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Author Topic: Are you a 1-Percenter?  (Read 4364 times)
Finnegans Wake
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« Reply #10 on: Jul 27, 2009 at 17:38 »

Also, Medicaid and Medicare are getting the dregs of the system, so to speak.  The healthcare companies get the cream of the crop, or at least until those people get too sick. 

http://www.pnhp.org/facts/why_the_us_needs_a_single_payer_health_system.php

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« Reply #11 on: Jul 27, 2009 at 19:25 »

In fact, we're spending two, three times what other Western nations are for healthcare.  For every person who says Canadian, French, Brit, etc. healthcare involves long waits and substandard care, there are plenty of others who say that's nonsense.  IMO, it's moot: we already HAVE the healthcare providers in place AND we're spending the money.  What we're not getting is ROI in terms of life expectancy (and other metrics) for health dollar spent.  We should be able to maintain (or improve) care, not increase per capita spend, and expand coverage for what we pay right now.  

That's where I'm coming from, well said.

And Scac, yeah, more often than not I fall in with libertarian ideas, but I'm not gonna cut off my nose to spite my face.  Health care for all?  I'm there, let's do it - it makes sense.  We're already spending the money, let's get the service corrected.

From what I understand, we haven't even taken advantage of learning the ups and downs from countries who are doing more with less.  WTF is that?  It's where we should have started.
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« Reply #12 on: Jul 27, 2009 at 19:28 »

And after health care is fixed, let's tear down and rebuild the education system from K-12, college and beyond.  We are falling waaaay behind the rest of the civilized world.  It's shameful, really.

But that's for later.  Gotta get those bastards in DC to do what's right for the people.  That's us.
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SCacalaki
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« Reply #13 on: Jul 27, 2009 at 22:04 »

While there certainly are pros to a national system, I guarantee you that you don't want to see it model M'care.  

Guaranfuckintee you.

Patient Rx doughnut holes, non-coverage of FDA-approved medications (osteoporosis medications for the elderly being one I have seen often), minimum coverage standards for education (medical nutrition therapy is only covered for those with dx of diabetes and renal failure....high cholesterol, obesity, hypertension, and hyperlipidemia are not covered by Medicare; Carefirst and BC/BS cover for these dx), and a black/white policy of approving procedures.  

Not to mention they pay a fraction of what private insurers pay.  About $30 on a $100 charge for outpatient services.  And that is to cover a 45 minute visit with a physician, who has front desk and medical assistant help.  Overhead.  Billing.  Malpractice insurance.  Rent.  Medical benefits.  Retirement benefits.

I'm telling you, we ain't breaking even.   Not close.

And we're on the EHR now.

One key to keeping down costs is to keep patients out of the ER and inpt. side and have preventative care promoted on the outpt. side.  ER is killer on the pocketbook.  This is where patient responsibility comes in...not waiting until the condition is beyond outpatient treatment, if possible.  Diabetes is a perfect example.  Patients not taking medication (insulin), not attending diabetes education classes (not knowing carb counting or meal portioning), and not having annual eye and foot checks.  I hear my dept. physicians complain often about patient non-compliance, yet the same patient(s) come back month after month with A1C values at 10+ complaining about how poorly they feel.  Diabetes (DM II) can be managed through proper diet, exercise and sometimes medication.   The patients who make the leap to lifestyle changes are the ones who are seen less often, reducing the cost to the hospital and insurer.

Now, I have heard many stories of families not being able to pay their health care bills.  Many are well-to-do middle class families who recently lost a job and had a major health emergency or who are small-to-medium business owners with no health insurance, amongst other scenarios.  I think these scenarios of financial ruin best illustrate some of the problems with the current health care system.  For the impoverished, there are free clinics and sliding fee scales (what my office uses for those who make certain annual incomes v. # of people in the household).  Those two opportunities are not available to middle class America.  

Re: European systems, I'll look into the malpractice and negligence lawsuits in those countries against physicians and hospitals.  My guess is the % is much higher here in the US than Europe but that's just my reflection on U.S. society in general and nothing based in fact right now.
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« Reply #14 on: Jul 27, 2009 at 22:24 »

Re: European systems, I'll look into the malpractice and negligence lawsuits in those countries against physicians and hospitals.  My guess is the % is much higher here in the US than Europe but that's just my reflection on U.S. society in general and nothing based in fact right now.

