"What's wrong with health care in America?"

Great Debates
1

I’ve been thinking about starting this one for a while. Hope to see people from both sides joining in. Since it’s 2:41am, I’ll just start with a few thoughts:

  1. We can’t afford to see doctors because they are too expensive. It used to be you could go see a doctor for a cold and pay $20. Now you can see a doctor for a cold and get charged $100. Why? Insurance may only pay 80%, and the doctors have huge overheads. A nurse may come in to take your temperature and ask questions, things that the doctor can do, but they’re too high and mighty to do that anymore, so they pay $30K a year for someone to do that and they end up pocketing the same $20. They charge more because a lot of the fee is eaten up.

  2. Getting money from insurance company sucks. Insurance tries to control what the doctors do now and pay as little as they can get away with. I’ve heard from one insurance adjuster that they went to a seminar which taught them to underpay doctors and only 50% would write back to dispute the bill. Sometimes they refuse to pay for something that is legitimate and it’s in your contract with them that their determination is final and you cannot collect from the patient.

  3. Insurance should be run by a non-profit organization, like hospitals were run by the religious orders in the old days. Making money is actually a conflict of interest for insurance companies. They collect money from the insureds and pay it out to the providers. To them, maximizing profits means covering as little as they can get away with and paying as little as they can to the providers. For the greatest benefit to all, all monies should be spent in covering their insureds and paying the providers, not making more money for themselves.

Insurance companies can legitimately deny payment by saying that the patient didn’t need the treatment (that’s like the adjusters actually diagnosing the patient and being the doctor), the doctor didn’t get authorization first (that’s getting off on a technicality), not billing in time etc.
4) Part of the increased cost is the fault of lawyers and patients being sue happy. Doctors are not gods. If someone comes in with a problem, doctors generally look for the most common problems first and then proceed on. Everything that someone comes in with can be cancer. It seems that doctors are fair game if the patient thinks he was misdiagnosed, but the fact is diagnosing a problem is complex task. It’s like a mechanical replacing different things on a car before he fixes the problem.
5) Having said that, there are bad docs around. There are still a lot of people who go into medicine thinking it’s a gold mine. Unfortunately, it’s not true anymore. And anyway that’s the wrong reason to go into medicine. The worst part about it is that if a doctor is inept and they can keep practicing for a long time. There should be no malpractice insurance. This would cut overhead. If a doctor screwed up royally, their license should be taken away from them, instead their malpractice pays and they keep on practicing.

Thoughts?

2

In France and Germany the Hospitals by and large are privately run.

The differance is that the State pays for the treatment.Insurance companies only have involvement if individuals take out private policies.

I do not know how high their standards are but I can’t imagine the Germans in particular puuting up with poor healthcare.

In the UK the National Health involves no private companies at all. The disadvantage is that it has to compete for funding against all the other priorities that a government has and of course come election time there are always promises by one of the protagonists to cut taxes.

The UK’s NHS problems are being addressed but it takes many years to train staff.

So your choice is pay directly or pay through taxation.

In theory cutting out insurance companies with their shareholders should result in more going to treatment and lower costs but public funding becomes something of a political football.

3

(This is the third time I’ve started this post, only to have my computer crash. As such, this is the short version.)

One problem is that third-party payers undermine the concept of cost-effectiveness.

To use an example mentioned before by edwino, let’s say you come to my office with a sinus infection. I could give you amoxicillin, which costs less than the plastic bottle it comes in and usually does the job. Or, I could give you Augmentin (amoxicillin + clavulanic acid), which is a slightly more potent drug. It might cover a few cases that amoxicillin won’t, but it costs 15x as much. If you’re paying a $10 co-pay for your medications, then you probably want the Augmentin.

Of course, your HMO could just say that it won’t pay for Augmentin until I’ve tried regular amoxicillin. The problem with that is that I might have a good reason to prescribe Augmentin first. I might have seen several cases of what looks like the same bug lately, and plain old amoxi didn’t do the job. You might be old or sick, and I wouldn’t want to take a chance on keeping this around for very long. I can call and explain this to the B.A. in Art History that your HMO pays to answer the phone, and she’ll tell me that her computer says that they can’t cover it.

When you can’t rise above the minimum standard of care, you reduce medicine to an algorithm, and you undermine the idea of treating the patient instead of the problem.

