403 calls over 730 days is a little over once every two days.
Definitely far less than the 100+ calls a day Dr. Strangelove claims
https://www.miamiherald.com/news/nation-world/national/article264570371.html
11,000 times over 8 months. That’s an average of 46 times per day. And:
On May 30 alone she made 406 calls to the police department, the affidavit says.
And yes, obviously this is atypical… the point is that a single person can consume a significant portion of resources all on their own.
It’s not going to be quite that drastic with health care, but nevertheless it can be significant.
Not once have I said that the moral hazard is equally applicable in all circumstances. Obviously in the case of medically necessary procedures , there are enough barriers that it’s basically impossible to abuse.
But on the other hand, public prescription coverage in Canada does have co-pays essentially everywhere. I still have not gotten an explanation for why these would be necessary except to avoid the moral hazard.
Somewhere in the middle you have situations like general visits to the physician. Some mentally ill people would simply schedule visits multiple times a day, forever. I suspect this problem is solved simply by rationing–abusive patients don’t get appointments.
Not “fun”, but inappropriate use of the ER is absolutely a problem. Of course there’s a moral hazard for a service that’s “free” to the patient but has great cost to provide.
Most of the inappropriate ER use in the US is driven by people who don’t have health insurance. So they go to the ER when their kid has an earache because at the ER, a doctor sees you before anyone asks you how you plan to pay.
The emergency department is one of the least fun places you can go. If everyone had access to normal clinics for minor stuff, inappropriate ER use would pretty much disappear.
(And the hypochondriacs and munchhousen types wouldn’t become more of a problem. They’d be the same problem.)
I still have not gotten an explanation for how drugs that are only available under a doctor’s prescription can be abused for fun & profit. Or how a $4 fixed dispensing fee is a disincentive to anyone but the homeless.
Remember, too, that regardless of what the Ontario Drug Benefit calls it, this is not a co-pay in the ordinary sense that is mandated by the drug plan, as with private insurance which makes you pay a portion of the drug cost. The federal government regulates patent drug prices and provincial plans cover those costs 100%; they simply leave the matter of dispensing fees – which some pharmacies don’t charge at all for those with ODB coverage, and others charge varying small amounts – as a matter between the pharmacy and their customer.
@puzzlegal already addressed this. It’s mostly a problem in the US for obvious reasons. I think earlier I mentioned a documentary I saw about a California hospital struggling with a massive volume of patients using the ER as their only source of health care. It’s probably a significant contributor to the exorbitant cost of US health care.
Public health care protocols should not be based on the behaviours of a few mentally ill people who are easily identified and appropriately dealt with.
Agreed, though you’d get a small win by virtue of clinics being cheaper to operate per patient an an ER. Then again, maybe some types of extreme hypochondriacs get off on the more intense environment of an ER. Why have just one doctor looking over you when you can have several?
You don’t have several doctors looking at you in the ER, although you might get shunted from one doctor to another, with a long wait in between.
I’ve been to the ER too many times in the last five years. It’s really not a fun place to be. Mostly, it’s a boring and uncomfortable place to be, with a great deal of waiting.
The more likely situation is more people getting very low-value care when prices decrease. It’s not like that there haven’t been studies on this sort of thing. For instance:
The effect appears to operate across all types of care, with estimated increase in both “high value” care (such as preventive care) as well as in potentially “low value” care (such as emergency room visits for nonemergency conditions).6 Indeed, contrary to the argument that Medicaid would decrease emergency department visits, the evidence indicates that Medicaid in fact increased emergency department visits by 40%; this increase in emergency department visits occurs across all kinds of patients (e.g., those who had used the emergency room frequently prior to the experiment and those who had not recently been) and all kinds of visits (e.g., on-hours care and off-hours care, or care classified as “emergency” and care classified as “non emergency”), and is persistent across the two years of the study (Taubman et al. 2014; Finkelstein et al. 2016).
So the argument that people with access to clinics won’t go to the ER seems to be false.
On the other hand, I would not claim (nor have I claimed) that the moral hazard is equally powerful in all circumstances. For instance, there’s this paper out of Canada:
we show that demand responses are concentrated in the top two deciles of risk for developing mental health disorders. These higher-risk children increase take-up of mental health drugs by 7-8 percentage points. We find even stronger effects for stimulants (8-11 percentage point increases among the highest risk children). Our results suggest that reductions in out-of-pocket costs could achieve better uptake of mental health medications, without inducing substantial low-benefit care among lower-risk children.
Great! Increased medication use among high-risk (what you want) without an associated increase among low-risk (what you don’t want). So there is something to the argument that people don’t arbitrarily increase drug use when the costs go down unless they need it.
Still, the authors didn’t just declare this to be true in advance. They looked into it. And this is just one study applicable to mental health medication, which probably has to go through more barriers to be prescribed than, say, a course of antibiotics.
Dealt with if the system allows it. But you can’t just assume the system has such a mechanism! 911 is especially abusable because they can’t just start ignoring calls from some number. They have to levy some punishment against the responsible individual.
The point is that Munchausen types want attention. And the kind of attention you get is more public and intense in the ER than sitting quietly in a clinic.
I’ll bet you get attention faster if you scream and writhe around on the floor.
Here’s how it works in my European country of Luxembourg.
I go to the doctor.
I pay the cost of the doctor visit out of pocket, on the spot. (Did this yesterday, in fact, at the ophthalmologist. As an American, it’s pretty funny when the doctor finishes the consultation and then reaches for the credit card reader. But that’s how it works.)