I think your instinct is correct on that one.
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« Reply #15 on: Jul 27, 2009 at 23:52 »

To back up Scac's assessment - Medicare simply doesn't work as a health care system, and that's what we'll have.  Either that or the V.A. system, which if you've experienced it, probably won't sit too well with the general public either.  I can tell you with no doubt - when I was in practice, if my payor mix was 100% Medicare/Medicaid, I would not be able to keep the doors open.  Every single year Congress voted to cut Medicare reimbursement, and every single year, after much wrangling, agreed to put it back where it was and acted like they were doing doctors a favor.  Well, rent, slaries, insurance, office supplies, etc, don't stay the same - they go up.  If your income is flat, and your expenses continue to increase, doesn't take long for those lines to cross.

YOu think there's a physician shortage now?  Wait till there's a national system with no tort reform in exchange.  Then the real health care crisis will hit.

As far as quality based care goes, on the surface it makes a lot of sense.  Unfortunately, it will lead to difficulties for the sickest patients to get the care they need.  Physicians will shy away from the people with six chronic health problems who can't/won't follow treatment regimens; surgeons won't want to operate on high risk patients, etc., because those patients will make your numbers look worse.

 An important thing to remember is that while health care costs are high, and many people suffer high bills without insurance (or with it in some cases), the vast majority of those people can still get care.  The medical field is probably the least aggressive in regards to collections.  Most of the time (not all, I realize) if the patient is making an effort to at least pay something on a regular basis, doctors won't refuse to see them.  And emergency rooms legally cannot refuse to see anyone on the basis of an unpaid bill.  So while the bills aren't fun to recieve every month, people can still usually get the care they need.  Usually - I know it doesn't always work that way.

FYI, I agree that the government does some things well - Post Office as another example to add to Finny's list.  To this point I haven't seen any evidence that they can manage health care.

I'm not a big fan of private insurance by the way, in case it sounds like I am.  At least not in its current form.  What I'd like to see is a system that turns back the clock.  In our current system, we expect insurance to pay for office visits, medicines, and basically everything related to our health.  As an example, think about how much auto insurance would be if it also covered your gas, oil changes, and basic maintenance.  Or if you use your homeowner's to pay for electricity, gas, water, paint, light bulbs, etc.  So why do we expect our health insurance to cover everything?

I would like to see everyone go to policies that cover major medical only - ER visits and hospitalizations.  Cost would be significantly less.  Then, people could take the difference and have medical savings accounts to cover office visits, medicines, etc.  Then patients have much more input into the cost of their care.  If your medicines are too expensive, discuss with your doctor if there are less expensive options.  Maybe they'd be more inclined to follow treatment plans and/or make lifestyle changes to improve health and decrease their cost.  Also hopefully premiums would be lower so more people could afford them, decreasing the number of uninsured. 

I know this is all over the place, but one more thing.  One reason we aren't seeing the benefit of increased cost of care in life expectancy or however you want to measure it is that we are battling against an ever-worsening lifestyle.  We eat more, eat worse food, and exercise less than most other countries.  I think the fact that we're in the ballpark with those nations is a testament to a pretty good health care system.  We live longer than previous generations despite a less healthy lifestyle.  Why?  Better health care.
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« Reply #16 on: Jul 28, 2009 at 09:01 »

To back up Scac's assessment - Medicare simply doesn't work as a health care system, and that's what we'll have.  Either that or the V.A. system, which if you've experienced it, probably won't sit too well with the general public either.  I can tell you with no doubt - when I was in practice, if my payor mix was 100% Medicare/Medicaid, I would not be able to keep the doors open.  Every single year Congress voted to cut Medicare reimbursement, and every single year, after much wrangling, agreed to put it back where it was and acted like they were doing doctors a favor.  Well, rent, slaries, insurance, office supplies, etc, don't stay the same - they go up.  If your income is flat, and your expenses continue to increase, doesn't take long for those lines to cross.

Ok, ok, ok - no Medicare! 

An important thing to remember is that while health care costs are high, and many people suffer high bills without insurance (or with it in some cases), the vast majority of those people can still get care.  The medical field is probably the least aggressive in regards to collections.  Most of the time (not all, I realize) if the patient is making an effort to at least pay something on a regular basis, doctors won't refuse to see them.  And emergency rooms legally cannot refuse to see anyone on the basis of an unpaid bill.  So while the bills aren't fun to recieve every month, people can still usually get the care they need.  Usually - I know it doesn't always work that way.

From personal experience, that $15K bill mentioned earlier and the $1.5K portion that was mine to pay - that happened between the layoff, contract work and where I am now, regularly employed, benefits, etc.  So, I was making a good faith effort to pay that debt at a rate of $100 per month.  After about 6 mths the hospital turned it over to a collections agency b/c I couldn't pay the balance.  Gee, thanks.  That's for a patient who had good insurance, paid the copay, paid the first $300 up front for the bed, paid for all the incidentals like extra fees for catscan and x-rays, etc.