Imaging studies and lab tests are even bigger offenders than drugs in this category. One surgeon at our med center told me that as many as half of the CT scans that we do are unnecessary. The patient knows that a CT scan is better, the doctor is busy and doesn’t want to take five minutes to do a comprehensive neuro exam, and neither of them is paying for it, so why not get a CT? Then again, when you start slapping regulations on when a CT can be ordered, you undermine the judgement of the doctor.

I don’t have a good solution for this quandary, but it is one of the bigger sources of ineffeciency I’ve seen(along with HMO CEO salaries :slight_smile: ).

Dr. J

4

Perhaps health care costs could be significantly reduced by reducing the amount of coverage that insurance companies provide in cases in which the expense is relatively controlled and families can afford to pay more. For instance, perhaps only covering 40-60% in the $0 to $2000 dollar range.

5

Before I start, I’d like to address my qualifications. I’m not a doctor, but I am a trained and practicing coding specialist. It’s my job to get claims paid as ethically and as legally as possible.

First of all, there are different levels of service, as far as reimbursement is concerned. The fee your doctor’s office charges is based on the level of service. Spending five minutes with a nurse for a routine injection costs a lot less than seeing the doctor for thirty or forty-five minutes for a more complex procedure.

Second, the doctor isn’t too high-and-mighty to take vitals and history. It’s simply not necessary and not an efficient use of his time. He prefers to spend the majority talking to you about your problems and how to treat them and not taking vitals and asking about medications.

**

Not true. Any insurance organization that consistently tried to underpay doctors would be nailed for bad faith. And it’s not true that only half would complain. Sometimes, it’s not worth it to complain, or we know in advance that something’s not going to be paid, but we file the claim anyway because it’s illegal to pick and choose which claims to file.

Furthermore, an insurer’s determination is NEVER final. The doctor’s office can file appeals right up to the level of state and federal government, if need be. And, under certain circumstances, we CAN collect from the patient.

**

Deciding what gets paid and what doesn’t is a tricky business. The government keeps detailed statistics on what is done for what conditions, and why. Some procedures (like chest X-rays for colds) are usually unnecessary. These don’t get paid. If a procedure denies for “medical necessity”, it’s usually because the procedure is not indicated for that condition. HOWEVER (and this is a major exception), if the physician’s office can supply documentation (such as chart notes or reports) that the procedure WAS indicated (such as there were unusual lung sounds in the above example), the insurer will take the claim under advisement, and the claim will usually be paid.

**

This statement is self-contradictory. If doctors assume that everything that came walking through the door could be cancer, health care would cost twice as much as it does now. Usually, the most common problem IS the likeliest suspect. Sometimes, the likeliest suspect is the hardest and most expensive to definitively diagnose. Most doctors worth their salt would try the least-invasive approach to treatment, unless circumstances dictate otherwise.

Patients are also susceptible to what I call the “Reader’s Digest syndrome”. When I was billing radiology, an article on health-care fraud or a particular disease would trigger a lot of phone calls on those topics, usually from patients who insisted that they had that disease and the radiologist misread the X-rays or that they were being cheated on their bills. After all, if it’s printed, it must be true, right?

**

Sadly, humans being humans, this is wishful thinking. For every legitimate malpractice claim, there are God-knows-how-many frivolous claims. There are patients who sue at the drop of a hat. One mistake does not make an inept doctor. There are many factors involved in medical care, and not all responsibility rests with the doctor.

Were it not for malpractice insurance, most good doctors would not be able to practice medicine, out of fear of lawsuits. And it doesn’t make sense to pull a license after one or two mistakes.

Robin

6

Well all the frivilous lawsuits would be dropped if they could get no money from lawsuits.

7

Minor nitpicking:

The least invasive approach to most patients is a good history and physical exam. This will uncover the most likely diagnoses more than 95% of the time. A doctor does not need to ask all the questions needed from the patient but a better view of the big picture may be needed than the simple fill out the form histories that many nurses take.

The most common problem as the likeliest suspect? To some degree, it depends on how picky you want to be with designations. It can be hard to distinguish between ulcer and non-ulcer dyspepsia or where in the upper respiratory tract the infection is. If I was having abdominal pain, the differential is far tricky. I agree in most cases medical treatment as a trial is far better than an expensive test. Cases are significantly different that doctors should not be constrained by strict laws on what they can and cannot do (if one can remove their vested interests).

8

Asmodean knows. This country is overtaken by lawyers, health care is one of the largest feeders. It’s too late now, but we can chat.

