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ulthar
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« Reply #15 on: December 07, 2007, 10:22:26 AM »


I am not forced to prescribe, or not to prescribe, anything.  But ... there are direct and real implications in the choice....

I can prescribe anything I want -- but what the patient's insurance will and won't cover is and remains a separate issue.

In our system, though, we try to align what the insurance will and won't cover with what makes sense to cover first, or not.


I think I may have mistated my position a little bit.  I realize that you can prescribe whatever you what, but as you state here, how/what is covered is the issue.  In effect, the insurance companies ARE 'telling' you what to prescribe in that you wish to do right by your patient's wallet.

My opinion is: the insurance companies should have NO SAY whatsoever in what is covered.  If you are a qualified, duly accredited physician, they should defer to your judgement.  ESPECIALLY in the insurance programs with 'approved' physician (like most HMO's, right?).

My rant that started this thread was precisely about the insurance companies.  How my 'cardiac' event, though not serious, was not covered due to what amounts to my going straight to a specialist rather than via the ER yet how the ER copay is 9 times that of a regular office visit to discourage ER trips!!!

My wife has cases of drugs that the generic is not covered, but the trademarked is, even though it costs 20x as much.  Worse, there is a particular drug, that they use VERY commonly, that they don't get reimbursed for, so they have to send the patient to the hospital to get the shot.  This costs the insurance company (medicaide in this case) like 10x as much as if they just reminbursed the private practioner to give it directly, but they won't do that because they are "afraid" the private physicians will overuse the drug and therefore run the cost up.

Even though they ONLY use it when it is MEDICALLY INDICATED!!!!!!

All you guys hoping for socialized medicine, latch onto a private practice whose primary patient base is medicaide and you will see what government provided cost coverage will do.  It's a mess.  And, it ultimately does not help those that NEED the care, at least not efficiently.

My solution:  make people PAY for health care (ie, most people, those of us with jobs), or at least their own insurance - get away from the 'health insurance benefit' provided by employers.  As long as the costs are "hidden," people don't know where the cost abuses are.  Federalizing the system only hides the abuses more.  At least that's my read, based on peripherally dealing with Medicaide issues for several years.
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« Reply #16 on: December 07, 2007, 10:45:32 AM »

My solution:  make people PAY for health care (ie, most people, those of us with jobs), or at least their own insurance - get away from the 'health insurance benefit' provided by employers.  As long as the costs are "hidden," people don't know where the cost abuses are.  Federalizing the system only hides the abuses more.  At least that's my read, based on peripherally dealing with Medicaide issues for several years.

Fine in principle, except for one little sticking point:  Sick people.

The reason that group health insurance works (even as poorly as it does) is that it allows costs to be spread.  You work in a company with ten young fit single guys, and one diabetic depressive who has to have pre-cancerous polyps two years?  The costs incurred by the one are carried in large part by the other ten (and also by other clients of the insurer).

Those ten guys could easily get their own individual insurance policies.  But the one with health problems?  Ain't NO way.  Just to cover their costs, the insurance company would have to charge the sick one a premium of thousands of dollars each month.  So they simply won't take that person on as a client.  That increases the number of uninsured, and targets those who are ill -- who need health coverage more.

There are a few states where the legislatures, in their infinite wisdom, have mandated that insurers offer individual coverage to anybody who applies.  The insurers have responded by jacking their individual coverage premium to $30,000/year so that NO ONE will apply.
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« Reply #17 on: December 07, 2007, 12:51:43 PM »


Fine in principle, except for one little sticking point:  Sick people.

The reason that group health insurance works (even as poorly as it does) is that it allows costs to be spread.  You work in a company with ten young fit single guys, and one diabetic depressive who has to have pre-cancerous polyps two years?  The costs incurred by the one are carried in large part by the other ten (and also by other clients of the insurer).

Those ten guys could easily get their own individual insurance policies.  But the one with health problems?  Ain't NO way.  Just to cover their costs, the insurance company would have to charge the sick one a premium of thousands of dollars each month.  So they simply won't take that person on as a client.  That increases the number of uninsured, and targets those who are ill -- who need health coverage more.

There are a few states where the legislatures, in their infinite wisdom, have mandated that insurers offer individual coverage to anybody who applies.  The insurers have responded by jacking their individual coverage premium to $30,000/year so that NO ONE will apply.

That's a big part of the problem: the INSURANCE company can charge premiums based on pay-out.  It's nothing more than legalized gambling, but with a garantee that you won't lose.

When they take my premium, they are gambling that I will pay in more than they have to pay out.  That's our tacit agreement.  Where the system goes bonkers is that AFTER they "lose" their bet, they get to charge me back for it.

