I have nothing to say in this debate- I’m here to learn. All I want to do is start the ball rolling with some quotes from my pit thread in November (if you don’t know which one, don’t worry about it)-
My hope with this thread is that you will debate the merits and faults of the American health care system, while citing as many sources and reference works as you can (and adding personal stories, too).
The problem is so complex it is hard to know where to start. My opinion is it starts with people’s view of health care and that it is a God given right.
The problem starts, I think, with peoples’ notion that they should have access to unlimited health care with no regard for costs or outcomes. There is no incentive to lower costs when people with insurance can often times insist on hugely expensive and extensive health care regardless of the end result. For instance, a person may be given 1 month to live without treatment for, say, cancer but with $500,000 of treatment may be given 6 months to live. Is that a reasonable use of limited resources?
I know the above sounds harsh and it is but the above, for me, is not hypothetical but an anecdote from what is currently happening in my family. My 87 year old father was diagnosed with throat cancer a few months ago. Long story short he was put in for a very aggressive surgery that had a good likelihood of killing him but he went for anyway to remove the throat cancer. Once opened up they found the cancer had spread extensively and stopped the surgery as there was little point to it given how the cancer had spread. He is now on chemotherapy treatment, is being fed by a tube exclusively and is bound to a wheelchair. Currently his treatment has cost over $500,000 (his hospitalization was over 3 months non-stop and he is back in the hospital nearly weekly today). Honestly my family is surprised he is still alive (glad but surprised).
So, does the above make sense from a fiscal perspective? Mind you this is my dad and I love him and I cannot imagine anyone telling me my dad is not worth it so they are not going to bother with treatment. Of course anyone would want the best of care and do whatever needs doing for their loved ones. Nevertheless the medical system in the US is faced with this sort of analysis all the time and the answer is invariably “do whatever needs doing, costs be damned, results be damned.” Who could ever decide otherwise? Who wants to tell a family their loved one is simply not worth the money to treat?
I’m not sure how it could be otherwise but till people are faced with bearing more of their own health care costs I see no way there will ever be downward economic pressure on healthcare prices. At what point would my family have decided my dad’s treatment was too expensive to be worthwhile? $10,000? $50,000? The full $500,000 and bankrupt them? Would our analysis change if he was 50 rather than 87? I do not know and very glad we didn’t have to answer that. This doesn’t even get into the issues of the rich then being able to access treatment and the poor being told sorry…you’re not worth it.
There are many, many other aspects to all this but I do think as long as our society cannot face some sort of triage when doling out healthcare the hospitals, doctors, nurses, drug companies, attorneys and so on will continue to milk this for all it is worth and solutions pointing at them are ineffectual at best.
Maybe you’d care to narrow the debate a little and provide a better grounding for it than a few rants? Ill bite anyway.
In brief American Healthcare economically suffers from being neither fish nor fowl. We will never allow a hospital to let someone die unattended to on their doorsteps for lack of coverage but we refuse to rationally provide basic care to all. We are using a flawed funding system but have insufficient political will to fix it. Our irrationed healthcare is crippling the economy and the free market leads to research in blockbuster “lifestyle” drugs more than meds less profitable but very needed.
We docs are a mixed bag. Some indeed are only interested in their bottom-line. But more are motivated by those world famous egos, and our egos want to see us do some good for the world and be recognized for it. Those egos also allow many of us to feel that the Pharmas can’t influence us with their gifts and advertising, and of course they do.
We are indeed undertrained for dealing with the many psychosocial isssues we are faced with everyday … and totally undercompensated when we use our meager skills as best we can. The system rewards procedures more than compassion. I don’t know how to fix that.
Trunks Tom Cruise channelling rant against modern psychopharmocology has been the subject of many many other threads … I won’t revisit it yet again.
I have a problem with how billing is done in the US. It is vastly unfair to uninsured.
I’ve got insurance and not long ago had to have three operations. My yearly out of pocket is $1000. I had the first procedure and watched the bills come in. The procedure cost about $8000-9000 for both doctor and hospital services. My $1000 out of pocket was split between the doctor and several hospital services. The insurance company would only pay a set amount to the doctor and hospital. If I recall the doctor bill was around $3500, I paid $500 to him and insurance paid about $2000. $1000 was not paid and was written off without anything else said about it. The same thing happened with the hospital.