Many years ago I wrote a letter to the AMA, in which many points raised by Major, were touched, and then some. The overall thrust of the letter was that human life is too precious and that healt care should be removed from the market forces as much as possible, at least all motives for profit should be eliminated. Etc., etc., etc.
Surprisingly, the AMA replied ( I am not a member, the AMA is a private organization). A vice prezident or something. It was a solid, two page letter, answering my points. It could be summarized as follows:
America is a free country. Any profit-limiting restrictions would be unamerican. Limiting lawyers or anyone else profits would be unfair. Nothing could be done. People do not die in the streets, therefore the system works, leave it alone.
It was the time of first HMOs, and many bright kids still went to medschools as it was the shortest way to nice leaving.

9

msrobyn:

  1. “First of all, there are different levels of service, as far as reimbursement is concerned. The fee your doctor’s office charges is based on the level of service.”
    Well, I’ve seen some docs routinely charge 99203 or 99204 for an initial visit for a common cold, what do you think about that?

  2. “Second, the doctor isn’t too high-and-mighty to take vitals and history. It’s simply not necessary and not an efficient use of his time. He prefers to spend the majority talking to you about your problems and how to treat them and not taking vitals and asking about medications.”
    It’s the doc’s job to know about medications. And taking vitals is part of the visit too. Why should someone else be doing those 2 jobs? What’s more important than history? Like the other doc said, the majority of dx can be found from the hx. To me, it’s just extra overhead.

  3. “Not true. Any insurance organization that consistently tried to underpay doctors would be nailed for bad faith.”
    How would you prove it?

  4. “And it’s not true that only half would complain. Sometimes, it’s not worth it to complain”
    That’s true, some don’t bother to complain, because if you try to call up the insurance company you go through a maze of options which you can spend 20 minutes on and not get to the right person.

  5. “Furthermore, an insurer’s determination is NEVER final. The doctor’s office can file appeals right up to the level of state and federal government, if need be. And, under certain circumstances, we CAN collect from the patient.”
    Wrong, wrong, wrong. Many of the new contacts between docs and ins do not allow that or state that their determination is final. You can always complain to the Insurance Commissioner’s office but they will not look at contract disagreements anyway. How many contracts have you read?

  6. “And it doesn’t make sense to pull a license after one or two mistakes.”
    You really need to read carefully, I didn’t say mistakes, it’s for the truly bad doctors.

10

It’s precisely BECAUSE human life is so precious that health care must be kept in the free-market!! Please do explain to me how we are going to get the best and the brightest young minds into medicine without paying them top dollar? I know I’m certainly not altruistic enough to spend 7 or 8 years of my life after college for the sheer good of it. If I’m going to put in 12 hours a day and be on call the other 12, and be under constant stress saving people’s lives, then I’m going to expect top dollar compensation and feel that I earned every damn cent of it. Then again, I suppose that the rancor felt towards doctors is the typical resentment of success by the masses, who except for the fact that they’d die without physicians, would just as soon do without them. And I believe that any happy doctor is going to give me a hell of a better shot at surviving than one virtually held at gunpoint by these damn regulations.

Incidentally, if you want socialized health care, I imagine that there’s a lot of Canadians who would be more than willing to trade with you!!!

11

Please clarify what you mean by your derogatory use of the term “socialized health care”. Doctors in Canada are paid reasonably well, higher than in most countries. I am deeply in debt after ten years of studies and did not go into medicine purely out of charity although this does play a larger role than you might suspect. Most Canadian doctors have few socialist leanings, and I find the cliche confuses “unpopular” politics with sound health care practice – all people should have some level of care.

12

I would like to know where you’re getting this information. I do this kind of thing for a living. I attended college specifically for this, and have worked in both the insurance side (for a large insurance company) and in the billing side (for three physician practices). As part of my continuing education, I am required to attend training on the latest in coding and insurance requirements. Can you say the same?

Robin

13

“Everyone should have a right to health care.” I see. Reminds me of my last trip to England.
“You mean you have to pay every time you go to the doctor?” I was asked, gaping mouths around the pub table.
“You mean you have to pay even when you don’t?” I asked back. The conversation quickly ended there.

Doctors go through a tremendous amount of schooling to be who they are. The more specialized a doctor is, the more he is required to be top notch. It only seems reasonable to me that they be payed incredible wages. I can live without electricity, but if my bone was ever broke I am glad that there are elitist doctors out there. Now, whether or not I can afford them is another thing altogether. But, last time I checked, I came into this world with nuthin’. You aren’t born with a right to health care. Give me a break! I have heard great things about reasons for socialized medice, but inherent health-care “rights” are absurd.

