<p>Hayden…thanks for your post…</p>
<p>Sounds logical to me…</p>
<p>Jym626…I am sorry to read that you can’t afford medicaid patients…
Those patients are at the lowest end of society money wise…many are people with special
needs.</p>
<p>I know you know this…just bugs me…the way we take care of people in our society.</p>
<p>hayden, thoughtful suggestions. It’s clear that we’re not going to get single-payer any time soon; the idea that the free market always provides the best solution is just too entrenched, even when it clearly doesn’t. So we’re going to have to take a patchwork approach.</p>
<p>
</p>
<p>This IMO is the single best thing we could do. In addition to the benefits you name, it would also break the insurance industry’s stranglehold on the market. Anthem et al might behave better if they knew their subscribers had a real alternative. Who knows, the CEOs might even discover they can scrape by on a couple of million a year.</p>
<p>
</p>
<p>Behind SCOTUS’ closed doors, this could be the most hotly-debated issue of the whole case. [By overwhelming margins](<a href=“http://spotlight.ipsos-na.com/wp-content/uploads/2012/04/PPACA-components1.jpg”>http://spotlight.ipsos-na.com/wp-content/uploads/2012/04/PPACA-components1.jpg</a>), the American people favor this element of the ACA (and almost every other element). Even the most ardent opponents of reform won’t say that insurance companies should be allowed to deny coverage to sick people. </p>
<p>But here’s the rub – it can’t be done without the individual mandate that everyone purchase insurance. Without the mandate, healthy people would have no reason to pay premiums, knowing that they could buy insurance when they need it. It would be like allowing people to buy car insurance at the scene of the accident. And without a large pool of healthy subscribers to offset the cost of caring for the sick, the insurers’ costs, and their premiums, would probably get so high that even the sick couldn’t afford them. We could end up with more uninsured than we have now. </p>
<p>The premise of the law was that insurers would be required to cover everyone, and in return they’d be guaranteed millions of new customers, new customers who on average are younger and healthier (and more profitable) than their current customers. But without the mandate, the whole thing falls apart.</p>
<p>
</p>
<p>But, we don’t HAVE a freemarket system, now. I don’t even know what that means when people talk about having a “free-market” system. We don’t have that.</p>
<p>I like what the taiwanese have chosen to do. It’s simple and easy. The simpler the better.</p>
<p>Of course, that’s not even on the table.</p>
<p>We should all just have medicare, including congress and the military, including people who are now on medicaid. </p>
<p>I do believe we need to do something about the extreme costs of medical school and then we should just all have medicare.</p>
<p>It doesn’t have to be so complicated. It’s like the tax code. The progressive flat rate taxes with no loopholes.</p>
<p>All the rigamarole is what makes it political when it should be as simple as sitting down at the kitchen table with your accounts and balancing the books.</p>
<p>Great post… LasMa…</p>
<p>Yes…the mandate is key…</p>
<p>Zoos,
There is no recourse for a no-show/missed appointment for a Medicaid patient. There is no coverage since no service was provided and the patient cannot be billed. And what I do requires many hours to be set aside for one person, and payment to an assistant as well. So it is a large net loss when a person fails to show.</p>
<p>Dstark,
I make no apologies. I was a Medicaid provider for quite a while before I had to make the decision to discontinue my contract, as the restrictions on the services/units made it impossible for me to provide the kind of service I am willing to sign my name to. Its like saying you need 25 stitches to close your wound but we will only allow 3.</p>
<p>I do plenty of volunteer work in other capacities, and see a lot of Medicare clients that others will not. But there is a limit to what one can do. I respect those providers that can continue to provide Medicaid services. I have done my time.</p>
<p>I never thought you needed to apologize. I am sure you are doing more for society than I am.</p>
<p>My office pays 575 Medicaid providers. The reimbursement rates are too low. We all know that. We try to make up for that by making sure payment is timely. And for the most part, it is. But Medicaid clients are the most difficult part of the population - there really is no question about that.</p>
<p>We also have a Medicaid Managed Care Pilot. The program receives payment whether the client shows up or not - it’s a “capitated” system. The system is supposed to coordinate care better - with gatekeepers, and “health care homes”, etc., etc. Our experience is clients are more likely to miss appointments, and less likely to show up. There is no incentive for providers to create systems (reminders, pre-appointment calls, etc.) whereby patients are encouraged to do so. Coordination of care is less likely to happen (if we really wanted that to happen, we’d PAY for successful referrals). </p>
<p>It’s one of the reasons the Taiwanese system (for example) is attractive. But I don’t know how they deal with mentally ill or chemically dependent clients, or clients who miss appointments simply because they are too sick. The French system pays doctors to make house calls. Medicare hospice pays nurses to make housecalls. </p>
