I’m really serious about donating blood. 
Sure, some people go to the doctor too much, and some too little, but clearly costs will keep some people away, especially poorer people who might be more at risk from environmental factors in the first place.
You must be able to see the problem with this. We do not pay medicare premiums in advance. Current workers pay for the retired. Future retirees will depend on future workers. We see now that the retirement of the baby boomers is doing a number on all the entitlement programs for seniors. How much more will future workers have to pay to support a steadily increasing pool of retired people? Eventually we will have to resort to importing our taxpayers like much of Europe is currently doing.
I think the fact that we are preventing them from making a living and paying for their own care has something to do with it. If you offered prisoners a choice of free care in prison or being released to pay for it on their own, what do you think they will choose?
This may be true. But, you are forgetting that preventative care for the entire population is not cheap. If you screen 100% of the population for condition that affects only 5% of the population then you may end up paying more for catching the 5% early than if all of their diseases had progressed. This doesn’t seem to save any money…merely shift the costs and, perhaps, increase cost.
Yes, that is exactly what I meant by my cash flow comment. Given that we started out giving care to people who didn’t pay in because the program didn’t exist, it made more sense to pay the first costs out of the current revenue, instead of stashing Medicare payments and borrowing the money for the first recipients. But conceptually my future Medicare support comes from the money I’m paying in now, and, since the system is somewhat progressive, I pay a greater proportion than I’m likely to get back - which is fine with me.
Like everything else, the decision about what to screen and how often has to be evidence based. That’s why I didn’t freak out about the mammogram study. I work in testing, and I know full well it is possible to overtest, or spend more on test than is economically justifiable. I even had a paper on this about 20 years ago that caused quite a stir, because it is difficult in my area to stand up there and say it is okay to let things fail for customers some times.
You can think about it that way but it is still incorrect. If you are correct that your current payments are going toward your future benefits then we would not be facing a problem with the retirement of the baby boomers. If you wish to blame this on government spending the surplus then that’s fine with me. But, let’s not pretend that our money is going into an account set up for us.
Agreed. But, when you start telling people that they can’t have a particular test, charges of rationing will be thrown around. I doubt that the government will tell people that they cannot have certain tests or procedures. It’s a no-win situation for the government.
I think we’d have a bigger problem. Given the increase in healthcare costs, if our premiums for Medicare came out of our payments alone, we’d be all flat busted by 80. (Or something.) Getting money from the increasing (at the moment) pool of workers puts off the problem for the moment, but it only gets solved if healthcare costs get under control.
Which brings me to your other response. I share your pessimism. We are going to have a problem so long as some people are yelling about the cost of care one minute and about not giving those they like all the care they want. There is rationing today, of course, by ability to pay. So long as many people are unable to visualize themselves out of a job and in a pickle, we’re not going to have a rational discussion. Colbert satirized this view very well the other night.
It boils down to if we as a society want the default rationing by economic circumstances and for profit companies we have today, or rationing by need and some degree of evidence which would make more sense. The Senate bill includes the evidence part, at least.
It seems to me that there is no disincentive for the individual to seek out the most expensive care. Actually, there is an incentive as people love to brag about how much their hospital stay cost the insurance company versus how much they have paid in premiums. I’m as guilty of this as anyone…a pinched nerve a few years back required a lot of medical procedures which cost me maybe $200 out of pocket. I felt like I’d gotten my premiums back and then some. It’s the buffet mentality…pay one price and try to get as much back as possible.
It seems to me that the best way to keep prices low is to link the patient to the money being spent. All of the costs are masked by the insurance company so there is little pressure in the medical field to lower prices. I don’t know how one could accomplish this without getting rid of insurance companies unless the insurance companies reward us for getting a good price for the care we receive.
I think this reaction is simply from the joy of getting a bargain, and the desire that all the money you paid for insurance wasn’t wasted. In this thread, I think, a doctor said that none of his patients ever asked for cheaper treatments. I asked if any of his patients had ever asked for more expensive ones either. I don’t think he ever returned to answer. Have you ever requested more expensive treatment? I never have.
A lot of companies are now only covering 80 - 90% of big bills, so the link is happening already. My insurance statements say how much the list price of a procedure is, what the insurance company negotiated price is, and what I pay. It may be all a scam, but I get the impression that the insurance companies push for good prices. I’m sure that helps their profitability.
But there are some real problems with a price driven approach. When you shop for a car or a computer, you can pretty much link price differences to feature sets. (Quality is a bit harder.) I think very few of us can do that for choices of a medical procedure. In some cases we can - my dentist gives me a choice of crowns, telling me price points and the advantages and disadvantages of each. Also, you have the luxury of researching cars, many medical procedures are done on an emergency basis. I suspect the market benefits in reducing the price of elective surgery comes from the patient having the time to interview LASIK surgeons or people doing breast enhancements. My wife’s retina surgeon found he had to do a special and probably expensive procedure while operating. I don’t think it would have made sense for him to have come down and ask me if it was okay for cost reasons, and I doubt I would have responded rationally anyhow.