The doctor prints the paid invoice, stamps it, and signs it, again on the spot.
The doctor hands the paper to me.
I then mail it to the CNS (our national healthcare oversight agency) with a claim form, which includes my personal banking information (like the IBAN).
Seven to ten days later, I get a response in the post confirming processing for reimbursement.
And two or three days after that, that money reappears in my bank account.
That’s it. No co-pay or anything else. I pay the doctor directly, and then the state reimburses me.
It works like this because (a) it keeps the cost of health care entirely transparent*, and (b) it ensures that all such transactions are routed through the relevant state ministry to ensure that only Luxembourgish residents are being efficiently reimbursed. If you come in from Belgium or Portugal or somewhere with a reciprocal healthcare financing agreement, there is a reimbursement, but it takes a little longer while they tick the boxes with the relevant state agency (the details of this reciprocity vary from country to country). If you come in from the U.S. or somewhere that doesn’t have nationalized coverage and a clear reciprocation framework, you’re responsible for working out your own reimbursement with your private insurance carrier.
It’s purely bureaucratic, a mechanism for tracking who’s using the system and giving their money back to them according to the proper channels. If you tried to raise this “moral hazard” justification with my country’s medical administrators, they’d be extremely puzzled.
It has been amusing watching you make these authoritative pronouncements on things you clearly don’t understand as well as you think you do, but amusement is about as far as it goes.
*For the record, forty minutes with the ophthalmologist and a full eye exam cost me 80 euros, no added charges. Good luck with that in the U.S.
So all medical services are covered 100%, unconditionally? That is contrary to what I see elsewhere.
Incidentally, that whole system seems hilariously complicated even compared to American healthcare.
It’s not. It’s easy and it works like a breeze.
But please continue making unfounded assumptions on the basis of your own limited experience. It’s endlessly entertaining.
I’ve never had to submit anything to anyone for reimbursement. I just give my insurance info and later I get a bill. Or I can pay directly out of my HSA. It’s pretty simple.
Seems like you don’t always get reimbursed 100%:
The healthcare system in Luxembourg works on the basis of reimbursement, which varies from 80 to 100%. You pay the medical fees upfront and then submit the reimbursement claims to the CNS
Kinda funny:
https://internationalhealth.com/en/Health-System-and-Medical-Insurance/Luxembourg
The Healthcare System in Luxembourg is based on copay, which basically means that you’ll have to pay for your medical attention at first, and be reimbursed for about 80% of the expenses later on.
But maybe you can describe the difference between paying 10% upfront vs. paying 100% upfront and getting reimbursed 90% (or whatever the percentage happens to be in some situation).
I mean, it’s kinda nice to actually keep the money in my bank account for that extra time, but I’m not gonna worry about a couple bucks in interest.
I know you’re a supporter of universal health care, but here’s how it works in Canada, by way of contrast. I go the doctor. The doctor does whatever he needs to do. I thank him and go home.
I much prefer the way it works in Canada where there is no financial interaction whatsoever between patient and medical provider. I don’t see what such an interaction accomplishes, but I do see how it could be an obstacle to those of limited financial means (though I assume there are special provisions for that, but still, that’s something you’d need to apply and be approved for).
Doctors’ offices here don’t have any facility for accepting credit cards, or any need for such. On the very rare occasions when the patient has to pay for something it’s always an ordeal because they’re not equipped for it. On one occasion my doctor charged me for a missed appointment, which was fair enough as they have to book a slot on a busy schedule and then it goes to waste. Of course they don’t take credit cards, so I handed the receptionist the requisite $40 in cash. She looked at it with some perplexity, as if I’d just handed her the Voynich Manuscript, and, not knowing what else to do with it, she shoved it in a drawer.
I think there’s a really important principle in removing all monetary considerations from interactions between patients and the providers of medically necessary services. It’s hard for Americans to appreciate how important this is. When I left the hospital after nearly a one-week stay and my heart surgery, I left the same way I leave my doctor’s office as noted above – I thanked everyone and went home.
And here’s the key point – not directed at you, but for the record: the health care system in Canada may choose to save money by nickel-and-diming on the minor stuff (“You have a prescription for Atorvastatin? We’ll cover it if you’re poor or over 65, but otherwise get your supplemental insurance to pay for it, or pay for it yourself”) but if you need surgery costing $300,000, you get it at no cost.
Cite that Munchausen’s Disease is primarily driven by a desire for “attention”?
It’s basically definitional, but if you insist:
Their main intention is to assume the “sick role” so that people care for them and they are the centre of attention.
I look forward to your explanation, actually. You’re clearly the expert. It’s not as if the last hundred posts have been about you diagnosing the problems with Canadian healthcare and then pretending you aren’t being corrected by actual Canadians.
So I’d love to see your expert opinion on how the Luxembourgish system works.
So you think that “writhing around on the ER floor” and “assuming the sick role” are the same thing?
You’re the one trying to claim co-pays don’t exist in Luxembourg when the entire system is co-pays! Even the WHO calls them co-pays:
Having paid for ambulatory care, the insured patient is reimbursed most of the fee at the rate set by law, minus a proportion which is forfeited as a co-payment. Reimbursement is currently set at 80% of the fee for the first visit by a general practitioner to the patient in any 28 days (ie. copayment at 20%), 95% for the first visit made by a patient to a GP or for any specialist consultation, and 100% for further visits.
The difference between paying X% upfront vs. paying 100% upfront and then being reimbursed (100-X)% is what’s known in the industry as “fuck-all”.