What is insane is that we pretty much HAVE to have insurance.  If I chose not to, getting served is very problematic.

There are some doctors that are refusing to give care via insurance.  It's cash on the barrel-head.  And you know what?  The cost of providing care is MUCH MUCH LOWER.

Your arguement is premised on the notion that we ALL HAVE INSURANCE, and that we MUST have insurance.  I'm suggesting we break that premise, and go back to a system where one could CHOOSE to have insurance, and of course, requisite for 'my plan' to function properly, the insurance industry does NOT get to set the rules (as they are now).
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« Reply #18 on: December 07, 2007, 01:10:42 PM »


Your arguement is premised on the notion that we ALL HAVE INSURANCE, and that we MUST have insurance.  I'm suggesting we break that premise, and go back to a system where one could CHOOSE to have insurance, and of course, requisite for 'my plan' to function properly, the insurance industry does NOT get to set the rules (as they are now).

Take a look at what medical care costs these days; for instance, hospital charges on the average no-problem childbirth are somewhere between $3000-5000.  If you want to pay that kind of money on your own, go for it.
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« Reply #19 on: December 07, 2007, 01:31:01 PM »


Take a look at what medical care costs these days; for instance,


What do you think is driving up those costs?
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« Reply #20 on: December 07, 2007, 01:43:11 PM »


Take a look at what medical care costs these days; for instance,


What do you think is driving up those costs?

Many, many things.  One of them is new technology; baby-birthing didn't used to cost so much because the only equipment available was clean towels and some boiled water.  Same with so much of modern medical care: It's far better than it used to be, but better costs money.

One other is malpractice liability.  Malpractice insurance costs a buttload (yes, that's a technical term) because of the John Edwardses of the world who feel that every bad happenstance in the world should be somebody's fault, provided they get 40% of the damages.

And another, closely related, is pre-emptive or CYA care.  Doctors often order a full battery of tests on every hangnail not because they feel that that's what is reasonable for treatment, but to forestall a ruinous malpractice suit on the .001% chance that the patient has Galloping Hooperlungster Disease, and that a smooth John Edwards type may be able to rally a know-nothing jury into awarding umpteen gazillion dollars to assuage pain and suffering.

There are other reasons; like most systemic problems in the modern world, there's no one cause, and thus no one magic bullet that will cure it.
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« Reply #21 on: December 07, 2007, 02:33:09 PM »


Your arguement is premised on the notion that we ALL HAVE INSURANCE, and that we MUST have insurance.  I'm suggesting we break that premise, and go back to a system where one could CHOOSE to have insurance, and of course, requisite for 'my plan' to function properly, the insurance industry does NOT get to set the rules (as they are now).

Take a look at what medical care costs these days; for instance, hospital charges on the average no-problem childbirth are somewhere between $3000-5000.  If you want to pay that kind of money on your own, go for it.

What's particularly interesting about child birth is that giving birth at home/at a center with a midwife is almost exactly as safe (there are a few problems they can't take care of, but it evens out by a far lower risk of infections, etc, from not being in a hospital) and costs far, far less.
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« Reply #22 on: December 07, 2007, 03:20:29 PM »



Take a look at what medical care costs these days; for instance, hospital charges on the average no-problem childbirth are somewhere between $3000-5000.  If you want to pay that kind of money on your own, go for it.

What's particularly interesting about child birth is that giving birth at home/at a center with a midwife is almost exactly as safe (there are a few problems they can't take care of, but it evens out by a far lower risk of infections, etc, from not being in a hospital) and costs far, far less.

This is true; we had our second child at such a birthing center, and it was a much better experience for that than with any of our other three.  By the time #3 came along, the center was closed.  Why?  Liability issues.
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ulthar
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« Reply #23 on: December 07, 2007, 04:57:16 PM »


Take a look at what medical care costs these days; for instance, hospital charges on the average no-problem childbirth are somewhere between $3000-5000.  If you want to pay that kind of money on your own, go for it.


What truly boggles my mind is the notion that someone ELSE should pay for ANY service I receive.

All the reasons you mentioned for the rising cost of healthcare do play a part - I agree.  I also agree that it is a large, complex system with multifaceted problems.

But you did not mention insurance explicitly, though you did mentioned a corollary cause - law suits.  These are related, perhaps in subtle ways, but the malpractice lawyers and insurance lawyers are closely allied (morally, if not directly).  Both are after something other than the best service to the sick.  Also wrapped up within the same umbrella is the cost of patents for meds, which is a completely broken system in itself, and I alluded to some of those issues in an earlier post.

