# Health insurance suggestion from a lay-person to cut down on unnecessary care **URL:** \ **Category:** Great Debates\ **Created:** [October 27, 2016, 1:31pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844 "2016-10-27T13:31:31Z")\ **Posts on this page:** 20\ **Page:** 1
**Author:** ![iiandyiiii](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/iiandyiiii/32/7924_2.png) [@iiandyiiii](https://boards.straightdope.com/u/iiandyiiii)\ **Post date:** [October 27, 2016, 1:31pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/1 "2016-10-27T13:31:31Z")
An idea to reduce the incentives for unnecessary medical tests/scans when it’s not medically warranted: There would be two payment structures for scans and tests like MRIs – an expensive payment when the test/scan finds something wrong, and a much smaller at-cost payment when it does not. For periodic tests like colonoscopies, there would be an expensive payment for the recommended periodicity, but for other additional colonoscopies there would be an at-cost lower payment unless something significant was found. This way, doctors and hospitals would have no incentive to order an MRI scan (or similar test) unless they believe there was a real significant chance at finding something. Any negatives to this idea? Would it work? Could it be achieved by legislation, or would it require some other process? ---
**Author:** ![pool](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/pool/32/4152_2.png) [@pool](https://boards.straightdope.com/u/pool)\ **Post date:** [October 27, 2016, 1:39pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/2 "2016-10-27T13:39:45Z")
> [@](#): > > Originally posted by **iiandyiiii** > This way, doctors and hospitals would have no incentive to order an MRI scan (or similar test) unless they believe there was a real significant chance at finding something. Wouldn’t that just end up causing a lot of medical problems like cancer or something to never be found at all? “Oh well there might be a 65% chance of something being found but I don’t want to risk doing the diagnostic test unless I’m 90% sure something will be found.” ---
**Author:** ![iiandyiiii](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/iiandyiiii/32/7924_2.png) [@iiandyiiii](https://boards.straightdope.com/u/iiandyiiii)\ **Post date:** [October 27, 2016, 1:47pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/3 "2016-10-27T13:47:45Z")
> [@pool](#): > > Wouldn’t that just end up causing a lot of medical problems like cancer or something to never be found at all? “Oh well there might be a 65% chance of something being found but I don’t want to risk doing the diagnostic test unless I’m 90% sure something will be found.” I would hope the payments would be structured such that there’s no disincentive to order MRIs and other scans, but there would also be no incentive to order them without need – the payments would break even, essentially, so there’s no loss to ordering extra MRIs, but there’s no gain either. Right now, from my understanding, there’s a big gain and thus a big incentive for hospitals to conduct as many MRIs as possible. ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [October 27, 2016, 1:49pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/4 "2016-10-27T13:49:32Z")
I can see a couple of major problems with this. [ol] [li]Generally the person ordering the test is not the one who gets paid for it. (This is not always the case, but usually is.) You go to a doctor complaining of this or that, and the guy doesn’t find anything wrong, but just to be sure - and to cover himself - he orders some diagnostics. He doesn’t have the diagnostic machine, and his motive is not profit but CYA. So he gives you a prescription and sends you off to some imaging center and they do the test. In situations like this, the suggested approach would be penalizing the wrong people - the guy ordering the expensive test has the exact same incentive to over-order as previous, and the people being penalized for not finding anything are completely blameless.[/li][li]Whether the test finds “anything significant” is very frequently open to interpretation. This is why tech people doing the tests are generally instructed not to comment on the results, and only the doctor reading them does that. The issue here is that if you incent people to interpret tests one way versus the other, you are biasing the interpretation, and will degrade the quality of the test readings, causing all sorts of needless, harmful and expensive overtreatment, which is a lot worse than what you’re trying to avoid.[/li][/ol] ---
**Author:** ![iiandyiiii](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/iiandyiiii/32/7924_2.png) [@iiandyiiii](https://boards.straightdope.com/u/iiandyiiii)\ **Post date:** [October 27, 2016, 2:11pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/5 "2016-10-27T14:11:11Z")
> [@Fotheringay-Phipps](#): > > I can see a couple of major problems with this. > > 1. Generally the person ordering the test is not the one who gets paid for it. (This is not always the case, but usually is.) You go to a doctor complaining of this or that, and the guy doesn’t find anything wrong, but just to be sure - and to cover himself - he orders some diagnostics. He doesn’t have the diagnostic machine, and his motive is not profit but CYA. So he gives you a prescription and sends you off to some imaging center and they do the test. In situations like this, the suggested approach would be penalizing the wrong people - the guy ordering the expensive test has the exact same incentive to over-order as previous, and the people being penalized for not finding anything are completely blameless. What