An interesting article today : Demanding the Impossible From Our Health Care



The US spends more on health care per capita than any other country. source

Surprisingly, the government in the US spends more on health care than any other country except Norway (if we exclude such powerhouses as Monaco, Luxembourg, and San Marino) source




Questions for debate:

Which two of the three priorities (care to all people, freedom to pick doctors , control costs) listed would you pick?

Is there a factor which is the author is missing from his equation?

Do we need to "reconnect people with the public consequences of their private acts, as the author suggests?

Which two of the three priorities (care to all people, freedom to pick doctors , control costs) listed would you pick?

Care to all people and control costs. Patients must be entitled to a second opinion, but a system which guarantees them any number of opinions until they find the one they want to hear should not recent a single penny of public funds.

Is there a factor which is the author is missing from his equation?

Yes - waiting times. It is conceivable to have a system where you have all three priorities, but only where patients have to wait to see their doctor of choice.

Most non-life threatening conditions do not require immediate treatment. The British tax-funded NHS provides care to all people, keeps costs reasonably under control (historically at least - currently there is a desperate funding crisis driven more by government interference than any underlying problems with the efficiency of the system), and provides for second opinions in most cases (though at some inconvenience).

But since the inception, the way costs have been managed has been through making people wait for non-urgent "elective" surgery (as compared to emergency procedures, which have never been a particular problem in the NHS).

I don't hold the NHS up as the perfect example of how things should be done - it certainly isn't that. But it does illustrate that there are four legs to this particular stool, and not three. Certainly, I can't envisage a system where costs could be controlled, people could choose their doctor, care could be delivered free to all people, AND they could see a clinician at short notice.

Many continental European countries have health systems that are ultimately taxpayer funded and which do not have the same levels of central command & control seen in the NHS, but which provide superior public health statistics to the USA at considerably lower spending levels.

But they can only do this at considerably higher taxation levels, which is the big barrier to any improvement in US healthcare. You're happy to spend far more than anyone else to achieve outcomes that are better at the top end than anywhere else, but are rather worse overall. But if anyone suggests paying for a better system, which almost axiomatically involves wealthy healthy people paying for the treatment of poor sick ones, you recoil in horror at the very idea. Higher taxation, in the case of healthcare, is the lesser of two evils, in my view.

Do we need to "reconnect people with the public consequences of their private acts, as the author suggests?

Yes. That's true to an extent. Equally true is that people need to forcibly reconnect government with the public and private consequences of all their acts. You can't only care about healthcare (and the environment and education and everything else) between elections and then, come polling day, treat politics like like a Dutch auction where the candidate offering the lowest bid (= the biggest tax cut) wins no matter what they offer in return for it. It'll bite you in the end. There's a reason why the Thatcher / Major government - global high priests of privatisation of public assets - presided over three big recessions in the UK, and it isn't simply international events. (We haven't had any under Labour - yet - despite the post-9-11 stock crash.) And they had high public spending (higher even that Gordon Brown's public spending splurge of the last 3 years) and lower taxes, and a huge contribution from North Sea Oil....

...oh dear. I'd better go to bed before I start blaming the state of pop music and reality television on Thatcher as well. Though they are probably her fault as well, along with everything else wrong in the UK....

Is there a factor which is the author is missing from his equation?

Actually there's something in his "equation" that I wasn't aware of. He said,

"We should curb the subsidization of private insurance."

What subsidization is he referring to? If there's taxpayer subsidization of these private corporations, then I'd agree that not only should it be curbed, but eliminated altogether.

If I have to pick "two out of three," I'd say "care to all people" and "control costs." It's hard for me to see why being able to pick any doctor at all is extremely important. (I'm excluding physicians who are incompetent, of course.) This actually seems to describe pretty well the situation for most folks in the USA right now. If you have insurance of any kind, you have limitations on which physician you can see. If you are extremely rich, you can pick and choose. (But how many people can afford treatment for very serious illnesses? I'm talking about patients who stay in Intensive Care for many days -- that would bankrupt nearly everyone who is not very wealthy, if it had to be paid in cash.) If you are poor, you will go to the local emergency room and take what you can get, if you can get there at all.