If I had not had insurance I would have paid the full rate of $3500.
My second procedure was done in the same year but the payments made for the medical services were $1000 less because I’d already paid my full out of pocket for the year. This time the doctor only got $2000 instead of $2500.
Let’s say my insurance runs out right after I have the procedure and they don’t pay the doctor bill. You better bet the doctor will come after me for the full amount instead of the rate he would have gotten paid.
Something just doesn’t seem right with that.
From a couple of years ago, the Guardian published a very interesting special report - it’s well worth five minutes.
The logical conclusion IMO is that when health is a business like any other, the most profitable health insurance companies will be those who can anticipate their customers need most accurately and budget/set premiums accordingly. Of course, the easiest way to do this is by mandating genetic testing (by stealth if necessary - watch you don’t lick the envelope with your application form in!). Thus, genetically healthy people could rest easy that their premiums will be low and they’re unlikely to, say, develop cancer. Contrast them with someone who had the atrocious luck of being born with a genetic predisposition to cancer. Not only might they suffer the cancer, but their ill fortune begins in their teens when they realise their premiums are much higher than their healthy friends. Drinking or smoking might result in crippling premiums, while their friends might dabble so with only mild financial effects. Finding a marriage partner might be difficult - who wants the risk of losing their house to save their partner later in life? Truly, accurate genetic testing on behalf of insurance companies leaves a life of ease or pain to an accident of birth, which is surely anathema to a “land of the free”.
But prevent genetic tests being used and what happens? Everyone complains that they’re subsidising people who don’t do their health any favours (and highly inefficiently at that - the US spends a fortune in public health funding and doesn’t even achieve universal coverage!), plus there’s an enormous bureacratic cost of sorting out who gets what if it is not the simple case that anyone gets anything.
So the question is, should US health be a business like any other, given the dire consequences for the losers? That special report makes interesting reading on the subject.
Let me turn this on its head. Because I think you have the core of it but your conclusions are inverted.
We all agree (I think) that health care costs in the US are getting out of control. You postulate that it’s because there’s no pressure on individuals to control spending since insurance picks up the tab and the stakes are so high (one’s life).
Well and good and as far as it goes I agree with it. But here’s where I differ.
Health care costs in the US are climbing consistently because the market is distorted. But it’s not distorted by the demand side. The demand is there because people wish to live and live as long as possible. I think that’s simply natural on the part of the people. (Aside: this is not true for all. My great grandmother got sick in her late-80s and was hospitalized. After a few days in care she told us something like ‘Man, it’s been a great run. But I’m old.’ and decided to let go. Tough old bird, trust me. Heck, she remarried at 84 to a man born in the 1800s.)
Let me posit that what distorts the market is the existence of insurance…at least as it is currently organized in the US.
Simply put: hospitals and doctors and pharmaceutical firms have little incentive to go past the ‘development’ stage of R&D. They can invent a procedure, however expensive, and know that there will be a market out there that will pay for it because of insurance.
With less insurance the next step in the market, innovation and efficiency, would come into play. A hospital faced with a procedure that people won’t (or can’t) pay for will seek means by which such procedures can be provided cheaper and faster and more reliably as a means of containing costs and thereby increasing their market share of that procedure. This places competitive pressure on the healthcare system that should (if market economics are correct and I generally believe they are) lead to the eventual replacement of new and expensive treatments with cheap and routine treatments that acheive the same goal.
So it is my belief that having a system of insurance that distorts the market leads to increasing the overall cost of health care in the United States. Remove or severely curtail that and you’d see a shock to the system that would lower costs and remove the non-competitive (doctors, hospitals and other health care firms and professionals) from the market. It would, IMHO, be harshly Darwinian for a number of years on the industry. But why should they be any different that other industries in this regard?
Seven
Small point – this isn’t the way it works, if I understand you correctly. If you have a procedure on January 30, and your insurance runs out on February 1, your insurance still pays for that procedure, even if they don’t get the paperwork until later.
Another point is that if a doctor knows you have no insurance, you may get a break in the costs, especially if you ask. Also, every doctor and hospital I’ve dealt with is willing to take payments over time so long as you’re paying something regularly.
