place that is mandated to treat them.
3. ER includes cost of that mandated care in bills to those who do pay and are insured
4. Insurance companies price in these increases into premiums.
5. go to 1.

Looks like a positive feedback cycle that will lead to fewer and fewer employees providing medical coverage. I don't see how it ends well for anyone involved.

 

[mattpegher]

Exactly senseamp. Unfortunately the slight saving that the insurance companies make by denying benifits is eventually paid back years later with rising costs, but these execs aren't interested in long term stability only short term profits and it is this that they get their bonuses from. So in the long run who wins - only the exec. My prices and the hospitals may be higher but my net income has decreased. The consumer pays more premiums, and more people destroy their credit rating as they end up without insurance and expenses that they cannot afford.

I had a high deductable catastophic plan with a 5k deductable for a few years, I would have paid 1400/mo (16800/yr) for full coverage ppo, but I paid 800/mo (9600/yr) for the high deductable plan, I saved $7200, and I was allowed to put the 5K into a HSA. So by not giving the insurance company all of the money and dealing with the deductable with a savings plan I saved $2200. This was made possible because my employer gives me the stipend for Health care insurance as a full time employee whether I use it or not. It would have been even better had I been able to shop amongst multiple plans for the best rates.

 

[JSt0rm]

Originally posted by: mattpegher
Exactly senseamp. Unfortunately the slight saving that the insurance companies make by denying benifits is eventually paid back years later with rising costs, but these execs aren't interested in long term stability only short term profits and it is this that they get their bonuses from. So in the long run who wins - only the exec. My prices and the hospitals may be higher but my net income has decreased. The consumer pays more premiums, and more people destroy their credit rating as they end up without insurance and expenses that they cannot afford.

I had a high deductable catastophic plan with a 5k deductable for a few years, I would have paid 1400/mo (16800/yr) for full coverage ppo, but I paid 800/mo (9600/yr) for the high deductable plan, I saved $7200, and I was allowed to put the 5K into a HSA. So by not giving the insurance company all of the money and dealing with the deductable with a savings plan I saved $2200. This was made possible because my employer gives me the stipend for Health care insurance as a full time employee whether I use it or not. It would have been even better had I been able to shop amongst multiple plans for the best rates.

thats all very interesting but what is your solution to the prolem? Employers giving out stipends to employees? That seems worse because you don't have collective bargaining and you don't solve the problem of health insurance being tied to a job.

 

[mattpegher]

By that token why does the price of bread not go through the roof, Consumers free to choose any plan from any company willing to sell it creates great competition which keeps prices down. I have many gas stations on my way to work and the ones with the lowest prices are always the two that are across the street from each other. Whether your employer gives you a set amount of money for being fulltime or not it is still your money that he is buying your plan with. The collective barganing idea only works for large corporations. I propose that insurance companies should be forced to sell the same policy to the same age/sex/smoker for the same price no matter who employs them or what group they belong to. This will allow those with income but no group to get good coverage without paying more.

This isn't buying a car, we shouldnt have to haggle or get some special group deals. then again I think cars should be sold differently as well

 

[theeedude]

What about requiring hospitals and physicians to offer the lowest price to consumer willing to pay cash on the spot, meaning no preferential pricing for insurance companies? Seems unfair that an individual consumer gets stuck with the most outrageous bill while insurance companies get to dictate what they will or will not pay for.

 

[mattpegher]

Originally posted by: senseamp
What about requiring hospitals and physicians to offer the lowest price to consumer willing to pay cash on the spot, meaning no preferential pricing for insurance companies? Seems unfair that an individual consumer gets stuck with the most outrageous bill while insurance companies get to dictate what they will or will not pay for.

We do, but you must be able to pay by cash on the day of visit with cash or credit card. Up until a few years ago this was illegal, until a senator's son had to pay cash. The problem is that you set the price and the insurance company demands a discount to participate, so the billed price and therefor the cash price needs to be higher. Many facilities offer the cash pay discount automaticly, some only if you donot have insurance and some only if you ask for it. No matter what you set your price, the insurance co's are going to demand a discount, they consider it there way of collective barganing with providers. Unfortunately there is no way to make it illegal for the insurance companies to negotiate there price and since this usually involves about a 30% discount for physicians and a 90% discount for hospitals, the listed price is much greater. Think of it as MSRP, fleets never by at MSRP usually well under invoice.

I agree that the price schedule is rediculous, but there has been a form of inflation in medicine where the list price is almost never paid and has increased to offset the deep discounts.

 

[theeedude]

Originally posted by: mattpegher

Originally posted by: senseamp
What about requiring hospitals and physicians to offer the lowest price to consumer willing to pay cash on the spot, meaning no preferential pricing for insurance companies? Seems unfair that an individual consumer gets stuck with the most outrageous bill while insurance companies get to dictate what they will or will not pay for.