Other factors the author may have missed:

1. Americans are getting sicker. Part of this is just the fact that they are getting older, on the average. Part of this is due to the American lifestyle. In particular, the explosion of diabetes in the United States is going to be a huge burden on health care in the near future.

Link



2. Misuse of antibiotics is going to lead to infection becoming a greater challenge to American health care.

3. Advanced medical technology sometimes seduces health care providers into spending money on fancy equipment which would have been much better spent on basic health care.

I could go on and on. The truth is that health care is insanely complex and difficult, and it's not going to get any easier.

I'm not sure what the author means by "reconnect people with the public consequences of their private actions." Does this mean that somebody should think "I better not smoke, because that might cost the health care system more money"? If so, I don't think that is a realistic goal. Does it mean that somebody should think "I better not smoke, because it is very likely to make me very sick"? If so, that's an obvious goal.

This points out that education and prevention of disease are the two areas in which there need to be stronger efforts.

Most Americans pay for their health insurance on a pre-tax basis. In other words, money used to pay for health care premiums is not taxed. The article says this costs the treasury $126 billion a year.

Which two of the three priorities (care to all people, freedom to pick doctors , control costs) listed would you pick?

I would also choose priorities 1 and 3.

I think I understated what priority 2 includes. It includes not only the freedom to pick your doctor, but the freedom for the doctor to recommend necessary care. In other words, limiting option 2 means possibly limiting how far we will go when an illness is treated.

Is there a factor which is the author is missing from his equation?

The author left doctor liability off the list. In today's lawsuit-crazy society, a doctor who does not perform every conceivable test on a patient is deemed negligent if not outright reckless.

I wince every time I hear a news story that includes something along the lines of "complication arose from something that would have been revealed through a simple test". As if the doctor should perform every test simply because he could perform them.

In my eyes, the doctor is either negligent, not ordering tests that are par for the course, or he is not. When patients sue doctors because "they should have known" I always think about how close-lipped I am with my own doctor. I never give him a perfectly honest assessment of how I'm feeling ("Fine") or how my blood sugar levels have been ("Good"). For the most part I am honest, but not perfectly so. I am sure it is the same with millions of others who then transfer culpability to the doctor for ailments which they may have never reported to the doctor.

A doctor needs to know that if he makes a good faith effort, he will not be sued because one of his patients gets sick or he is unable to cure them.

Do we need to "reconnect people with the public consequences of their private acts, as the author suggests?

I think everyone needs to know exactly how much their medical care is costing them (and their company or government!!). Maybe a simple summary sheet at the end of the year which details treatments received and the associated costs. I think it would amaze them to discover that they get so much treatment (in terms of dollars) per year.

I agree with you, Amlord, but one thing to consider which isn't often brought up in these discussions is the contribution of the healthcare industry to our GDP. It isn't like an open hole in which we pump money with no return. Health care spending has increased at a faster rate than the GPD for the past 15 years, at over or around 15 percent of our overall GDP, that's a significant chunk of our wealth. Just an unconventional thought.

Which two of the three priorities (care to all people, freedom to pick doctors , control costs) listed would you pick?

Like everyone else, the second one would be the first to go.

Is there a factor which is the author is missing from his equation?

I agree with Amlord that litigation is a large factor here. I saw the costs generated by superfluous testing first hand when I worked in the hospital lab long ago. I am curious why freedom to choose doctors would result in increased cost, whereas freedom to choose schools through the voucher system would (ostensibly) reduce costs. It seems to me we've increased costs astronomically since the onset of the HMO system which reduces the number of doctors one can see to a short list. I'm curious if all the redtape and paperwork really help in the longrun.

I'll give you the military example. Back when I was a child, we had CHAMPUS. All one needed was their military ID card, and you could obtain an appointment which CHAMPUS would cover either all of, or a percentage. It was very easy, and seemed pretty effective. Then, in the early 1990s Tricare took over the military medical system in an effort to make military medicine reflect the HMO system on the outside. They are working out the kinks, so it isn't as bad as it was, but at first it was a mess. "Your 6 year old split his head open you say? Sorry, unless it's a threat to life or limb this isn't considered an emergency and you have to see your primary care provider. Unfortunately they won't be open until Monday from 9 until 5. You can go to an urgent care facility and pay for it yourself, though....."