The best way to save money is to reduce the incentive of doctors to recommend procedures that are unlikely to work, and to try to drive efficiencies into the system by hard bargaining. This is one of those cases where the model of the patient as a rational consumer, optimizing costs versus benefits, is pure fiction.
Most free-market models I’ve seen, though, suggest that this is precisely the kind of situation which would be covered by insurance in the “catastrophe insurance” sense. There’s no need to try to make homo economicus-like decisions when you get into a car accident, have your house burned down, or (hypothetically) encounter a serious catastrophe during otherwise routine medical procedures. That’s one of the benefits of insurance, and why insurance is usually a good thing. But the situation is different in more mundane circumstances, like you describe with the dentist example. What benefit does dental insurance give you here? It’s an impediment to finding the best dentist (in the free market sense of “best”) you feel is worth the cost.
Eliminating insurance is a bit insane, but eliminating “insuring against eventualities” (e.g., going to the company-approved dentist for a checkup) seems extremely sensible to me.
What I would do is determine how much a year of human life is worth.
Let’s say, for the sake of argument, that a year of life is determined to be $100,000. If a proposed procedure costs more than that per year of life expected to be extended, then the individual isn’t entitled to receive it from the public coffers, and must either rely on palliative care or raise the money on their own.
If the issue is expensive enough to go over your deductible, then it does. Not all do. My heart stuff wouldn’t have exceeded the kinds of deductibles I’ve looked at in catastrophic insurance.
For my crown, the insurance covered only half, but the real issue was that the choice was purely cosmetic and not health related, so it was a simple one that could be made without research. I could trade off the benefit to me of the more expensive one looking slightly better if I opened my mouth real wide (not much, in this case.)
One reason people choose the default option is because they think those who know chose the default for a reason, and therefore it is the best choice. I think this would really come into play in the case of selecting between procedures with health consequences, and for considerably more valid reasons. How many people have the mathematical sophistication to make head or tail of several studies of the options, let alone feeling comfortable in comparing them? homo economicus would, but people won’t in general. There is plenty of evidence that they will make bad decisions. These might be more cost effective in the short run, but not in the long.
Most insurances have exceptions about using an approved doctor in case of emergency, so even they accept that some procedures won’t be followed when split-second decisions have to be made. But I don’t think even the most fervent of free marketers think that there will be market based savings in this case, so I wasn’t really considering it.
I’m in a PPO plan, which requires me to go to company approved everybody for everything, or else pay more. I find this eminently sensible, since this allows the company to negotiate lower rates by promising customers, and this is a win for all. This also lets me choose doctors on attributes other than price, which is also an advantage to me.
That’s why we have doctors. Or lawyers. Or bankers. Or investors. Or automobile manufacturers. Or, basically, that’s why we have specialization. Most members of homo economicus wouldn’t have the insight necessary to do any number of things.
Precisely. Which is why when a doctor recommends a procedure, you don’t argue about the price of it. And making people pay personally for medical care is not going to change that.
Though I think that the ideal homo economicus would make the optimal choice of procedure, perhaps with input from a doctor but without following the doctor’s advice more or less blindly.
No, I have not. But, I think we all know doctors who will try to get us to have expensive tests that may not be necessary. Perhaps this is defensive medicine or an attempt to make more money. I’ve known doctors that give everyone a shot every time they enter his office…probably because he gets paid for shots but not for prescribing a pill. I’ve known doctors that want to take a throat culture even though I have a history of strep infections and they know it.
I will freely admit that it is difficult for most people to know if they actually need a certain test. Most people, over time, figure out if their doctor is running tests or giving shots to make a little extra money and would probably avoid these doctors if they were responsible for the cost of the visit.
I don’t consider shopping around for a better price comparable to looking at different model cars. It’s more like noticing that the same car is $2K cheaper across town. Kind of the same way we shop for vets. We find one that is a good fit and reasonably priced. Somehow people know when their vet is trying to screw them over by ordering expensive tests that are unnecessary.
Replace “doctor” with “mechanic,” “architect,” or “engineer,” and see if what you said makes sense.
people negotiate with mechanics and/or try to seek out cheaper alternatives all the time
architects, as far as i know, have a very standard rate (isn’t it 10% of the building cost?) for their services
regardless, probably 99% of people in their personal lives when they use their own money don’t ever engage the services of an engineer or an architect.
doctors are probably the last place where people price shop - probably because it’s the last industry where there is little a priori information regarding the cost of your services. and they’re hell bent on keeping it that way from all i’ve ever experienced in my attempts to figure out the cost of a medical procedure before i actually go in.
Of course it will! I don’t argue with my grocer, with T-Mobile, with my car insurance company… I don’t argue with anyone about price. I consider everything take it or leave it. And since I am paying, sometimes I leave it.