The proposition to force insurance companies to be non-profit is ingenious. Another restriction on the free market, of course, but if it was a choice between the two I’d rather leash insurance providers than doctors. When I’m lying under the knife, I don’t want to think that the doctor’s only “motivation” is that “people have a right to health care.” He can think that without being nationalized, wouldn’t you agree?

Because the field of medicine is largely patent-driven (especially in the drug market) pharmaceutical companies are charging top dollar for their product. And its no wonder. It takes almost five years to bring a drug to the market. Five years! That’s a LOT of time, money, and effort on behalf of a LOT of people. God be praised that they want a profit. That profit enables them to make more and more drugs. A pharmaceutical company’s goal is to come out with one drug a year, but hopefully more. To acheive this they need people from every branch of chemistry and biology. Those people, as well, need good schooling.

To think what doctors and chemists and such give us as a society. And all they are asking for in return is some money, and only when we require their services!. I think its a steal on our part.

14

I think one way to curb prices in health care is to reform the tort system. If you cap total awards at some multiple of actual damages that would reduce payouts which would reduce premiums which would reduce prices. There are some specialities which half of the cost of doing business is malpractice insurance.
As has been already posted the only real way to bring prices down is to have the person getting the service to pay for the service. One way to do this is medical savings accounts. Let people save before tax money for medical expenses. In conjunction with this have an insurance plan with high deductibles. This would give an incentive to reduce health care costs while protecting them in case of something catastrophic.
Health care is a commodity if you remove the profit from providing it you will have less people providing it.

15

Actually, IIRC, payment to medical plans is taken out before taxes.

I like the idea of a personal savings plan. Actually, I like the idea of the ultimate 401K plan. We phase out social security and introduce the ultimate 401K. All savings are tax-deferred and collect interest on the market as usual. Money removed from this plan is not taxed when used for health care or after retirement age. In all other times, money removed from the account is taxed as regular income.

Now, this is obviously an “only the rich get health care scheme” isn’t it? Well, that argument is a tough one to defeat. Health-care insurance is still a necessity if the bulk of the population is to receive any care whatsoever. To encourage spending in this way, all donations of health care by either insurance companies or health-care providers themselves can be 100% written off in taxes. Now THAT’S incentive. Hell, they already lost the money to someone anyway, better that it be a patient who needs it than a bloated government.

Now, we still haven’t eliminated the problem of poor people getting health care because there’s only so much charity can do. We’ve still got thousands of McDonald workers who need health care. I don’t see an easy way of doing this without forcing businesses to pay more for they’re low-quality workers. It’s a bad move no matter what. I can’t see a way around this that doesn’t involve either screwing the poor or screwing the rich.

Incidentally, the rich have just as much of a right to not be screwed as the poor. Only a statist or a socialist would feel that the poor are somehow deserving of the rich’s money. As much as I would love to be a part of the looting that goes on, I find it unethical to take from the upper crust just because there’s more of “us” poor people.

16

Q:Health care is a commodity
Many people agree with that, many people do not.
If HC is a commodity, the less of it you have, the more expensive it becomes. The more miserable you are, the richer the providers become. Their goal is to keep you as sick as possible. If you are rich, you have the money to mountain ski. If you are poor, you are stuck in the inner city. That is fair. If you break you leg while skiing, you have the money to be treated. If you break your leg because of potholes in your ghetto, and do not have the money, you will die, because providing your HC means loosing money on you. This is not fair.
Doctors study long and hard. They work long hours. Their annual pay is over ~$100,000. Their hourly pay is almost twice less, because of long hours. Plus huge responsibility. Plus inability to go on long vacation. But the reward is more than money. Not only they do not work on the conveyor belt (very few people do today), it beats any other work, even equally paying plumber’s (last time I called a plumber, it was $90/hr).
We have enough bright people in the society who will be attracted to the medical profession by the combination of tangible and non-tangible incentives. I am not talking about a few zealots who are willing to treat poor in the rural areas for the sake of it and ere willing to stay as poor themselves. But I pesonally know of more than one doctor, who quit practicing medicine because it can’t provide living anymore. They would have stayed and work at lower income levels, but they refuse to do the paperwork for the government and the insurance companies and to pay greedy laweyrs.
So, RugbyMan, I understand that free markets attract the best and the brightest, but they bring unsolvable problems with them.