The bottom line is that the true value of the service is now divorced from the cost.   We are all paying for various abuses - whether it is the abuse of a patient seeking upper end care for a runny nose or abuse in the courtroom or abuse in the insurance companies dictating how care is delivered (to maintain their profits, not the best interest of patients), it is all one. 

I stick by my basic premise: if you hide the cost from the consumer, the abusers get free reign.  I am coming at this from a much broader pespective than I think it seems at first reading of my earlier comments.  The insurance based system in which we currently find ourselves mired is a part of the problem - a big part, I contend.
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« Reply #24 on: December 07, 2007, 05:10:38 PM »

What truly boggles my mind is the notion that someone ELSE should pay for ANY service I receive.

But you do that every day, don't you?  Most government services are paid for by taxes which, in large part, you didn't pay (unless you're a lot wealthier than I assume); many commercial endeavors gear their business model toward aggregate profit, not individualized bills (remember, movie theatres are losing money on you every time you see a film without buying something at the snack bar).  That's one of the premises of civilization:  Pooling of resources for the common good -- from each according to his ability, to each according to his needs.  I'm not claiming that private insurance companies are the best (or even a good) example of this principle in practice, merely that the principle itself is nothing to decry.


Quote
I stick by my basic premise: if you hide the cost from the consumer, the abusers get free reign.  I am coming at this from a much broader pespective than I think it seems at first reading of my earlier comments.  The insurance based system in which we currently find ourselves mired is a part of the problem - a big part, I contend.

I will agree that the current "health insurance" system isn't truly insurance, in the form seen in house insurance or life insurance or car insurance... it's a pooled health services payment program.
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« Reply #25 on: December 07, 2007, 10:25:06 PM »

Ulthar, I do not mean this antagonistically.  I'm just asking you to flesh out your thoughts with a specific example.

Let's assume you are fifty, you have diabetes with end-stage kidney disease, neuropathy, foot ulcers, and some coronary disease. 
You have been diabetic since you were six.  You have taken the best care of yourself, your whole life, that you could.  You have never rebelled against taking insulin, you have always done what you could.  It wasn't perfect, but you weren't stupid about things. 

So you had your first heart attack at age 46, and your kidney disease is getting worse.  You are certainly going to need dialysis within one to two years, despite best treatment.  You work, and still are able to, but you make, let's say, fifty thousand a year, and you live alone.  No relatives to help you, and some retirement money but that's it. 

Let us not assume that you are at any point crippled from working by a cardiac or infectious event, but simply that you require hemodialysis to survive.

Let us also assume that there's no insurance, and that you are going to pay for it all yourself.  Let us also assume that you have managed to save up some modest amount in a self-made medical savings account.  Let's say, fifty grand?  I don't know.  It doesn't matter greatly.  A hundred grand.

How are you going to afford this?   Okay, you spend some of your savings.  Not sure how much dialysis costs per week, but it's not chump chnage.

Okay.  Fast foward the scenario six years.  You are having an MI, and you are being wheeled to the cath lab, which you direly need.  You are found to have five-vessel coronary disease, and you are told you need CABG.  You won't work for weeks.

How are you going to afford this?  Let's even assume that you now have enough money to cover most of the bills you just incurred -- but that's all gone now.  You still need dialysis, and you're in the second half of your fifties.

What I'm saying is that it's one thing to criticize, and another thing to have a better idea.
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Newt
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« Reply #26 on: December 07, 2007, 10:56:26 PM »

...Rebecca... If you could command the Canadian system to change, which changes would you make to improve it?

TANSTAFL - There Ain't No Such Thing As A Free Lunch.

Any improvements I can think of - greater efficiency, better truly 'universal' access - would have to involve a huge amount of funding.  That's the rub: it is fine and dandy to say that everyone should be covered for everything and to have equal effective access - but it is going to cost us.  Canada is already one of the most taxed populations in the world.  The money to improve the delivery of our health care has to come from somewhere - and that somewhere will be our own pockets.  A fact that our more socialist politicians tend to (intentionally) gloss over.  They say, "Make the Rich pay" - implying that the billionaires should be taxed at a rate that will carry the costs for all the average Joes and their families - but they neglect to give their definition of "rich", which is anyone making more than minimum wage.  That's US.

In recent years, our health care system has undergone drastic cuts and closures - for lack of funds, in the name of increased efficiency.  We do not have enough nurses, doctors, EMT's, technicians...and we are closing hospitals and centralizing services.  This does NOT improve delivery/access in a country with a small population and wide spaces!

You can have all the social safety nets you want - as long as you pay for them.  And we are paying for what we get.