<p>But these are all solvable problems. As a nation, we just have to want to solve them.</p>
<p>There is an attitude of survival of the fittest.</p>
<p>I know people who have relatives that were very sick…and luckily…they had good healthcare…</p>
<p>The cost of the care ran up to $1 million. </p>
<p>Yet…these people don’t believe in universal healthcare.</p>
<p>They have money. They have had good careers. So there must be something wrong with people who don’t have money…who don’t have good healthcare.</p>
<p>The people that don’t have money…too bad.</p>
<p>
There are a lot of people who believe, just as strongly as some here believe insurance companies are populated by demons, that the government doesn’t do a very good with managing healthcare, either. That case can be made quite easily.</p>
<p>I DON’T believe insurance companies are populated by demons. It would be easy to deal with if they were. Exorcise the demons, and things would be fine. No, the problem is a system of incentives set up whereby it makes sense to delay and deny care, provide substandard care, and then pass along the resulting problems to the next insurance company, or to the government (i.e. Medicaid - that’s exactly what I described in my friend’s case - and then we blame Medicaid for not effectively providing the care that the insurance companies essentially shunted off to them.) And a system that turns employers into shoppers for insurance with the resultant competitive “race to the bottom”. And doctors and hospitals forced to follow the Hypocritical Oath rather than the Hippocratic one. </p>
<p>Demons would be easier.</p>
<p>It doesn’t have to be this way.</p>
<p>jym, do you see any difference between Medicaid and Medicare in terms of prompt reimbursement?</p>
<p>Well…zoosermom…</p>
<p>My daughter worked for a health insurance company.</p>
<p>I don’t think health insurance companies are occupied by demons.</p>
<p>The self interest of an insurance company might be different than the interest of society.</p>
<p>hayden,
I don’t see medicaid patients so I cannot answer your question. Apologies.</p>
<p>
The same could be said of any bureaucratic operation.</p>
<p>There often isn’t any motivation for people with no accountability to do a good and efficient job.</p>
<p>Ok…so you think private health insurance companies would do a better job than the government in providing a healthcare payment system?</p>
<p>If so, why?</p>
<p>
That’s not what I said. Don’t do that.</p>
<p>No, insurance companies are no populated by demons. But they are subject to</p>
<p>[Perverse</a> Incentives in Healthcare](<a href=“HuffPost - Breaking News, U.S. and World News | HuffPost”>Perverse Incentives in Healthcare | HuffPost Latest News)</p>
<p>“What would you do instead? I have to assume that, like most opponents of reform, you really don’t have a better idea, or any idea at all.”</p>
<p>How 'bout doing something obvious, like cutting healthcare costs for the rich and letting the benefits trickle-down to those less fortunate? A 100% medical care tax credit for those earning >$500K would do that.</p>
<p>i wrote…“If so, why?”</p>
<p>Ok…zoosermom…</p>
<p>I am multitasking here. </p>
<p>What do you think?</p>
<p>What do you want to see done with our healthcare system? If ANYTHING? ;)</p>
<p>"It doesn’t have to be so complicated. It’s like the tax code. The progressive flat rate taxes with no loopholes.</p>
<p>All the rigamarole is what makes it political when it should be as simple as sitting down at the kitchen table with your accounts and balancing the books. "</p>
<p>With health care and other complex issues, things like this (or the flat tax for that matter) fall under something HL Mencken said many years ago “For every problem, there is a solution that is simple, clear and straightforward…and dead wrong”.</p>
<p>The problem with health care is it is not a serialized process nor does it lend itself to efficiencies of scale entirely. What the free market people leave out is that ‘competition’ in health care isn’t likely to happen, if there is any kind of competition it is on quality of care, not on price (where you do see price competition tends to be lifestyle treatments not covered under insurance, like boob jobs, nose jobs, tummy tucks, and laser eye treatments and those tend to be pretty routine; though quite frankly I would never go to one of those places advertising 400 buck laser eye treatments, for a number of reasons). The outcomes for serious medicine is not guaranteed, when you have heart disease or cancer it varies what works, what doesn’t, and how much it is going to cost. </p>
<p>Likewise, our health care system is weighted towards treating disease rather then preventing it. Most of the money spent on cancer research, numbers i saw say about 75-80%, go towards treating it, not prevention. We treat diabetes with drugs and such, when large percentages of the cases are caused by bad lifestyle/nutrition and the like, but for every dollar spent on ‘curing’ diabetes maybe 5c is spent on trying to find ways to prevent it, and so forth…and medical training in terms of preventing disease is a joke, quite frankly, most doctors today are saying the same thing my GP did 30 years ago, lose weight, exercise, don’t smoke, drink in moderation and so forth…and if you are oveweight, it is ‘eat less’, and traditional medicine is still obsessed with things like BMI tables, rather then in fitness and health for example…put it this way, I’ll ask any MD’s on here who might have graduated or kept up with med schools, how many of them put emphasis on training doctors in prevention, in nutrition, etc? Not many years ago, Tufts medical school was one of the few that even had a nutrition track for med students…</p>