about for big hospitals? An individual doctor may not personally profit from ordering an MRI to the upstairs techs, but if the hospital he works for does, is it possible that his supervisor might hint that he should make more liberal use of MRIs and other tests? > [@](#): > > 1. Whether the test finds “anything significant” is very frequently open to interpretation. This is why tech people doing the tests are generally instructed not to comment on the results, and only the doctor reading them does that. The issue here is that if you incent people to interpret tests one way versus the other, you are biasing the interpretation, and will degrade the quality of the test readings, causing all sorts of needless, harmful and expensive overtreatment, which is a lot worse than what you’re trying to avoid. Could there be a neutral third party that makes this determination? Alternately, what other methods could reduce unnecessary treatment? Or do you not think it’s a significant problem? ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [October 27, 2016, 2:23pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/6 "2016-10-27T14:23:16Z")
> [@iiandyiiii](#): > > What about for big hospitals? An individual doctor may not personally profit from ordering an MRI to the upstairs techs, but if the hospital he works for does, is it possible that his supervisor might hint that he should make more liberal use of MRIs and other tests? So you want to have a separate payment system for big hospitals as for others? (Even if you could do this, you would probably end up with the hospitals splitting into separate divisions to get around it, I would speculate.) > [@](#): > > Could there be a neutral third party that makes this determination? I suppose. But that neutral third party is going to charge a lot for their services (if they’re qualified) and take away much of your savings. > [@](#): > > Alternately, what other methods could reduce unnecessary treatment? Or do you not think it’s a significant problem? It’s a huge problem. I think tort reform would help a bit, since there would be less of the CYA that drives a lot of it. At the core, insurance itself is a big part of the problem, though. Any time you have people making decisions with other people paying for it, the system is skewed. Here, patients and doctors make the decisions, while insurance companies and/or employers pay the vast majority of it. High deductible health plans were intended to address this issue, as are other forms of cost-sharing generally (this was the primary intended purpose of the “Cadillac tax” in the ACA), but there’s no real good solution. Other countries address this by having bureaucrats make health care decisions for people, under national health care schemes. But the people obviously lose a lot of freedom and control this way, so there’s a trade-off. ---
**Author:** ![Bone](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/bone/32/407_2.png) [@Bone](https://boards.straightdope.com/u/Bone)\ **Post date:** [October 27, 2016, 2:46pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/7 "2016-10-27T14:46:44Z")
The fee for service model, third party payors, and defensive medicine are the causes. Eliminating those may be worse than what we have now. ---
**Author:** ![PatrickLondon](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/patricklondon/32/4422_2.png) [@PatrickLondon](https://boards.straightdope.com/u/PatrickLondon)\ **Post date:** [October 27, 2016, 2:50pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/8 "2016-10-27T14:50:35Z")
> [@Fotheringay-Phipps](#): > > Other countries address this by having bureaucrats make health care decisions for people, under national health care schemes. But the people obviously lose a lot of freedom and control this way, so there’s a trade-off. In the NHS, doctors decide with patients; their decisions _aren’t_ second-guessed bureaucratically. The only time there’s a need to get specific financial clearance is for treatments that have not been assessed as both clinically and cost-effective in principle: if it has, the local NHS organisation has to cover it. It’s up to doctors to manage within the overall budgets, so if there’s a financial pressure, it shows up in waiting times for non-emergency procedures. ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [October 27, 2016, 3:03pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/9 "2016-10-27T15:03:54Z")
> [@PatrickLondon](#): > > In the NHS, doctors decide with patients; their decisions _aren’t_ second-guessed bureaucratically. The only time there’s a need to get specific financial clearance is for treatments that have not been assessed as both clinically and cost-effective in principle: if it has, the local NHS organisation has to cover it. It’s up to doctors to manage within the overall budgets, so if there’s a financial pressure, it shows up in waiting times for non-emergency procedures. ISTM that as a practical matter, your subsequent sentences contradict your first. You’re acknowledging that you need financial clearance for something which has not been declared to be “clinically and cost-effective in principle”. Who made the “cost-effective” decision? Not the doctor and their patient. And being technically eligible for something that you can’t actually use because there isn’t enough of it to go around is the same thing as rationing. A doctor can “decide with patients” but if that decision is heavily influenced by the long wait times, then the bureaucrats have an unseen hand in that decision. ---
