Monday, June 15, 2009

Reform School

What if every American of a certain age knew they had medical coverage; what if all they had to do was register? What if, in this program, they could choose their doctors, who would be privately or self-employed, not government workers? What if the hospitals they went to were the very ones they go to now? What might you call such a program?


And what if this coverage were extended to all Americans? What might you call that?


For those who have insurance, the only thing different would be the paperwork: it would become far less, or cease to exist. Neither the care nor the people and places providing it would change. From the point of view of the consumer, I simply see no advantage to having multitudes of companies standing between them and care, sucking money out of the system which goes into the pockets of executives, investors, and into the paychecks of tens of thousands of workers filling out forms at both ends of the transactions. No one -- NO ONE -- is talking about a national health service, ie, a plan whereby everyone goes to government-run hospital, staffed by government employees. (Well, that's not entirely true: several in Congress are comparing the so-called "public option" to the Department of Motor Vehicles. But that's completely disingenuous. The comparison, as I've said, is to Medicare.)

I'm not saying there are no arguments to be made against that "public option," or to a single payer system that enrolls everyone. Many doctors worry about losing control over reimbursement, having to accept ever-decreasing payment for service; they fear the monolithic. It's not without reason, or precedent. Funny thing is, as I've said, Medicare is already pretty much calling the shots: insurers largely take their reimbursement cues from them. Moreover, I've seen several situations in which an insurance company plays docs against one another: fearing losing their patients who are covered by a particular company, they cave to the demands to accept lower fees. It works particularly well in towns that have several competing physician groups.

It's also been a repeated theme of mine that endlessly cutting reimbursement to "providers" is a policy doomed to failure. We're about as low as it can go, if there's an expectation that smart and dedicated people will take up the caduceus. Rather -- and President Obama at least speaks the words -- the real savings will be in identifying those treatments that are the most cost-effective; and, even more importantly, finding those docs that provide the best care at the lowest cost and spreading the word.

The concept is ripe for demagogurery. "Do you want the government to get between you and your doctors?" they ask. As opposed to, what, a high-school grad in an insurers cubicle, telling the docs what they can and can't do? Like it is now? (In the linked article, it would also appear some want to prevent -- by law!! -- research into what treatments work best. To me, that's pretty hard to explain. How awful could it be to be told you can't have one operation that has been shown to be inferior to another?) (Okay, I recognize the potential problems. But if an idea is a good one, surely there's a way to implement it with safeguards.)

Reforming health care, it seems to me, is a perfect metaphor for everything that's wrong with our political system. While faintly acknowledging that for tens of millions it's not working, some in Congress nevertheless want only to maintain the status quo. Their efforts, unashamedly, are mainly limited to coming up with loaded (and disingenuous) phrases calculated to obfuscate. Given the complexities, it would be daunting even for legislators committed to comprehensive and effective reform. Would that we had some.

I'd bet very few people feel loyal to their insurers, per se. They may be loyal to their "providers" and to their preferred hospital. (Sort of. I read a study a few years ago that put the price of loyalty at, as I recall, about twenty bucks: ie, if switching docs meant saving more than that per month, it was hasta la vista, dockie.) What is the argument, from the consumers' point of view, of having insurance companies in the middle of the system? Where, specifically, is the value-added?

I fault the whole gang: Republicans, Democrats, and those in the White House. I can think of no reason why single-payer isn't on the table, except for the fact that it has so little support in Congress. But why? Whose goose is being greased? (If that's the term...) If a plan were to provide the same care we're now getting (or, hopefully, better), using the current infrastructure of doctors, nurses, clinics, and hospitals, while costing less by keeping more money in the system, why would that be bad? Because some call it.... SOCIALISM? Might not the result be more important than the name?

Some who've traveled these parts before will know I've made some suggestions. Funny thing: President Obama seems to have read them and bought everything but the single-payer part. He talks about identifying best practices; he talks about a larger role for the Medical Payment Advisory Commission. The latter, of course, is a double-sided axe; how acceptable it might be to physicians and hospitals would depend on its makeup and its responsiveness to reality. But it's the idea that is a good step. Cautiously endorsed.

[Acknowledgment: I know I said recently I didn't want my return to this blog be by way of the politics of health care. But I find myself unable to cast it out. I think I may have to get a little rubble off the desktop before I can find my way back into the mind of a surgeon.]


AlisonH said...

Oh, the rants I could go off on... The people who are so afraid that their insurance coverage would get worse can only be those who've never had to really use theirs.