<p>The point is there are a lot of problems, and reforming health care requires looking at the whole picture not the fragmented mess we have. Those who argue, for example, we need competition in health insurance ignore the realities of providing insurance, how expensive it is to capitalize and so forth, and that if competition happens, if it drives down the cost of premiums, to keep profit margins the companies will prob compromise care, making the insurance useless (I have seen signs posted around neighborhoods now, for example, claiming to have ‘family health insurance’ for 69 bucks a month…and basically it is a scam, it offers some discounts and such, but doesn’t do much else…which the price is a giveaway (standard family coverage in toto is about 15k these days a year…). It is not only unlikely a lot of firms would enter assuming, for example, you do this across the country (rather then state by state), and if they do compete it is likely to be a false savings.</p>
<p>The real problem with the payer side is the motley of payers means all kinds of weird things happen. Medicare and Medicaid dictate rates they will pay, and to ‘save money’ they basically tell doctors and providers “this is what we will pay”…if they accept it, the providers make up the difference by overbilling people with private insurance, the same thing they do to uninsured patients they have to cover, they cost shift it to insurance companies (want to know why getting treated for a sprained ankle costs so much? You got it, those 100 buck aspirins are part of the cost shifting). Likewise, in the current system if you are fouled by a doctor in a network, you have little recourse (cute things some MD’s do, like have multiple tax id’s, you go to a doctor in your network, they submit payment at out of network rates using the different tax id because it pays more, and guess who gets to pay the rest? You do, and your insurance company will tell you “not my problem”…</p>
<p>On the provider side, there are all kinds of issues. Doctors often have pieces of MRI centers, surgical centers and the like, and even though they by law are usually required to disclose it, if a doctor tells you you need an MRI, are you going to question it? Meanwhile, there is major conflict of interest there, since they have incentive to send people for treatment where they benefit. Talk to guys who run the MRI units at hospitals and they will tell you that people in the hospital are encouraged to keep the units busy, since the units are expensive and to pay for them they need to keep the assembly line going…and yes, there is also the issue of cya care by doctors, it is real, though it isn’t quite as prevalent as some claim (even where malpractice liability is limited by law, there has been no sign of slackening in cya medicine, for example, nor have malpractice liability insurance rates slowed down or stopped rising.</p>
<p>Single payer systems have some advantages, one of which is there isn’t the cost shifting (unless someone chooses to buy private insurance and can afford it), since there is only one payer and there generally is a lot less incentive to do what private health insurance companies do including fighting paying bills, conveniently losing payments, etc (things consulting companies like McKimsey have told them to do, as a way to increase profitability, or refuse to pay and then say “sue me”…). There is uniformity, you know what to expect and it can cut down overhead of duplicated efforts and so forth you have with the current system; and employers don’t spend time and resources managing health care. It also gives you the largest pool you can have, with the current fragmented system you have things like medicare, that represents mostly people likely to need medical care, and even the largest group plans covering 10,000 people has less of a base then a single payer one…</p>
<p>Downside is single payer systems, especially government run ones, have problems because of politics. The VA is a classic example of this, often VA hospitals are put in places because some congressmen wants it in his district, rather then where needed, a number of years ago they decided to put up a huge VA complex in the boston area, when the VA already had too many beds there, and this goes on with state run programs, where often where there is critical need politics causes those to be ignored. For example, a bright new shiny hospital is put into a relatively rural area thanks to the influence of congress people (assuming the US adopts this) while an inner city area with need of beds but little political power is left with little or nothing, and so forth. </p>
<p>I hear the argument about the wait for elective procedures and so forth, but I wonder how many people have dealt with private insurance with those? How many of them got one of those done, and then get hit by a whopping bill they weren’t expecting? How many of them had to fight to get the procedure at all, let alone wait for it, literally having to fight back and forth to get it covered? Is the inconvenience of waiting for a hip replacement worse then a)not getting it at all or b)ending up paying huge bills you shouldn’t be?</p>
