Of course not. I just think that people define single payer systems in theory as much simpler than they are in reality. The government functions as an insurance company with all the complexities that involves. It’s only simpler to the extent that doctors know what’s covered and what’s not since they aren’t dealing with a lot of different payers with different coverage levels.
These treatments aren’t experimental. They are FDA approved with proven benefits for certain patients. Some private insurance covers expensive treatments, some doesn’t. Depends on your insurance. But if your insurance does cover stuff like that, you’ve got pretty damned good insurance and you’re probably very well compensated insurance-wise(or you shelled out for an awesome individual policy).
The VA directly employs doctors and runs the hospitals, like the NHS. Medicare, by contrast, does not directly employ doctors or run hospitals, it just pays claims.
Completely false. Yes, the government functions as a kind of “insurance company”, but a completely different kind from a private health insurer. It’s the kind that requires nothing more for payment than a doctor’s procedure code. There is no review, adjudication, pre-approval, clinical meddling, “recommending” something cheaper, partial payments and shared costs, claims denials, or any of the myriad other administrative complexities that make private insurance so expensive. Indeed there is no actuarial rating at all; everyone pays the same, whether they actually directly “pay” anything or whether it comes out of general taxation.
That’s one of the big reasons that single-payer or its equivalent regulated public multi-payer is so much cheaper than private insurance. The other reason is the ability of a centralized or centrally regulated payment system to negotiate and cap provider costs. In my view the numbers given in the OP assume only savings from the first factor and not the second. There seems to be a fatalistic assumption that in the US, the costs of the provider system can never be brought under control. This may be a realistic assumption but it need not necessarily be so. Canada, for instance, has a thriving private medical practice under a strict single-payer insurance system.
A single payer system CAN be that way, but unless you make doctors justify medical necessity, the system will increase costs, not decrease them. Again, are we going to cover all Botox treatments, medically necessary or not? No system works this way. Britain has an agency that decides this stuff called NICE. NICE dictates what is covered and under what circumstances. You’re right that it doesn’t get AS complex as private insurance companies make it, I was wrong there, but it’s also not as simple as you make it out to be either. A system that just pays all claims without review, especially in THIS country, means massive fraud.
It is harder here because of the power of the relevant players, and the public support they enjoy. Doctors can campaign very effectively against anything that reduces their income. And they don’t even need money to do it, they have the ears of their patients and they are trusted.
You can do a single payer system here, but you will still have to pay the doctors what they make now.
Oh, there’s one more problem with single payer from a political standpoint: the trial lawyers. You can’t extract big settlements from the taxpayers. You know that won’t be allowed. It’s certainly not allowed in other single payer systems. Think the trial lawyer lobby will permit that? People like to think that Democrats didn’t support single payer because of the power of the insurance companies. I think unions and professional guilds like the trial lawyers had more to do with it than the insurance companies. They would lose big in a single payer system.
No, you wouldn’t cover cosmetic treatments. A basic principle of single-payer, at least single-payer as I know it, is that it covers only defined medically necessary procedures. It eventually became enshrined as a fundamental social principle that every citizen is entitled to the same high quality of medically necessary care as everyone else, regardless of ability to pay.
It’s surprisingly simple to define what “medically necessary” is, mostly through a list of procedure codes that doctors are able to charge, and partly through trust of the medical profession to be gatekeepers. It’s actually not that hard to prevent fraud under such a system, too, as evidenced by the fact that there isn’t much of it under the Canadian systems. For one thing, procedures that might be subject to abuse like unnecessary testing can be curtailed by limits and red flags. Just as a random example, there are limits to the number of ultrasounds a doctor can do or prescribe during pregnancy, but not if he deems the pregnancy “high risk”. But such a designation without justification could bring serious consequences in the event of an audit, and no doctor who has spent a good portion of his life and hundreds of thousands of dollars in training and then establishing his practice would risk everything just to make a few extra bucks. So it just doesn’t happen, and the system chugs along smoothly, with doctors submitting e-claims and getting e-payments by EFT, no questions asked, at a total cost of less than two-thirds of the US system.