Now, there is tricare North, South, East, West, Pacific, Europe, ect. Every time we move we have to reregister at the new location to obtain the list of things which are covered. Often things go wrong with the paperwork, and it is a mess. I spent about 8 hours on the phone last week trying to obtain an explanation as to why my children weren't in the system and I couldn't obtain an appointment with them. Everyone I called insisted that it was not their responsibility and gave me an alternate number. To juxtapose.....

When I lived in Italy things were easier for my Italian family members. They just went to the doctor, they didn't have to be placed on a list for certain doctors, ect. It just seems more efficient. ( They also have a system to limit litigation)

Which two of the three priorities (care to all people, freedom to pick doctors , control costs) listed would you pick?

Of course the second- but there is a system problem with our system that makes that an issue- explainede next.


Is there a factor which is the author is missing from his equation?

How about eliminating the AMA? Drs in the US have an incredibly high salary because they allow the AMA to force the various medical university to keep too many Drs from graduating- and allowing the market to control Drs prices. We keep pretending that some free market forces are involved in our health care system- and that is not right. We have no problem outsourcing darn near everything to other countries- but GW get's his panties all in a wad when we buy drugs from Canada- and claim it is because of safety- which is a straight up lie- if Universities were allowed to graduate accredited MDs at the rate the market would allow- we would have alot more Drs.

The insurance industry wants you think it is liability costs-

Mrs P-
http://www.press.uchicago.edu/Misc/Chicago/036480.html
First, we know from the California study, as confirmed by more recent, better publicized studies, that the real problem is too much medical malpractice, not too much litigation. Most people do not sue, which means that victims—not doctors, hospitals, or liability insurance companies—bear the lion’s share of the costs of medical malpractice.

Second, because of those same studies, we know that the real costs of medical malpractice have little to do with litigation. The real costs of medical malpractice are the lost lives, extra medical expenses, time out of work, and pain and suffering of tens of thousands of people every year, the vast majority of whom do not sue. There is lots of talk about the heavy burden that “defensive medicine” imposes on health costs, but the research shows this is not true.



Medical malpractice is less than 1% of the cost of the rising health care costs-

we learned that in my health care trust-trustee training. Frivilous lawsuits are just not even a factor- most lawyers and common folks just don't have the resources to go up against an insurance companies FLEET of lawyers-

Here is an example- we have an annual budget of around 43 million dollars in our trust account. We have "stop loss" insurance of 250K- it is like an insurance policy on our insurance- with a 250K deductable. We have had to activate that in the first year, with over a 1million dollar doctor bill- becuase of- you guessed it- actual malpractice- so blantant anyone can see it- so the stop loss insurance company is suing the malpractice insurance for the money- which is correct and reasonable- and this accounts for about 99% of all malpractice lawsuits

" In one indication, the proportion of lawyers who bring personal-injury lawsuits has remained steady since 1975, while the share of lawyers involved in business litigation has more than tripled."

How about the drug companies and frivilous patent renewals- keeping drug costs high?

Here is another myth debunker :


The researchers compared the number of malpractice claims and awards in the United States, Canada, Australia and the United Kingdom and found that while U.S. citizens sue more often, the actual settlements from all four countries were comparable.

According to the study authors, defensive medicine probably contributes more to higher health spending than malpractice premiums, but determining which tests and second opinions should be defined as defensive medicine is less clear. The highest estimate for costs of defensive medicine in the United States is only 9 percent and many experts believe this number is too high.

http://www.jhsph.edu/publichealthnews/pres...thspending.html

http://www.makethemaccountable.com/myth/Ri...ceInsurance.htm

http://content.healthaffairs.org/cgi/content/full/25/1/289

Yes- there are some reforms that should happen in the health care regarding litigation and such- but a big chunk of health care costs is rising drug costs- boltered by frivolous patent renewals:


http://multinationalmonitor.org/mm2002/02j...une02corp3.html

Naturally, brand-name companies do everything they can to defer generic competition. Critics, including the federal and state cops on the beat, say the companies manipulate a complex legal and regulatory environment to block generics from entering the market. They charge the companies with using tactics including bogus patent claims, collusive settlements with potential generic competitors, new patents on methods of formulating drugs and special legislated patent extensions. The companies typically deploy these tactics in a strategic campaign run in tandem with ever-more elaborate marketing efforts, to ensure ongoing consumer reliance on expensive brand-name products.