It broke my Dad's heart back in the '70's when our Provincial Health Plan got rolling: he was a true "country doctor" and when bureaucrats started telling him how much time to spend with each patient (he took too long and saw too few per day), how much each service was worth (he delivered a LOT of babies and was incensed that since a c-section paid $10 more than a vaginal delivery, many doc's were opting for more sections for the money...AND our veterinarian got 3X as much for the same procedure on a cow!  The joke at the time being, "But Doctor, these are valuable animals!"),  and so on.  He called it "assembly-line medicine" and felt he could not do right by his patients under such conditions.   It is worse now.

As for "from each according to his ability, to each according to his needs..." last I knew, that was a premise of Marxist Communism, not civilization at large.  It assumes "an abundance of goods and services" produced and controlled under a communist system.  Canada may be considered fairly socialist in its general outlook, but we have not yet achieved an "abundance" of anything, let alone health care services, adequate for the entire population (again: to have equal effective access) and simply awaiting distribution.  That takes money (as converted goods?)  and a great deal of it: another "abundance" we do not have individually or to share "for the common good".

Look at the "Canadian system" as being the 'economy' model and you won't be far off. Like democracy itself, it is far from perfect, but it is the best we have, given current conditions.
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« Reply #27 on: December 08, 2007, 12:55:56 AM »

Quote
As for "from each according to his ability, to each according to his needs..." last I knew, that was a premise of Marxist Communism, not civilization at large.

You're right, the slogan is from Marx, but I think it's true outside the ideas of Marxist communism, which was a top-down enforcement of ideas hinging on class struggle.  (Believe me, I'm no fan of communism of any flavor.)  In a successful and equitable society, the citizenry buys into that idea for the common good.

Which, I suppose, leads me into admitting the problem here:  That too many people are weasels, trying to chisel the system -- ANY system.  No form of health insurance, tax equity, or other social mechanism will work well unless individuals grasp "enlightened self-interest," i.e., that what is good for the whole is also ultimately good for the individual.  When individuals are motivated by greed, no system works; when individuals are motivated by brotherly love and unselfishness, any system works.
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« Reply #28 on: December 08, 2007, 03:38:57 AM »


I think I may have mistated my position a little bit.  I realize that you can prescribe whatever you what, but as you state here, how/what is covered is the issue.  In effect, the insurance companies ARE 'telling' you what to prescribe in that you wish to do right by your patient's wallet.


I agree with what you say about removing barriers between what we buy and how much it actually costs.  I think there's a real value to a person coming in and demanding an MRI for his knee that he injured yesterday, after being told by a physician that it's not at this point an indicated test, and then being told how much it actually costs.       But how do you pass on the cost in some systematic way without certain examples being utterly devastating to people?      Perhaps there's no solution.  But you are not actually posing a realistic solution, I think.

I might also point out that no matter the agency of it, the fact is that no matter to whom I prescribe anything, I must consider how and if the person will pay for it.

When I worked for a free clinic, I had to elaborately consider the choices of antibiotics and other meds against a given patient's ability to actually obtain the med.   Doesn't do a lot of good to ask someone to take a med when they can't actually buy it, does it? 

Working for an HMO, now, I know that the common and actually useful drugs ARE affordable to everyone I see, which is admittedly a selected poplulation (the insured).  But within that framework, I am more likely to successfully treat patients because they will get what I prescribe.

Your knee-jerk reaction to formulary logic is an unrealistic one.  Within any health care system, unless resources are limitless, one is of necessity going to make certain choices, force certain emphases if need be, to serve the greatest number.  To do otherwise is irrational and wasteful.  You speak of an insurance company as though it were a separate entity looking down on me and pulling my strings.  It isn't.  The cooperative for which I work is run and lead by physicians, and the kinds of choices we make in, for example, formulary is made by us, not by an outside agency.  That is not true everywhere, granted, but I think you misapprehend my argument here.

An element that we haven't touched on yet is the influence that pharmaceutical companies have on "accredited, duly qualified physicians," and the effects these companies can have on the spending patterns of health organizations.  Certainly physicians are not incorruptible.  My point is that there are many other forces besides insurance companies that influence physician behavior, and I think that the insurance factor is one of the more easily measurable, on-the-table and potentially changeable ones. 

Which drug are you talking about (the generic not covered, the brand-name covered)?
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« Reply #29 on: December 08, 2007, 06:03:27 PM »


Ulthar, I do not mean this antagonistically.  I'm just asking you to flesh out your thoughts with a specific example.