**Author:** ![PatrickLondon](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/patricklondon/32/4422_2.png) [@PatrickLondon](https://boards.straightdope.com/u/PatrickLondon)\ **Post date:** [October 27, 2016, 3:45pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/10 "2016-10-27T15:45:59Z")
> [@Fotheringay-Phipps](#): > > You’re acknowledging that you need financial clearance for something which has not been declared to be “clinically and cost-effective in principle”. Who made the “cost-effective” decision? Not the doctor and their patient. Other doctors in the National Institute for Clinical Excellence, and it’s an overt and public process arrive after consultation and overt discussion of all the evidence, not a decision in each individual case by an anonymous insurance company based at best on what the individual customer chose to buy as an insurance policy, at worst legalistic quibbling. All systems, of course, have some such decision at some level: and in our system as in yours, if someone wants to pay for it, they can still get it. > [@Fotheringay-Phipps](#): > > And being technically eligible for something that you can’t actually use because there isn’t enough of it to go around is the same thing as rationing. A doctor can “decide with patients” but if that decision is heavily influenced by the long wait times, then the bureaucrats have an unseen hand in that decision. Well, ultimately, the elected government in its budgetary decisions and the voters who put them in have the unseen hand: but even then, it’s not about whether you get the treatment but leaving it up to the doctors to say when, in terms of relative needs of the different people waiting. Not quite the same thing as some unqualified pen-pusher saying yes or no to every prescription. ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [October 27, 2016, 4:01pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/11 "2016-10-27T16:01:02Z")
> [@PatrickLondon](#): > > Other doctors in the National Institute for Clinical Excellence, and it’s an overt and public process arrive after consultation and overt discussion of all the evidence, not a decision in each individual case by an anonymous insurance company based at best on what the individual customer chose to buy as an insurance policy, at worst legalistic quibbling. All systems, of course, have some such decision at some level: and in our system as in yours, if someone wants to pay for it, they can still get it. > > Well, ultimately, the elected government in its budgetary decisions and the voters who put them in have the unseen hand: but even then, it’s not about whether you get the treatment but leaving it up to the doctors to say when, in terms of relative needs of the different people waiting. Not quite the same thing as some unqualified pen-pusher saying yes or no to every prescription. But the point is that the decision is not made based on purely on the medical aspects; it’s also made based on budgetary considerations - that’s the “cost-effective” part. And the significant point here is that it’s not the budgetary considerations of the guy who has the medical issue, it’s the budgetary considerations of society at large. (The guy could theoretically pay out-of-pocket, as you say, but he wouldn’t get insurance to pick up 80% of the tab.) So the individual loses freedom and control, which was exactly my original point. Same goes for the waiting line issue as well. ---
**Author:** ![DrCube](https://avatars.discourse-cdn.com/v4/letter/d/a3d4f5/32.png) [@DrCube](https://boards.straightdope.com/u/DrCube)\ **Post date:** [October 27, 2016, 4:04pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/12 "2016-10-27T16:04:17Z")
> [@Fotheringay-Phipps](#): > > And being technically eligible for something that you can’t actually use because there isn’t enough of it to go around is the same thing as rationing. Everything is rationed all the time. That’s what capitalism _is_. The problem is that healthcare rationing is currently based on ability to pay, rather than patient need. That is THE problem with healthcare in the US. Changing the way we ration healthcare is the _goal_. ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [October 27, 2016, 4:06pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/13 "2016-10-27T16:06:53Z")
Healthcare in the US is very mildly rationed based on ability to pay. The real issue raised in the OP here is that it’s not rationed enough, in any form. ---
**Author:** ![DrCube](https://avatars.discourse-cdn.com/v4/letter/d/a3d4f5/32.png) [@DrCube](https://boards.straightdope.com/u/DrCube)\ **Post date:** [October 27, 2016, 4:09pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/14 "2016-10-27T16:09:19Z")
> [@Fotheringay-Phipps](#): > > So the individual loses freedom and control, which was exactly my original point. How? The individual, as you said, still has the same “freedom and control” to purchase what he wants at market rates, just as he would in the US. He just also has the further option of government subsidized care, subject to the government’s cost- and clinical-effectiveness criteria. There’s no loss in that scenario, simply more, and more affordable, options. ---
**Author:** ![DrCube](https://avatars.discourse-cdn.com/v4/letter/d/a3d4f5/32.png) [@DrCube](https://boards.straightdope.com/u/DrCube)\ **Post date:** [October 27, 2016, 4:11pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/15 "2016-10-27T16:11:47Z")
> [@Fotheringay-Phipps](#): > > Healthcare in the US is very mildly rationed based on ability to pay. The real issue raised in the OP here is that it’s not rationed enough, in any form. True. I just hate seeing “ration” used as a scary word in these discussions. ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [October 27, 2016, 4:19pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/16 "2016-10-27T16:19:14Z")