http://www.pbs.org/wnet/journaleditorialre...ntmsg.php?id=47

The high cost of reserach is a myth. The costs of marketing drugs by the drug companies is about 35% of their revenue, while R and D costs about 17%. Profit varies but it is quite high for most drug companies. This information is available on the web by using Google. The Wall Street Journal board is either misinformed, or being disingenuous when it talks about price being driven by R & D. The need for government incentives to do research is a good idea. The drug companies develop drugs that are treatments that one must take over and over like celebrex, viagra and zocor. Live saving drugs that are taken infrequently like vaccines and antibiotics needed against drug resistant bacteria are not being developed by the industry.


It is special interests groups combined lobbying that makes are costs so ridiculously high- and they are anti-capitalist in nature- it is the opposite of socialized medicine- which, seems to work pretty good in every western country in the world but ours- so I guess the only thing we can all it is "fascist health care system"? You come up with a better word for it, I will go with it



Do we need to "reconnect people with the public consequences of their private acts, as the author suggests?


No- not until we force the medical industry into one or two things:

1) make it a true free market

or

2) make a single payer insurance system.


Right now- these different, and competing medical fields are to 100% to blame for our broke system- and they buy all the politicians on either side of the aisle.

Until we get some real leaders in office that are actually willing to deal with these industries head on- we will have a problem- I would say the first thing we have to do is eliminate private health insurance altogether and make it only allowed as a supplemental insurance- folks can buy extra insurance for what the state doesn't cover.

This may even makes us more competitive with other western nations and business costs.

Ah, that clears it up. In that case, I agree with the author. And to answer your first question, I would focus on cost containment, but in the right way, of course (not by cutting corners on necessary treatment). I think that ending this subsidy would help reduce costs, by divorcing health insurance from employment, and forcing competition between insurers on an individual-by-individual basis. Another way of reducing costs is by getting a handle on malpractice suits. Doing that will help greatly with the other two goals - health care for all (or at least more), and doctor choice.

Did you read any of the links provided- litigation and malpractice suits would NOT do ANYTHING to rising health care costs- not a dang thing!

Sorry, I hadn't looked that over when I posted. My other point about improving competition by removing employer subsidies, however, I think is still valid.

I don't think it is possible to have an actual free market insurance market- it is a type of gambling- you are betting your health is going to cost you less than 1200 bucks a month for your average family of 5 with the northern European standard for a couple with two kids under 10.

Couple things to remember when it comes to health care :

1) In every utilization revue I have ever seen- the consumer uses 90% of thier lifetime benefits in the last 6 months of thier life- because, regardless of age- there is some kind of big illness that precipitates the death- the big C and chemo treatments, trying to administer drugs for a stroke to induce recovery = total care all that stuff.

Some are much higher of course- some much lower- but on average- regardless of what age you put the consumer at, that is when they end up utilizing the health benefits.

2) Most insurance companies we "shopped" when we decided to be a health trust vs buying insurance through, say , Aetna- HAD A WHOPPING 26% ADMINISTRATION COST- this means paying big money to execs, tons of payperwork, lot's of snafu's- and all that- when WE went to running our own health trust, contracting out the billing and benefits to a Seatlle company we now operate our fund while using only 13% administration costs.

Regardless of what you think about competition- insurance companies fight against each other and THAT drives costs through the freakin' roof!

Malpractice suits are insurance company vs insurance company.

Aetna is a classic example, which, when I was covered under Aetna, experianced routine denial for a year! Every single month, they would deny every other bill- and then I would have to pay it, appeal it, and wait six months for the "appeal check (my words)"- because I never lost an appeal on a bill- they just denied it on routine to see if I would fight it- I bet it averaged out pretty good for them until it started to cost them in lawsuits- a settlement here for 170 million, a court loss there for 120 million, but, of course, it is the fault of the consumer we have these lawsuits- not the guy that loses?

http://www.usatoday.com/money/industries/i...-22-aetna_x.htm

Doctors settled a long-running dispute with Aetna (AET) on Thursday over charges that the health insurer cut their payments and interfered with patient care.
The amount of the settlement in the class-action case — up to $170 million — is one of the largest settlements reached between a health insurer and doctors or government agencies, but the actual dollar amount going to individual physicians is small, about $142.