Mine, in January, delayed approving Humira because it didn't want to pay for it, till my colon got so bad that there was no longer a chance of its responding to it when I finally did get the med. Result: a total colectomy to keep me from bleeding to death, when that operation might have been avoided. Then when I had a Crohn's relapse in the upper GI last month, on a holiday weekend with nobody in the office to listen to my doctor arguing that I needed Zofran to keep me from barfing, they automatically refused the Zofran. No cancer=no Zofran. Period. The fact that Phenargan doesn't work for me, that I'd had to be on two stronger IV anti-nausea meds for nearly three weeks in the hospital, proof that there was history there, didn't matter to them. Barfing from Crohn's? Crohn's doesn't really cause barfing, right? Not in their little formula.

There's more, but that's enough.

I was so glad to see the headlines talking about which lawmaker is on the take from which part of the medical industry. Go get'em, reporters! We need real health care reform and exposure and accounting for every detail that's in our way!

AlisonH said...

Not to take over your blog, but one thought to add: the simplest way to cut costs immediately in the system is to return to the banning of advertising prescription drugs. The excuse, when it became allowed, was that people needed to know what was out there. That was before Google.

Margaret WV said...

Wondering if you had any thoughts about Atul Gawande's article in The New Yorker, "The Cost Conundrum:"

Sid Schwab said...

Margaret: only that, in essence, it confirms a central point of my thesis, as I've been saying for longer than Gawande (if neither as well nor to such an audience as his): that there are some docs who do a much better job of cost effective care than others, and that the differences need to be discovered and promulgated. I'm going to write some more, about the conundrum that is fee for service vs capitized or salary-based reimbursement.

Doctors, as the article shows, could do a hell of a lot better at controlling costs. Some do it as a matter of course, even though there are no incentives to do so -- disincentives, even. Those docs always will and would, I'd guess. Others need re-directing. Whether it's greed, thoughtlessness, poor training, fear of malpractice, or a combination of all I don't know for sure. How to fix it and still have willing and able docs? Harder still.

Anonymous said...

Some people think of insurance as a guaranteed investment; an entitlement program. Whereas you pay $200 a month, or whatever, and in return the insurance company promises to ensure your health and life regardless of the cost, forever and ever Amen. In reality, insurance (the system as we know it today) is a for-profit business. Whether or not health care should be a for-profit business is a whole different blog post.

People need to learn to be health care consumers, not just sponges of money.

First, Alison, you have to realize your insurance policy is a contract between you and your insurer. They money they pay out to the providers is REAL, and in order for your insurance company to stay in business, there have to be limits. It's all in black and white in your policy, what's covered and what isn't, and what is covered but has limits or requires pre-authorization.

Not once in your comment did you mention the cost difference between your Zofran and Phenergan. I'll give you an idea.. 12 Zofran for $277.81, or 12 generic phenergan for $5.62 (since your didn't give quantity or dosage I'm being generic).

While I'd say in most cases your health is your doctor's #1 priority, as Sid has pointed out some physicians, for whatever reason, make no attempt to be cost conscious. Look at the time and effort people spend choosing what ind of car to spend their hard earned money. Then compare that to the time and effort those same people spend on educating themselves and making cost-informed decisions regarding healthcare. Whats the difference...? It's all fun and games when your spending someone else's money.

Anonymous said...

And I'll tell ya another thing. Some doctors and friggan greedy money grubbing bastards. Sid, I'm not calling you a bastard, but I would point out in your post you talked about cutting out insurance companies to keep more money in the system, and not in the hands of insurers et al. If you're cutting out the middle man, and yet keeping the money "in" the system, where does it end up? In the pockets of providers.

As the devil's advocate, insurers play a VITAL role in keeping money in the pockets of consumers, and not doctors.

Three months ago I had an anterior cervical discectomy. The surgeon I chose (very important, I chose) to do it, does not accept insurance. He says he is very good at what he does, and the insurance company won't pay him what he feels he is worth, and so to simplify the problem, he just doesn't take it. So going into this, I knew I would pay OUT OF MY OWN POCKET the cost of the surgery, and it would not be controlled by the insurance company.

I had maybe 5 or 6 visits before the surgery which included some x-rays, steroid injections, etc. This does not include the stuff like the MRIs that were ordered, just what he did in his office. Then there was the surgery itself, it his private surgery center. I got there at around 10:00am, and left for home at about 5:00pm that same day. Any idea what my bill was?

Between the surgeon and his surgery center, $88,000!!! Add it up, including time in surgery, time in office visits, he maybe spend half a day of his life involved in my life, and for him, thats worth EIGHTY EIGHT THOUSAND GOD DAMN FRIGGAN DOLLARS!!??!!

I won't go into whether or not I think it was worth it, but had I used my medical insurance, how much do you think they would have allowed him to bill? I dunno, but I can guaran-gad-damn-tee you it's nowhere near that much.