We do, but you must be able to pay by cash on the day of visit with cash or credit card. Up until a few years ago this was illegal, until a senator's son had to pay cash. The problem is that you set the price and the insurance company demands a discount to participate, so the billed price and therefor the cash price needs to be higher. Many facilities offer the cash pay discount automaticly, some only if you donot have insurance and some only if you ask for it. No matter what you set your price, the insurance co's are going to demand a discount, they consider it there way of collective barganing with providers. Unfortunately there is no way to make it illegal for the insurance companies to negotiate there price and since this usually involves about a 30% discount for physicians and a 90% discount for hospitals, the listed price is much greater. Think of it as MSRP, fleets never by at MSRP usually well under invoice.

I agree that the price schedule is rediculous, but there has been a form of inflation in medicine where the list price is almost never paid and has increased to offset the deep discounts.

I mean by law, hospitals should be required to offer the lowest price offered to insurers to customers willing to pay cash. So if they offer discount to insurers, they should be automatically forced to offer same discount to cash customers, or at least capped at charging cash paying customer more than a certain percentage over the lowest price. Otherwise we keep hearing about how if consumers had more control over their health care spending, they would get better value, but the reality is that if they take control over their health care spending from the insurer and pay cash, they are going to get raped.

 

[JSt0rm]

Originally posted by: mattpegher
By that token why does the price of bread not go through the roof, Consumers free to choose any plan from any company willing to sell it creates great competition which keeps prices down. I have many gas stations on my way to work and the ones with the lowest prices are always the two that are across the street from each other. Whether your employer gives you a set amount of money for being fulltime or not it is still your money that he is buying your plan with. The collective barganing idea only works for large corporations. I propose that insurance companies should be forced to sell the same policy to the same age/sex/smoker for the same price no matter who employs them or what group they belong to. This will allow those with income but no group to get good coverage without paying more.

This isn't buying a car, we shouldnt have to haggle or get some special group deals. then again I think cars should be sold differently as well

So what about those who dont have jobs that provide insuarance? Where do they fit in your plan?

 

[mattpegher]

The problem is that your talking about making it illegal for insurance companies to negotiate a cheeper price. Otherwise you are saying there is one price for cash pay and insurance patients and one price for anyone who is out-of network or anyone who doesnt have the cash or credit card today. I actually agree with the first idea, but I have yet to find any politician powerful enough to go directly after the insurance industry. We are talking about american politics here where the majority of effort spent after election is toward the next election.

 

[theeedude]

Originally posted by: mattpegher
The problem is that your talking about making it illegal for insurance companies to negotiate a cheeper price. Otherwise you are saying there is one price for cash pay and insurance patients and one price for anyone who is out-of network or anyone who doesnt have the cash or credit card today. I actually agree with the first idea, but I have yet to find any politician powerful enough to go directly after the insurance industry. We are talking about american politics here where the majority of effort spent after election is toward the next election.

Yes, I mean making it illegal for insurance companies to negotiate a lower price than cash paying customers. One argument for why insurance companies get a low price is that they pay up. But if someone is paying cash, that argument goes out of the window. At this point, I believe offering insurance companies a discount over cash paying customer should constitute illegal collusion between provider and insurer, which channels customers to insurer in exchange for ensurer channeling those customers to the provider.

 

[mattpegher]

Originally posted by: JSt0rm01

Originally posted by: mattpegher
By that token why does the price of bread not go through the roof, Consumers free to choose any plan from any company willing to sell it creates great competition which keeps prices down. I have many gas stations on my way to work and the ones with the lowest prices are always the two that are across the street from each other. Whether your employer gives you a set amount of money for being fulltime or not it is still your money that he is buying your plan with. The collective barganing idea only works for large corporations. I propose that insurance companies should be forced to sell the same policy to the same age/sex/smoker for the same price no matter who employs them or what group they belong to. This will allow those with income but no group to get good coverage without paying more.

This isn't buying a car, we shouldnt have to haggle or get some special group deals. then again I think cars should be sold differently as well

So what about those who dont have jobs that provide insuarance? Where do they fit in your plan?

If you could buy health insurance the way you buy car insurance, it wouldn't matter whether your employer gave you the money or not, the cost would be the same. It would likely bring to light the inadequacy of current minimum wage levels. At least then the only ones that would need medicaid would be those that cannot work. Those that choose not to work but are not eligible for medicaid are are the only ones left out.

My companies system only works because it is for physicians who are either responsible enough to pay for insurance or pay there bills.

 

[mattpegher]

Originally posted by: senseamp

Originally posted by: mattpegher
The problem is that your talking about making it illegal for insurance companies to negotiate a cheeper price. Otherwise you are saying there is one price for cash pay and insurance patients and one price for anyone who is out-of network or anyone who doesnt have the cash or credit card today. I actually agree with the first idea, but I have yet to find any politician powerful enough to go directly after the insurance industry. We are talking about american politics here where the majority of effort spent after election is toward the next election.