> [@DrCube](#): > > How? The individual, as you said, still has the same “freedom and control” to purchase what he wants at market rates, just as he would in the US. I addressed this earlier. In the US an insured patient would have most of the tab picked up by private (frequently employer-sponsored) insurance. Virtually no one purchases medical services at market rates. > [@DrCube](#): > > True. I just hate seeing “ration” used as a scary word in these discussions. It is a scary word, if you’re the one being rationed. There are winners and losers in every system. ---
**Author:** ![iiandyiiii](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/iiandyiiii/32/7924_2.png) [@iiandyiiii](https://boards.straightdope.com/u/iiandyiiii)\ **Post date:** [October 27, 2016, 4:31pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/17 "2016-10-27T16:31:13Z")
> [@Fotheringay-Phipps](#): > > There are winners and losers in every system. Who are the losers in active duty military health care? That’s a government run system that delivers amazing care (at least it did 10-15 years ago, in my experience) to everyone involved. ---
**Author:** ![DrCube](https://avatars.discourse-cdn.com/v4/letter/d/a3d4f5/32.png) [@DrCube](https://boards.straightdope.com/u/DrCube)\ **Post date:** [October 27, 2016, 4:31pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/18 "2016-10-27T16:31:22Z")
> [@Fotheringay-Phipps](#): > > In the US an insured patient would have most of the tab picked up by private (frequently employer-sponsored) insurance. Virtually no one purchases medical services at market rates. Buying unsubsidized insurance (or employer subsidized insurance) is still buying medical care at market rates, just in a complicated way. Insurance companies aren’t charities. The problem is that poor people can’t afford it here in the US. Maybe I’m misunderstanding you, but it seems like you’re moving the goalposts, or baiting and switching, or something. Paraphrasing what I infer is your position: “The NHS is worse for poor people because if they were rich in the US they would have better care and/or more options.” Substitute “can’t afford health insurance” and “can afford health insurance” for “poor” and “rich” if you feel those are loaded terms. Is that about it? Having the government decide what is cost effective is far better than not having the option to decide with your doctor because you can’t even afford to have the discussion. ---
**Author:** ![Velocity](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/velocity/32/18006_2.png) [@Velocity](https://boards.straightdope.com/u/Velocity)\ **Post date:** [October 27, 2016, 4:39pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/19 "2016-10-27T16:39:26Z")
When it comes to rationing, we’re bound to hear horror stories along the lines of, \* “Because of rationing, I didn’t get a biopsy/scan for my tumor, and now I have terminal cancer. Thanks Rationing!”\* It’s always the horror stories that carry weight. ---
**Author:** ![Fotheringay-Phipps](https://avatars.discourse-cdn.com/v4/letter/f/d9b06d/32.png) [@Fotheringay-Phipps](https://boards.straightdope.com/u/Fotheringay-Phipps)\ **Post date:** [October 27, 2016, 5:06pm UTC](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844/20 "2016-10-27T17:06:51Z")
> [@iiandyiiii](#): > > Who are the losers in active duty military health care? That’s a government run system that delivers amazing care (at least it did 10-15 years ago, in my experience) to everyone involved. I’m not familiar with active duty military health care. But I’m guessing either healthcare is rationed in some form or other, or the taxpayers are the losers. > [@DrCube](#): > > Buying unsubsidized insurance (or employer subsidized insurance) is still buying medical care at market rates, just in a complicated way. Insurance companies aren’t charities. More like lotteries. If you’re the guy that wants/needs some expensive medical treatment, then you have the option of getting it subsidized indirectly by other people who don’t want/need it. You don’t pay full price yourself. > [@](#): > > The problem is that poor people can’t afford it here in the US. Maybe I’m misunderstanding you, but it seems like you’re moving the goalposts, or baiting and switching, or something. > > Paraphrasing what I infer is your position: “The NHS is worse for poor people because if they were rich in the US they would have better care and/or more options.” Substitute “can’t afford health insurance” and “can afford health insurance” for “poor” and “rich” if you feel those are loaded terms. Is that about it? You’re the first guy to introduce the issue of poor people in this thread, and the discussion in this thread has not been about that particular problem. So it’s weird that you seem to be accusing me of moving the goal posts, when you seem to be trying to have an entirely different discussion. And FWIW, I do think that “poor” and “rich” are loaded terms, if you’re trying to define the majority of the country as “rich”, as you apparently are. In any event, for purposes of this discussion, the point I was making is that for the typical middle-class person, who would be covered by private (usually employer-sponsored) insurance in the US versus NHS in England, the latter amounts to a loss of freedom and control. As to how the poor people stack up, I’m not sure. Most poor people in the US are covered by some combination of Medicaid and free ER services. I don’t know how that matches up with NHS. [Next page](https://boards.straightdope.com/t/health-insurance-suggestion-from-a-lay-person-to-cut-down-on-unnecessary-care/769844.md?page=2)