Did I mention he owns a professional sports team?

Sid Schwab said...

Mike: I don't defend those charges at all. The people who are most screwed in our system are those who have no insurance and who don't qualify for medicaid. They are the only ones who are expected to pay those unvarnished charges, and it makes no sense. My "charge" for a given operation was, for all but that category, was like vapor: the actual reimbursement, as you well know, was around a third of the so-called charge. Why those "charges" actually exist, I can't explain.

As to keeping the money "in the system." Poorly worded, perhaps. What I mean is there's no reason so much money is sucked away by insurers. Were it not the case, costs ought to be less. And if some if it were to go to hospitals, at least, I assume overall charges would go down.

Unknown said...

Hello there, Europe calling.

I live in Denmark where we have a system pretty much like the one you were describing. The state runs a single-payer system called The Health Insurance, which is a national system funded by a special tax.

This system then pays private doctors, and public hospitals. Also some special doctors are public, but most GP's have privately owned practices, and all costs are disimbursed by the state. If the public hospitals are unable to treat you within a month, you are entitled to treatment on a private hospital.

Socialism, I hear somebody cry, but then again:

I choose my own doctor, I decide which hospital I want to go to (secured by law), and I can even buy private insurance.

That's right, some people choose to buy a private additional insurance, so that they can go to the private hospitals immediately.

This system is quite cheap, as it amounts to 8% of the income tax.

Why don't you guys copy our system?

Sid Schwab said...

zxmaster: Good question. No answer. Why we (especially the conservatives) are wedded to a system based on literally hundreds and hundreds of differing insurers I have no idea. It's reflexive. To me, a public system with universal coverage (with, no doubt, some restrictions) along with the ability to purchase private insurance makes sense.

The idea of taxes to pay for it seems nearly an impossible hurdle, even though the taxes would be in lieu of premiums, and would likely be a lower total cost. Over here there's just too much cynical politicking. It's a shame, to put it mildly.

Sam Spade said...

Most don't seem to realize that, with medicaid/medicare, half of our medicine is socialized, so we have the ills of capitalism and socialism. Most other countries have collective bargaining power for drugs, but we do not. Many insured do not in fact have many choices to make, as in a capitalistic system; they have to see someone on the preferred list, and then only those doctors referred by the original one, and so forth. Our system fails in preventive care. US citizens change jobs often, so insurers see no incentive to save money for their competitors via preventive medicine.

The VA system has extremely low admin costs, yet provides very good care overall.

Mike, I could see a mutual insurance company for health care, but I am not comfortable with the conflict of interest I have with for-profit insurers. Every dollar they spend on me comes off of their bottom line.

Anonymous said...
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Anonymous said...

Sam: I don't like the idea at all of for profit insurers, but unfortunately that is all we have to work with now. I like the idea of a nationalized health system, yet in what form I don't know. Maybe a Medicare Part-D type system where a basic coverage is afforded to all, but one can purchase premium services. Really, I like the system that zxmaster described.

Anonymous said...

No, it's great you're taking the time to write on this issue! This is not a simple political topic -- it's a raging issue.

I agree 100 %. The thing is, how do we provide input into this issue? Who can we write to? Can we as a nation write letters to obama? How can we as a nation of physicians, former physicians and medical students put our input into the decisions of this "Obama care" plan?

We need to do something. This is getting ridiculous.

Anonymous said...

It strikes me that we already have the single payer system that's been described. It's called public schools, and the providers are the teachers. Are there some good teachers? Of course. If you're able to send your child to a private school do you send them there? Of course.

Teachers aren't employed by the federal government, but now they have more and more control over them. At least the control the NEA will allow. Oh, crap, that's no control.

Can you imagine the government being responsible for oversight of providers? When's the last time you heard of a teacher getting fired for something less than rape?

Public sounds so great - until the best providers start opting for private practice outside the system. It will happen. Already 28% of Medicaid patients have difficulty finding a primary doctor. Why? Because the best just see privately insured patients.

Look up the subject of medical tourism and see who the primary patients are: socialized medical system patients. Why? Because there's a waiting list in their home country.

If you know someone that had a hip or knee replacement, consider how long it took to get it. Chances are it was long enough for the patient to get their affairs in order for the rehab. In the social systems its that time plus eight months. What's a bit of limping, pain, and agony for the sake of a public system?

Hey, the doctors are busy, paid well, they're not going to get fired, and we all get the equivalent of public school educations. Sign you up, right?

Sid Schwab said...

You appear not to understand the difference between single payer and a socialized system. In your defense, it's true of lots of people, even ones who should know better.