Your analysis of why it would be difficult to control provider costs in the present state of the US system is probably quite valid. But it mostly centers around various popular misconceptions and the power of special interest groups, which is a different thing from what is possible in principle.
I would assume in most countries health costs are growing faster than GDP growth due to all the medical advances coming out in the last couple decades.
But it isn’t nearly as bad in countries other than the US.
Most wealthy nations saw the % of GDP they spend on health care grow 2-3% from 1980 to 2006, the US rates grew by 6%. The US went from 9 to 15%, places like Germany went from 8 to 10%.
The fact that other nations are actively trying to rein in costs while the US system is designed to drive up costs means this problem is just going to get worse.
A very small percentage. Health insurance companies have a below-average profit margin for their services, compared to other industries (at least, as of several years ago) and, unsurprisingly, most of the money spent on health care goes to health care.
Overall, there’s not all that much difference between the breakdown of how much is spent on health care between the US and the UK/Canada, except for that amount spent on drugs, implements, and other physical items. Those tend to average about double the cost in the US.
Who gets them? That depends on care standards. If you look across health insurance companies, you’ll see that the higher-cost treatments require prior authorization and specific guidelines. These guidelines are based in care standards as documented by various specialty associations and groups such as AHRQ.
For example, Botox for Migraine. You need prior authorization for medical Botox treatment for most insurance. A physician would bill with the procedure codes for the Botox treatment and a diagnosis code for the reason for treatment. These codes HAVE to be billed or the claim won’t be paid.
For example – a patient getting Botox for chronic migraine, the doctor would bill:
Botox (the drug), however many units, procedure code J23456
Chemical denervation (the injection procedure), head and neck, procedure code 12345
Diagnosis code – 569.42 indicating chronic migraine.
Supporting documentation submitted with the claim or before services rendered must indicate that the patient had tried and been unsuccessful on 2 or more of a list of pharmacy treatments for chronic migraine, and that the patient has been treated for chronic migraine.
All of this is reasonably easy to set up in a billing system. And ***none ***of it is new – most of these high-cost treatments already have prior authorizations and specific billing guidelines associated.
Not really relevant. Insurance companies are a plague on the system not because of their profits, but because of the enormous waste in the system that they engender, the only system in which they can operate. Focusing on insurance company “profits” is worse than not seeing the forest for the trees, it’s so focused on minutiae that one isn’t even seeing the tree!
That’s ridiculous. Spent by whom? The total per-capita health care expenditures in the US are about twice the OECD average. And prescription drugs are generally cheaper in Canada because of price controls – though generics are sometimes a bit more expensive because of smaller markets and less competition.
In the UK their system is they will cover things up to £35,000 per quality adjusted life year. So a cancer drug that costs £100,000 but only extends life expectancy by 6 months would not be covered. However I believe the NHS will cover the first £35,000 of the drug if you choose to take it.
It is unrelated, but botox isn’t strictly for cosmetic purposes anymore. It is used to relax muscles that are pinching nerves, and it has some researching showing it as a treatment for depression, incontinence and migraines. Botox is turning out to be a cheap treatment for a wide range of health problems.
Also botox is only a few hundred dollars per shot, I think. I believe these debates about whether a treatment is cost effective or not usually revolve around end of life cancer treatments or using a new pharma drug vs a generic. If you have a cancer treatment that costs half a million pounds but adds 20 years to life expectancy it should be covered by the NHS.
Profits aren’t really the problem, the medical loss ratio is the problem. Private insurance usually only spends about 80% of funds on health care. I don’t know what Medicare spends but it is probably closer to 95% since their administration costs are much lower.
That reminds me of another thing. Medicare is pretty darn generous coverage, they don’t worry about how many years a patient has left. I don’t see how that’s affordable if we’re also extending the same care to the non-elderly. But you’ll never be able to cut Medicare spending in that way. 90-year olds will still get their hip replacements, transplants, and $100,000 drug treatments. Or else a lot of Congressmen will get caned to death.
When I asked “spent by whom”, I meant spent by what entity within a given country – i.e.- what the government spends, vs. what individuals have to shell out for insurance premiums, co-pays, and other direct out-of-pocket costs. The US spends an absolutely staggering amount more than any other country on earth.