<p>There also is the politics of medicine, where doctors are going to head for the more lucrative specialties, rather then internal medicine/family medicine, because that is where there is better compensation. Given the cost of medical school and the kind of debt doctors have (though these days seems like anyone going to higher ed faces that,music students, who face some of the crappiest job prospects of any field, that go to the kind of schools that give them a shot of making it, are paying ivy league level tuitions, and even with aid can come out with significant debt) not surprising, but it leads to all kinds of things that aren’t optimal. If I go to a doctor with a sore throat, do I need an ENT to diagnose it at ENT rates? Unfortunately, with the number of specialists increasing and internal medicine doctors/family doctors declining, it is a likely situation in many practices. </p>
<p>It also raises questions about who is treating you. If I get a case of poison ivy that needs prescription treatment, do I need to see an MD, or could a nurse practioner or even physicians assistant handle it? If I go in with a fever and a sore throat, and a strep test comes up positive, do I need a doctor to give me a prescription, or could a NP do it? If I cut my hand and need a tetanus shot and a couple of stitches, do I need a doctor for that?</p>
<p>Then too are the questions about what is effective medicine and what isn’t. In our current system MD’s have significant reason to prescribe name brand medicines or the latest and greatest, when they may not be any more effective then generics or older ones (and not to mention the idiocy of allowing prescription drug companies to advertise their products…if what to prescribe is best left to a doctor, why have tv ads convincing older people that celebrex will allow them to run around and jump for joy again?).</p>
<p>Then we have the ’ blame the consumer’ crap, that we use ‘too much medicine’…but how can people be using too much health care, when that decision goes through doctors? We don’t choose the medicines we take, the course of treatment, we don’t have the knowledge to make those choices …I have heard blowhards like Chris Christie (who should talk, the man is a walking medical disaster area waiting to strike) and Rudy Giuliani blaming people for ‘using too much medicine’, driving up costs…that is making the argument that if a kid is sick, don’t take him/her to the doctor to ‘save money’, it is like saying "oh, my stomach hurts, well, not in the budget, just sit and live with it’ as if getting medical care is like the decision to buy a new car <em>grrr</em>…</p>
<p>And some of them are going to be troubling, for a number of reasons. If significant portions of medicine are spent prolonging the last month of life, what should we be doing? Should we be spending 100k to revive someone with catastrophic heart failure whose heart is pretty much shot? Should we spend money and time keeping someone on life support like a Terri Schiavo or reviving someone with stage IV cancer that has spread to all parts of their body? Likewise, we have extended people’s lives, but one of the costs we face is we have extended lives, but they also are lives spent dependent on costly medical care, where the quality of life hasn’t necessarily been extended (it is roughly analogous to what is going on with wounded from Iraq and so forth, the success rate in saving lives that otherwise would have been lost is staggering in how good they have done, but it also has left large numbers of soldiers who in past conflicts would have died, needing significant long term care for brain injuries and so forth…)…how do we handle that, and it isn’t a small cost?</p>
<p>It isn’t going to be simple, there are too many stakeholders (want to tell someone that granny or mom and dad should be made comfortable and all nature to take its course, rather then trying everything to keep them alive…), are you going to tell doctors they can’t expect to make good money after spending the time and training it takes to get there, especially when they have 200k in debt? Are you going to tell pharm companies they can’t charge 2000 bucks a year for a cancer drug? Are you going to convince the rock hard Ayn Rand types that medical care should be a universal thing, rather then the province of those (in their eyes, not mine) smart enough and clever enough to be able to pay for it? </p>
<p>My guess is we won’t have resolution until all the band aids and patches out there have fallen (and yes, Obamacare is a band aid, and not a particularly good one), it won’t be until everyone has experienced the realities of our current system, losing health insurance because they lose a job or their employer drops it, facing financial devastation when a family member gets sick and so forth…even though we have 10’s of millions facing these and other issues, until ‘the middle’ sees that kind of pain, nothing will be done…and it is going to be a painful transition when it happens. </p>
<p>Mini, Nicely put btw, yes, Demons would be a lot easier. The problem is the real demons are the clouds that are around the issue, it is not clear, it is not simple and there in the current system are too many competing interests that run across one another. The best i heard at one point was some delta bravo from down in the bible belt, some congressman from one of those states, who basically said the US should adopt the health care system they use in China, that China’s economy is booming and in healthcare as in other things, the US should be copying what they do (for the record, China’s health care system is basically non existent, it is not a model for anything, and for most of China’s population, it doesn’t exist)…</p>