17

Not that you don’t bring up a good point about doctors leaving the profession due to red tape, but perhaps you might stop to notice that the red tape is the effect, “fairness” is the cause. Further regulation WILL NOT remove this.

Beauracracies are famous for their sluggard nature, and the government is the larget beauracracy of them all. As much as it makes sense to have some centralized office creating infrastructure like roads, sewers, etc, I find that on the other end of the spectrum it stops making sense at all. The only way it makes sense is to assume the two following conditions:

  1. You have a right to take something from someone who has more than you provided
  2. that everyone is allowed to survive at some median level.

This is the justification for socialized medicine. I am certianly not arguing that the free market is more efficient, cheaper in the long run, etc., but that it creates better doctors. I feel RugbyMan is clearly on the same page as me there. In the end, after all the red tape on all sides, it comes down to the meeting of the doctor and the patient. We feel that the drive for higher profits, in addition to the desire to help people (which is probably what drives many to get into medicine in the first place), is what creates excellent doctors.

18

Socialized health care…when the government has a majority/total financial interest in the health care system. Medicare/aid may be socialized health care, but (fortunately) governmental control hasn’t completely pervaded the US health care system.

Then if doctors are so well-paid in Canada, explain the recent “brain drain” to the US? If doctors go into it for charity then why complain about it…after all “from each according to his ability, to each according to his needs” and all, right? But since I don’t believe that trash, and that a doctor has many more skills than a burger flipper is going to, then they deserve to be paid more. If you are fresh out of college, then I suppose you’re going to have debts…after all, those years of college don’t pay themselves off (unless you think that free education is a right too?)…but once the payments are made and as you gain more experience and skill, then the money will be there, and if you are discontent with the rate of pay of your current job, then you move on to another one…the market equilibriates itself quite nicely.

Yes, but why should I be forced to pay for them to do so? If someone doesn’t have private health care, then to be frankly honest they have a shitty job and should move on, and hopefully their old employer will realize that they’re losing the best and provide it themselves (and if they’re not, then they’re just going to lose more good employees until they do). If you’re on a McDonald’s level, then go to a 2 year school, get an associate degree and find a job with health care. The market does an excellent job of providing care for those willing to work for it, but if they won’t try, then that’s not my problem, is it?

19

Yeah, I’m a retired doc, and I’ve seen a lot of abuses from all sides, patients, docs, insurance cos. I’ve read a few SDMB topics that touched on health care and I idylly wondered about it, that’s why I started this topic.

For starters, if insurance wasn’t that hard or complex to collect from, your job would be history (pardon the pun) and I mean that in a good way. That would be less overhead, a lot less. I know practices with 2-3 people who do billing full time. What for? $80K+/year just to mail in forms? Your own existence contradicts your statement. If insurance was so easy to deal with, why do you need to have to go to college for it? Why need the continuing ed? Why need the latest in coding and insurance requirments? LOL.

20

OK, I’m a little out of the loop right now (1.5 years since I have been in medical school, working now on a PhD), but this is a problem that will directly concern me, I suppose.

I think a legitimate start would be to ration health care in the USA. This is not a pretty picture, but I think it would work. I believe Oredon has had a rationing system in place for a few years now, and they have been able to keep it stable.

The way rationing would work is not by price. It is by proven efficacy of a certain treatment or sensitivity/specificity of a test. For instance, bone marrow transplants, which work very well for some cancers yet are extremely expensive, would be high on the list. So would heart transplants. So would CT for concussions.

You make your list. Let’s say 1000 things are on the list. You then calculate costs and draw your line.

The problem is that this involves serious sacrifices – hospice care may be covered, but aggressive treatment for stage IV adenocarcinoma of the lung isn’t. Whipple for ampullary pancreatic cancer is covered, but Whipple for any other type of pancreatic cancer isn’t. (These examples may be wrong, I’m thinking off the top of my head, basing them on knowledge of 1.5 years ago).

The uninsured would be guaranteed #650 and above. If you wanted other treatment, your insurance would pay, or you would pay out of pocket.

This can also work for drugs. For drugs, however, it may be that you might need to factor in prices. This is specifically to deal with prescription drugs for the elderly – many get expensive hypertension or heart drugs when a far less expensive course of generic diuretics and beta blockers may work nominally less well. Y