Yes, I mean making it illegal for insurance companies to negotiate a lower price than cash paying customers. One argument for why insurance companies get a low price is that they pay up. But if someone is paying cash, that argument goes out of the window. At this point, I believe offering insurance companies a discount over cash paying customer should constitute illegal collusion between provider and insurer, which channels customers to insurer in exchange for ensurer channeling those customers to the provider.

I fully agree, except for the myth that insurance companies pay up, they pay so late and with such a need for increase expenses by the provider that cash pay patients are much better than insurance patients.

 

[Hayabusa Rider]

My concern Matt is that I've been looking at the degree of control the government is going to have over practitioners, and it's alarming. At least with private insurance they can't punish you for not obeying.

Spooky.

 

[theeedude]

Originally posted by: mattpegher

Originally posted by: senseamp

Originally posted by: mattpegher
The problem is that your talking about making it illegal for insurance companies to negotiate a cheeper price. Otherwise you are saying there is one price for cash pay and insurance patients and one price for anyone who is out-of network or anyone who doesnt have the cash or credit card today. I actually agree with the first idea, but I have yet to find any politician powerful enough to go directly after the insurance industry. We are talking about american politics here where the majority of effort spent after election is toward the next election.

Yes, I mean making it illegal for insurance companies to negotiate a lower price than cash paying customers. One argument for why insurance companies get a low price is that they pay up. But if someone is paying cash, that argument goes out of the window. At this point, I believe offering insurance companies a discount over cash paying customer should constitute illegal collusion between provider and insurer, which channels customers to insurer in exchange for ensurer channeling those customers to the provider.

I fully agree, except for the myth that insurance companies pay up, they pay so late and with such a need for increase expenses by the provider that cash pay patients are much better than insurance patients.

What happens if provider offers a lower price to a cash customer and insurance company gets wind of it?

 

[GuitarDaddy]

Thanks for posting here Matt, if we listened more to the frontline pro's like yourself we likely wouldn't be in this mess.

I believe the insurance priciple of "pooled risk" is very necessary and very important to provide top notch health care for people who wouldn't otherwize be able to afford it. Unforetunately insurance companies have "gamed" the system for so long that the current system has become a nightmare that benifiets no one except insurance companies and their stockholders

The current system is so broken that no amount of insurance co reforms or tort reforms can save it IMO. I fully support the injection of a public insurance option, even though it will be a difficult transition it is the ONLY viable way forward. I truly believe there will still be room for private insurance comapnies to make a reasonable profit providing coverage for people who don't want a public plan and providing extended coverage above what the public option covers.

And if it turns out like the opponents claim that private companies can't compete and we end up with a single payer public system, then so be it. Anything is better than the current travesty.

And on the topic of tort reform I agree that changes need to be made to limit excessive payouts and penalize platiffs that bring forth frivilous cases. But I also believe the insurance companies have more to do with excessively high MP insurance rates than the legal system, but they spend millions deflecting blame to the lawyers

 

[GuitarDaddy]

Originally posted by: senseamp


What happens if provider offers a lower price to a cash customer and insurance company gets wind of it?

Most likely they would lose their membership in the preferred provider network of that company

 

[Hayabusa Rider]

Originally posted by: senseamp

Originally posted by: mattpegher

Originally posted by: senseamp

Originally posted by: mattpegher
The problem is that your talking about making it illegal for insurance companies to negotiate a cheeper price. Otherwise you are saying there is one price for cash pay and insurance patients and one price for anyone who is out-of network or anyone who doesnt have the cash or credit card today. I actually agree with the first idea, but I have yet to find any politician powerful enough to go directly after the insurance industry. We are talking about american politics here where the majority of effort spent after election is toward the next election.

Yes, I mean making it illegal for insurance companies to negotiate a lower price than cash paying customers. One argument for why insurance companies get a low price is that they pay up. But if someone is paying cash, that argument goes out of the window. At this point, I believe offering insurance companies a discount over cash paying customer should constitute illegal collusion between provider and insurer, which channels customers to insurer in exchange for ensurer channeling those customers to the provider.

I fully agree, except for the myth that insurance companies pay up, they pay so late and with such a need for increase expenses by the provider that cash pay patients are much better than insurance patients.

What happens if provider offers a lower price to a cash customer and insurance company gets wind of it?

What happens if the average reimbursement becomes less than the cost of providing the care?

Real life example- We sold a med which cost us about $2900. We were paid $50 less than we paid for it.

Virtually every drug is reimbursed at lower than actual cost by someone. What happens if the most you can charge is less than what you paid for it?

Everyone goes out of business is what happens. You charge people to work for you to make up the difference? Likewise, physicians and nurses can only see so many people. If you cut the reimbursement to less than it costs to see them, that's that.