Are you claiming that the lower cost of prescription drugs in Canada is why Canadian health costs are almost half of what they are in the US? You said “there’s not all that much difference between the breakdown of how much is spent on health care between the US and the UK/Canada, except for that amount spent on drugs, implements, and other physical items”.
If the US spends almost twice as much as Canada per capita, and more than twice as much as the UK (graph linked above) then the US must spend one hell of a lot of money on “drugs, implements, and other physical items” that other countries don’t – so much so that the well documented overhead of insurance administration of more than half a trillion a year and inability to have any centralized control of provider costs must all be relatively unimportant factors. Do you have a credible site for how “drugs, implements, and other physical items” account for this massive difference between US health care costs and those of any other country?
Yes at one point in time I was able to narrow it down, based on sources like the OECD, government reports by Canada, the UK, and the US on the relative overhead costs of the NHS, Medicaire, etc., websites that give current going salaries for medical workers (GPs, neurosurgeons, etc.) It was a fair amount of work, and I doubt that most of the links would still work. The OECD has some great charts for a lot of this, btw.
The CBO later had a report that came to the same conclusion, and which I think was probably better researched - since they have better access to this sort of data. I’ll see if I can track it down.
Seeing how about 85% of people survive to reach medicare age, the vast majority of end of life care is covered under medicare. Expanding the coverage to people under 65 shouldn’t cause too much end of life care since most people live to 65.
I posted a link earlier that had some charts, including this one.
Pharmaceuticals are not that big of a part of why we spend more compared to other nations. The US spends $1105 per capita vs $853 in Canada or $904 in Germany (a couple hundred dollars of the 4-5k per capita a year we spend more than those nations). The big difference is hospitals, nursing homes and ambulatory care.
Seeing how the vast majority of prescriptions filled are generics (something like 80%) and I’m assuming many of the branded pharma drugs aren’t insanely expensive (a couple hundred a month for many of them) I guess the savings on pharma don’t do much to explain the price differences.
Yeah, but how much money do we spend on things the NHS would deny? Such as Obama’s example of hip replacement for his 90-year old grandmother? Is there anywhere in the world besides the US where the taxpayers would cover that?
Proponents of a free market system should embrace the notion that insurance companies be no longer limited by state boundaries, that all equally must ensure everyone who applies, and the competition will only be each other and the inefficient government single payer system.
I endorse that wholeheartedly, but let’s be clear about what competition would mean: it would mean that if the single payer system performed so poorly that it ran out of money, it’s over and done with.
Yeah, SP wouldn’t solve all of the gross inefficiencies of the US health care system, but it would certainly go at least some way towards addressing that larger behemoth of skyrocketing costs. But really, I don’t think that that’s the POV from which most liberals are examining the issue anyway.
Note, I am in favor of a COMPLETELY government-run system a la the NHS, wherein the hospitals would be administered by the feds, doctors & nurses would be government employees, & so on. Socialist to the extreme, really, with private insurance only needed for supplementary procedures or other added benefits. It’s true that the US government already operates a SP program for our elderly population (and let’s not forget the IHS which facilitates universal coverage for American Indians), but Medicare has far more in common with the Canadian system in that the government is really just a broader health insurance agency.
No, I think most lefties approach the problem of US HC from two perspectives, and everything operates secondary to that: (1) Plainly, it just ISN’T universal, and in a country as ostensibly wealthy as the US that absence of universal coverage is resolutely stupid & absurd, and (2) access to insurance is still tethered to where a person works, which, in the 21st century, makes no Gawddamned sense.
So yeah, if we’d address the access issues first then I think you’d see a lot more liberals get on board with additional ways of lowering costs. The ACA mostly gets us to universal coverage - or at least it’s projected to within the next decade - but it still doesn’t do anything to decouple insurance from employment.
Really, I’m just hoping that Vermont gets its SP system right in ‘17 so that my state (CA) can get off its ass and follow suit. Failing that, I’d just fuckin’ move to Vermont.