The settlement offers doctors other concessions, including the ability to appeal billing or medical treatment decisions made by Aetna to an independent reviewer.


I think outside of Vegas style betting- you can't have a "pure" market driven insurance industry- it will always have all kinds of barriers to competition or barriers to services or barriers to everything- and fact is- insurance companies don't help the health care industry and American's health one tiny bit.

You CAN make other parts of the health system MORE capitalistic and competition driven- but that would be taking on the AMA- and if you may recall- Bill Frist is a Doctor- not likely we will be getting any breaks there LOL - and we can blow apart the entire FDA and rewrite the entire organization dealing with drug approval and patent renewal!

We would have outstanding medical care at a lost less cost to both society in general terms, and society in fiscal terms.

If you take away the need to finance employees medical plans- because you simply can't hre and retain employees without one- unless you are unskilled labor- because the first job that comes open, even with a pay cut, they will go.


Companies could compete without the constant threat of rising healtch care costs or sickly employees and get back to the business of being in business.

This is actually misleading. You get to deduct health care costs once they reach a certain level. Those who do not itemize deductions and those whose health care costs do not reach the minimum level get no tax deduction.

So, taxes are paid on the money used, but theoretically you get some back, similar to a mortgage deduction. You of course need to have enough deductions (mortgage) and income for this to work.

That isn't what I was saying AuthorMusician, although that is another example of a government subsidy.

When I get my paycheck, the health insurance premiums are taken out in a pre-taz manner. In other words, I don't pay income taxes on income spent on health insurance.

There is no reason to give up any of the three. All three can be addressed at the same time. That would be the market place. The government intervention into the health marketplace is the root of evil which has caused the skyrocketing health costs. Anytime, the person receiving a service is divorced from the cost of such service, inequities will arise.

If we are all concerned with low income people's ability to have the option of better health care, give those people money so they can make their choices. If you want to have strings attached to hand outs, then do so but do not burden the average Joe with the bureaucracy, too.

As far as Cruisingram's position on malpractice, I can not disagree more. I know a dermatologist in town. Forty percent of his practice income goes to malpractice insurance. Another of my friend's is a family practitioner. He says services cost 3 to 4 times as high as really needed to do liability defensive medicine. Your link is to a lawyer who uses statistics but no substance. Lawyers tend to think they are a necessary part of doing anything. He is just defending his job and I disagree with him on his job's importance and relevance.

Doctors relocate for salary reasons where the difference in insurance premiums can result in six figure differences in yearly income.

The cost of medical items is priced outrageously. Why? Because of the losses on such items from those who do not paid. It is a hidden welfare tax.

To sum it up:

-Recognize the poor economic model we have in the United States due to government regulation.

-Provide welfare but not through everyone's health care.

-Get rid of malpractice. Period. If a person wants malpractice insurance they should buy it, not the provider. Healthcare procedures have risk and those risk are being taken by the patient, not the provider.

The fundamental assumption of the original article (pick any two: care to all people, freedom to pick doctors, control costs) is flawed.

Choosing #2 Freedom to pick doctors will cause #3 control costs to happen via free markets.

Choosing #1 care to all people makes it almost impossible to do either #2 or #3, unless the care to all is inherently unequal (and I think the implication of goal #1 is that you don't want an unequal system where the poor get really crappy care). Once you egalitarianize the system, without respect to means, you eliminate any ability to control costs because you have severed the link between costs and personal decision making. The money doesn't belong to the people receiving the care and if they don't use it they lose it, so they have no reason to spend it wisely.

Once the decision has been made to provide care for all there are two paths to take. Either set prices or keep a price based system.

If you set prices, you artificially prop up the cost of bad care and lower the cost of good care, creating a surplus of the first and a shortage of the second.

If you let prices float, good care costs will rise, which either means you have to raise benefits, which creates a prices increase spiral, or you don't change benefits, in which case only those who can chip in their own income on top of the hand-out (i.e. the rich) will get the good care.

The point being that in striving for goal one as an a priori goal, you find there are substantial barriers to its effectiveness. This is the great lesson of medicare and socialized medicine: it doesn't work.

