The Money Mustache Community
General Discussion => Welcome and General Discussion => Topic started by: EnjoyIt on March 07, 2017, 07:57:15 AM
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There is no conversation about the cost of care, we only talk about who will pay for it. It makes no difference if it is Obamacare or Trumpcare. In the long run the system is fucked because the cost is too high. Too much bureaucracy in our healthcare. Until we have complete transparency in cost, decrease regulatory waste, and remove the insurance middleman from most medical issues, the cost will continue to rise. There is no reason why gauze should cost $50 dollars at a hospital and $3 at a pharmacy. There is no reason why a physician can't tell their patient how much a procedure will cost because it varies by different insurance companies.
I just looked at Anthem and they made $18 billion last year and another $18 billion in 2015. Interestingly they made $14 billion in 2013 so Obamacare is great for the insurance companies. I'm sure blue cross and the other players are not that far off. These companies are like dirty bookies skimming cash from the top increasing the cost of healthcare for everyone. I just looked at the balance sheet for a large non for profit hospital system in my area. According to their figures Medicare/Medicaid together cover about 81% of what it costs to care for those patients. If every patient was on government insurance, that hospital would be out of business. Therefor single payer is not the answer either. The cost of care needs to come down and it must happen soon. The system is imploding and it makes no difference which president cares the most.
We need to stop talking about who will pay and start talking about how much we all pay.
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Yes, agree very much. There shouldn't be a "co-pay" if I can simply walk into the doctor for an office visit, pay him directly, and not have to run anything through insurance. I simply pay him the $20 or $30 or whatever he/she would charge. I don't need it to be run through insurance. Because realistically, a doctor visit is not worth $100 that is charged---it's because insurance is in the middle of it trying to make their profit.
Insurance companies are in the business to make money, and somehow have managed to wedge themselves into the hospital/doctor/patient relationship. I've never seen anything like it in all my years alive.
What I do find interesting is that no (and I'm not trying to start a debate here) candidate has ever brought up the issue of pushing insurance companies out of the picture. They are just so entrenched in everything. And there is no reason why families should go bankrupt/destitute over medical bills. That's just wrong.
I'll give some recent examples about waste. Husband went for annual physical. While waiting, he had to fill out forms. One was a "depression screen." What he didn't know was that he was charged for filling out that form--$40! Yikes!
Another, he had to go learn about how to give himself a shot. So, he goes to our local hospital into room # xxxx, only to find out that room #xxxx is a very, very large conference-style/large gathering room manned by a receptionist and, I believe, a nurse, who show him how to give himself a shot, and asked him if he knows how to read food labels. Talk about waste. He mentioned stuff like this could have simply been done in the doctor's office.
I could go on and on, but I'm sure there are lots of other people on hear who have stories to tell. :)
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It sounds as though you are still advocating fee-for-service.
The most radical proposals for changing our system involve dropping that model entirely.
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if we're going to socialize medicine, we have to socialize the system. don't make me pay out of pocket 200k for a degree, and then make me fight for every dollar I get. I have to charge $100 a visit because by the time it's all said and done, I'll make $33 or so.
you either have to socialize the whole thing (free medical education, get paid a living wage to not work shitty hours, etc) or go full consumerism (nobody gets free care). but we have hospitals who treat anyone that can't afford it has to pay for supplies and staff by milking the people that can.
It's bullshit.
Source: I'm an American Doctor. Medicare pays me like $18 a visit.
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It sounds as though you are still advocating fee-for-service.
The most radical proposals for changing our system involve dropping that model entirely.
Once again you confused the picture and talk about how we pay for healthcare instead of talking about cost. Capitation was a model this country attempted a few decades ago. Unfortunately it failed due to the rising costs of healthcare. Remember the money must come from somewhere. Someone must pay for the care no matter what model we use. You want the rich and middle class to pay for it then fine, but the cost of care must still come down otherwise it will continue outpacing the rich and middle class's desire to continue funding it for everyone else and themselves.