Yes, you are correct. My brain was moving faster than my fingers last night.
If I have the procedure while covered, and I follow the rules of my insurance company, they will pay if the bill arrives on their doorstep AFTER my coverage ends.
When I had my second procedure I was sent to a doctor out of my regular coverage plan. My insurance was contacted and the doctor was pre-approved to work on me. I’ve got a letter from them about it. The doctor wouldn’t schedule a surgery date until I gave him $1000 up front. I tried to explain to them I’ve already paid my current out of pocket for the year and I should have to pay anything else- the insurance company would handle it. I was told this is to cover what the insurance company wouldn’t cover.
My insurance has a thing about doing procedures in different hospitals. This doctor said he could schedule time at my covered hospital and that would save costs, but he’d still need to collect the $1000.
There is a pit thread around here someplace about this.
In a way, even though it bothered me, this was more like a regular business. The doctor charges a set amount to do a procedure and expects to get paid that amount EVERYTIME he does it.
At the end of the day I found another doctor to do the procedure within my coverage.
Several additional comments.
One of the things that are broken is that those who can afford it the least are the only ones asked to pay full retail price. Insurance companies get various discounts, the government pays what it determines is fair, so on. Some docs do have seperate schedules set up for the uninsured as a group that offer a discount from the full posted prices, some will write-off some visits for them, most will allow prolonged payment plans, but still. Same is true for insurance itself. If you are working at a job that doesn’t give you coverage, then the same or even much inferoior coverage will cost you much much more than coverage purchased for you by a megacorp.
Seven, voting with your feet is reasonable. If the procedure was not emergent then you have options. Do not ignore the cost in your calculus. Just out of curiousity, was that an oral surgery procedure? That money up front bit seems to be SOP for oral surgeons more than anyone else. But payments ARE your responsibility; insurance is for your benefit, no the docs. If he is a contacted PPO provider or on an HMO panel then he has agreed to the fee, if not it is on you. He may have gotten stiffed too many times.
I think we are actually on the same page with this. While I did not specify how such a change should work my idea was that insurance skews the market (i.e. if insurance is footing the bill why not do everything and nuts to the costs) and if individuals were made to bear more out-of-pocket medical expenses you would see pressure to lower prices. Of course the devil is in the details.
This sort of thing is common. The people least able to afford things are usually hit up for the highest costs. For instance, if you are poor and/or have bad credit then a loan/credit card will generally have much higher interest rates than someone who is wealthy. So the person least able to afford it is asked to pay more. Of course the lender has a point in arguing the higher price reflects the greater risks they take in having the person default on the loan. Catch-22.
Just to answer featherlou’s question…I admit (as a primary care doctor) that I am not very good at treating non-physical problems…but I’m not really sure why I should be. I’m not very good at fixing people’s teeth or sorting out their financial problems, either, but nobody really expects that. (Then again, you’d be surprised.)
Somewhere along the way, people got the idea that every component of a crappy life can be fixed with pills. People come to me with their lives in a shambles–family problems, money problems, job problems, you name it. I do what I can, which is usually words of encouragement, referral for counseling, general health advice (especially exercise, etc.), and usually an SSRI. I see them a month later, and they didn’t keep the counseling appointment, they have done absolutely nothing to change their lives except for taking the pills, and they’re pissed off because they’re not happy enough to walk on freakin’ sunshine.
So who gave patients that idea? You can blame the pharmaceutical companies, but the fact is that the SSRIs have given us the ability to treat depression and anxiety far better than we’ve been able to before, and it’s made us a little cocky. There’s also the “better living through chemistry” attitude that came out of the 60s.
Around here, the extent of prescription drug abuse has unfortunately made it very difficult to get legitimate prescriptions for things like narcotics and benzodiazepines, which has only increased their allure; people believe that if they could just get some pills for their “nerves”, life would be good. (In reality, they usually leave them with exactly the same crappy life as before, but with no energy and a benzodiazepine addiction.)
So I wouldn’t rip doctors who can’t do much for non-physical problems; instead, I would rip the ones who think they can. I consider it a big deal that I can do as much as I do in a fifteen-minute office visit with my limited arsenal; those who focus on what we can’t do are missing the point.
(More later on the main thrust of the thread so far.)