As for gov't subsidy of insurance, the earlier points about pre-tax premiums are correct but leave out an important point. In many cases employers also chip in for care in addition to premiums paid by employees. These payments are tax-free because corporations don't have to pay income tax on benefits. This tax law is the sole reason why companies provide health care benefits. Without it, insurance would be privatized as it is with other types of insurance (life, auto, homeowners, etc.), which would go a long ways towards solving the Dr. choice and cost problem. Once that was done, we'd need a separate system to assist those of low means to achieve goal #1.

I disagree. Who would the insurance companies be competing more for...Joe Smith's insurance, or GM's? One of the reasons companies provide insurance is that they can get it much, much cheaper than an individual can precisely because of competition. Remove that, and all of us would be paying much, much more for health insurance. I, for one, don't need that.



How do you figure? Without insurance, most people couldn't afford to see a doctor for anything beyond routine checkups. Without insurance, essentially no one would be able to pay for anything catastrophic that happened to them. This would then force doctors, hospitals, etc. to charge more for their services to cover the losses, initiating a vicious cycle which would end up with only the very rich getting any care at all for major medical incidents. This is what you are really paying for with most health insurance..protection from catastrophic illness costs. Insurance companies then realized that their costs on this would go down if they encouraged earlier office visits and preventive care, so you also get reduced costs for normal visits. Both of these are very beneficial to both the insured and the health care industry in general. So I would have to completely disagree with your statement. I would also ask...if insurance is so non-beneficial, why do you have it? Also, how does this 'betting' prevent a pure market driven insurance industry? Gambling is probably the purest form of market driven economics there is.



No, it isn't. Companies provide health insurance for employees as an additional means of competing for their services. As shown above, they can provide this service cheaper than their employees can get it on their own, thereby allowing companies to essentially add more value to the employee at a cheaper cost to the company than supplying additional salary. Take away the tax benefit, and companies would still provide it...but they'd probably reduce employee salaries to cover the additional costs. Besides, why would you take away the tax benefit. Taxes are on net income, which is essentially revenue minus costs. This is a cost, so why single it out as something the government should tax? That would open up all sorts of other 'costs' to government taxation...a path I don't think any of us would like. The money to pay those taxes has to come from somewhere, and it would ultimately boil down to higher prices and lower wages. Who wants that?

Is this like the government employee deal?

Gov Employee Pretax Insurance Premium

If so, this is fairly new to the private sector unless you've got a government job. Excuse my ignorance, but the last time I had a job with benefits was in 2001.

We used to have such a free market, didn't we, before the HMO Act, and before MediCare? Apart from the elderly having a hard time with it (which is where MediCare came in), did it work reasonably well?


OK, but unless I'm misunderstanding something (I confess I'm not entirely familiar with how health trusts work), is that option not part of the free market?


This is the way I see it: Under the current system, individuals have less incentive to wonder about the cost of insurance, because it's partly (or in many cases mostly) subsidized by their employers who get tax breaks for doing so. If the employee were to pay for it all himself, the same way he pays for auto insurance himself, and homeowners' insurance himself, and for that matter, food himself, then he'd revolt against a lot of these rates, and that would put pressure on insurance companies to provide insurance at lower rates if they want to stay in business.

Part of the problem is that while insurance companies may be too stingy when it comes to some things, they're all too easy with their money when it comes to others. Many people with insurance will go to the doctor's office at the drop of a hat. For example, when I was growing up, if we got sick - I mean like an ordinary illness like the cold or something - my mother would make sure we got plenty of rest and plenty of fluids, and lo and behold, we'd recover in due time. Nowadays, it seems like the thing for parents to bring their kids into the doctor's office for antibiotics or other medicines at the first sign of anything.

Whether this is because of pressure doctors might get from pharmaceutical companies, I don't know, but it seems like an awful waste, and may not be all that beneficial to the patients to constantly have those chemicals in their system if they don't really need them. An insurance company that's forced to reduce rates to attract customers might, on the other hand, require a significant co-pay for visits to the doctor (at least outside of six-month checkup time). That might dampen the enthusiasm a little for this kind of extravagance.

For my part, all I'd want out of an insurance plan is something in the range of a $7,000 deductible for something serious, and that's it. I don't need any particular perks or benefits, just a nice low rate, and I'll handle the rest. I think a lot of other people would opt for the same thing if it were available.