Let me be clear.  I am not opposed to insurance - as an OPTION.  I am opposed to the current system that has the following features with which I disagree:

(1) Pretty much have to have it; most doctors/hospitals won't look at you twice if you say "I want to pay cash."  The whole system is set up around insurance, so I don't really have a choice in the matter - well, not without HUGE, EXTREME inconveniences.

(2) Second derivative growth of the insurance companies; they cannot lose - they won't lose.  If they make a bet with me that I won't get sick, then I do, they lose the bet. But they then get to back-charge me for that in the form of higher premiums.  Or worse; they make that money back by increasing the premiums of others, sick or healthy.

(3) Insurance companies have WAY too much 'say' in the way the health care industry is regulated.  So far as I know, there is no Hypocratic Oath taken by Insurance Executives.  They are a business with the sole raison d'etre being to make money - to maximize profit.  Fair enough, but when the decisions they make to do so impact lives in a negative way, I find THAT problematic.

Someone (Nate, I think) above mentioned the comparison to car/home insurance.  You have a choice at what level of coverage you want, and you negotiate the value of that coverage against the premium it will cost.  If I have full coverage on my car, the Ins. Co is gambling that I won't wreck or get wrecked.  If the car is then totaled, according to the terms of my policy, they may have to pay out. 

They cannot say, "oh but you wrecked on a gravel road - we don't cover that" or "you were not using Goodyear tires, we only cover Goodyears."  Nor can they TELL me which mechanic to go to.  Futher, the pay-out is dictated by 'fair market value' of my car - NOT BY THEM.

In health care, the situation is completely different.  Much of the cost of things is determined by the insurance companies.  And, they DO influence behaviors (of both docs and patients) by what/how they pay.  To wit, my experience above with not getting coverage when I went straight to a specialist rather than the ER even though my co-pay is structure to discourage me from going to the ER.

So, my point is that I should have a (reasonable) choice in whether or not carry health insurance.  If I choose to gamble that I will remain healthy, then I get sick, the bill is on me and me alone.  If after getting sick with a chronic condition, and I try to get insurance then, I probably CAN but at a MUCH higher premium than if I had before.  That's fair, imo.

What I don't like is how it has become somehow expected or "normal" for health insurance to be the responsibiilty of the employer (of course, be self employed, this does not help me).  People complain about declining job markets, downsizing and the like, but often fail to realize just how much it costs someone to employ another.  Take base salary, add 14% for FICA, and another 20% or so for 'expected' benefits packages such as medical coverage.  To pay someone $35,000 per year, I would go about $55,000 out of pocket.  This is just insane.

If you are a small biz unable to negotiate large 'group rates' on medical coverage, it can be pretty bad.  Sure, there have been some recent improvements, spear headed by such groups as the NFIB, that allow small timers to pool their 'companies' to negotiate group rates, but that IS fairly recent.

My problem is that I cannot affort to front an employee $35,000 per year, much less nearly $60,000.  If I hire someone, the money they earn my company would go to their salary - I don't have a pile of cash laying around just to hire someone.

And I kinda resent the notion that I am responsible for their health outside the workplace.   Workman's comp covers at-work, so I am talking about MY paying for my employee's health benefit that ONLY covers their non-work hours.  Break a leg skiing on the weekend is my responsibility how?  Gray area of course is coverage for commuting.

So, to wrap this up, your example presents someone who would benefit from insurance coverage.  The kind of policy I would choose to carry (and always opted for when I was younger, pre HMO days) was catastrophic coverage - for chronic illness, real emergencies and long stays in the hospital.  Regular doctor visits were mine out of pocket, and I was cool with that.

Quote

What I'm saying is that it's one thing to criticize, and another thing to have a better idea.


But I do have a better idea.  Get the POWER out of the hands of the insurance industry, make "HEALTH' part of "health care" again, let doctors and patients be responsible for the care given and received.  Making folks pay for "regular stuff" is part of that, in my OPINION.  I (via my premiums) should not be paying for Sally's visit to the ER just because she had a runny nose, and if given OTC meds by the doc it is paid for, versus going to Eckerd's herself she'd have to buy it.

You see, my objections are the abuses the current system fosters.  My objections do not cross the line where need is very clear.

Does this clarify?
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    FROM THE BADMOVIES.ORG ARCHIVES
    ImageThe Giant Claw - Slime drop

    Earth is visited by a GIANT ANTIMATTER SPACE BUZZARD! Gawk at the amazingly bad bird puppet, or chuckle over the silly dialog. This is one of the greatest b-movies ever made.

    Lesson Learned:
    • Osmosis: os·mo·sis (oz-mo'sis, os-) n., 1. When a bird eats something.

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