That's utter bullshit.

I know this is all over the place, but one more thing.  One reason we aren't seeing the benefit of increased cost of care in life expectancy or however you want to measure it is that we are battling against an ever-worsening lifestyle.  We eat more, eat worse food, and exercise less than most other countries.  I think the fact that we're in the ballpark with those nations is a testament to a pretty good health care system.  We live longer than previous generations despite a less healthy lifestyle.  Why?  Better health care.

One can only blame the patient so much.  Yeah, they are 100% responsible for their lifestyle and their parents are 100% responsible for their genetics.  People can live what would be considered a perfectly healthy lifestyle and still get sick.  And with our current system, if it's a major illness, BAM!, they are fucked, their family is fucked, little Joe-Bob ain't going to college, retirement is down the drain, etc.

But people do like their unhealthy food.  Hey, everyone really likes piling on the cigarette tax.  Fuck it, let's tack on a 50% McDonald's tax and at the grocery store, a 50% beef tax and a 50% butter tax and a 50% high fructose corn syrup and sugar tax.  Oh shit!  Some things are getting through the cracks - 50% deep fry tax, 50% partially hydrogenated-anything tax.  And frankly, I don't like all the genetically-modified crap.  A tomato plant started growing out my back last month but the insurance wouldn't cover treatment plus my doctor is afraid I'll sue him if he removes it.  But the tomatoes do taste better since I quit smoking, so there's that.

I'm looking into a botany insurance plan.
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« Reply #17 on: Jul 28, 2009 at 09:09 »

Forgot about the emergency room issue.  I believe Scac mentioned that much of the money gets wasted there.  But isn't that a catch-22 situation?  Why do the people go to the emergency room first?  I'm assuming it's b/c they won't get turned away for not having insurance. 

Isn't that a problem that will instantly go away if there's coverage for everyone?  Then when people show up at the emergency room with a chest cold, the doctor or nurse can tell them to fuck off and go to their primary care physician.  Win-win.
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« Reply #18 on: Jul 28, 2009 at 11:14 »

I think we're all in agreement that some sort of reform is needed.  Where we differ is what type of reform.

To answer your question jonzr re: the ER, yes and no.  IMO, if a national system comes out, it needs to push preventative care and education.  Let the PCP and specialists treat the problem prior to the condition getting so poor that an ER visit is the answer.  So yeah, I think you're right to emphasize alternatives to the ER as a way to reduce costs.

A national system that pays for "all" won't solve the ER issue.  That's because there are many illegal immigrants that use ERs for primary care services.  And I have to assume this would continue as they would be covered by a national system. 

So the ER system might not be as overloaded with a national insurance system, but there would still be many patients not covered for ER services.

Again, I realize there are valid points on both sides.  For me, healthcare is my profession...my livelihood, like it or not.  So my perspective is different.
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« Reply #19 on: Jul 28, 2009 at 11:29 »

jonzr, sorry to hear your experience re: the bill and collections.  I can understand where you're coming from.

For me, if a patient reaches out to me re: an outstanding bill, I work with the patient and billing office to set up a payment plan.  Also look into sliding fee scales should a patient be eligible.  Various pt. assistant programs available from pharm. companies.

At the same time, I have patients who complain or flat-out refuse to pay their $5-$25 co-pays.  I have no sympathy.

Re: your response to taxes, your liberatian roots finally show! Smiley  But taxes would have to be raised, on everyone, to cover everyone in the US.  There just aren't enough 1% to cover the coming baby-boomer generation.  Heck, as it stands, M'care will have a tough time surviving.

What I can see is some type of national system with private "plus" plans.  Medicare already has them with Bravo Healthcare and CareImprovementPlus being the two I see often (though, I heard CareImprovementPlus is heading towards bankruptcy).  This would allow patients to pay extra for extra coverage, increased medicine coverage/availability, etc.  

I like msdmnr's idea re: major medical only...but I see a bigger problem for ERs under that system.  What is the incentive for the patient to use/pay for PCP when they can put off their condition long enough to warrant free ER service?  I would expect many patients would rather not pay $88 for a level 4 f/u with their endo if they could wait until their blood sugar was in the 300 range and have their insulin taken care of in the ER/inpt. for free.  
« Last Edit: Jul 28, 2009 at 11:35 by SCacalaki » Logged

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