I think if you have a sore throat and go to your doctor then fee for service is exactly what we want. If you have a true medical emergency then we need to make sure you don't go bankrupt over it which is where insurance must come into play. The reason fee for service isn't working is because there is no transparency over the fee and therefor no need to compete and lower the cost to the patient. Look at the post above by Itt. The reason why the visit is so expensive is because the health insurance company needs to get their cut. Plus regulations have forced this doctor to have a very expensive computer system and a billing/coding operation all which costs money. I'm sure Itt would have rather cut his insurance premiums by 75% and instead paid $50 for the visit. The doc would have been thrilled to cut his expenses and receive $50 instead of having to fight with the insurance company to get $100 and then pay for all the waste and bureaucracy in his office.
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"Who knew our healthcare system could be so complicated?"-President Donald Trump
-part of the current problem
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Still no conversation about the cost of care, only talking about who will pay for it. It makes no difference if it is Obamacare or Trumpcare. In the long run the system is fucked because the cost is too high. Too much bureaucracy in our healthcare. Until we have complete transparency in cost, decrease regulatory waste, and remove the insurance middleman from most medical issues, the cost will continue to rise. There is no reason why gauze should cost $50 dollars at a hospital and $3 at a pharmacy. There is no reason why a physician can't tell their patient how much a procedure will cost because it varies by different insurance companies.We need to stop talking about who will pay and start talking about how much we all pay.
Yes. Exactly
I just looked at the balance sheet for a large non for profit hospital system in my area. According to their figures Medicare/Medicaid together cover about 81% of what it costs to care for those patients. If every patient was on government insurance, that hospital would be out of business. Therefor single payer is not the answer either. The cost of care needs to come down and it must happen soon. The system is imploding and it makes no difference which president cares the most.
We need to stop talking about who will pay and start talking about how much we all pay.
Well, not exactly. Medicare and Medicaid have a margin built into their pricing so it should cover the cost of care. The hospital systems, even the "not for profit systems" are at fault if they cannot provide care in that pricing. Well, at least to some extent.
Ever wonder why hospital systems continually put up new buildings and renovate their hospitals? Pull up some hospital system's 990's and check out how much their administration makes.
Yes the insurance industry is a problem, but the hospitals are equally if not more culpable.IMHO
Bean counter, you are correct that the hospitals are at fault for not making a profit out of the low reimbursement from medicare/medicaid. That is why more patients are being sent home instead of being admitted, length of stay is being decreased so that you may be discharged at 11pm at night and have some tests still done as out patient and even still the cost of care outpaces reimbursement. Take a look inside of a hospital. Entire departments exist just to comply with regulatory burdens that provide no patient benefit and even sometimes cause harm to the patient. Another department exists for coding and billing, and fighting with medicare/medicaid to pay the bill. This cost is offset by self pay and the insured.
Today more and more providers are dropping medicare/medicaid. Some are dropping insurance all together and going for self pay and have the patient send the bill to the insurance company. Life is usually easier for those providers. In my town free standing Emergency Departments and Urgent cares are all over the place. They do not take medicare/medicaid because it is just not cost effective. I am still waiting for the day a hospital opens up that stops taking medicare/medicaid patients. There is a free standing ED down the street that has a very transparent pricing model. $800, $1000, $1200 depending on the complexity of care provided. You know exactly how much you will pay by going in there. Compare that to the nearby Hospital where you will pay anywhere near $2k-$10k depending on how lucky you are with in network vs out of network and the tests ordered.
Government insurance is not the answer. Cutting cost is the answer. Who will pay for care is a secondary problem.
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What about HCAHPS. My hospital spends money on private rooms with 90 cable channels and room service in order to get 5% more reimbursement. They even have comment cards like you get at Denny's. This is despite the fact that patient satisfaction actually increases mortality. What if they spent that money on medical research that can actually help people?
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What about HCAHPS. My hospital spends money on private rooms with 90 cable channels and room service in order to get 5% more reimbursement. They even have comment cards like you get at Denny's. This is despite the fact that patient satisfaction actually increases mortality. What if they spent that money on medical research that can actually help people?
HCAPS is a perfect example of waste. All the hospitals are trying to increase patient satisfaction paying tons of money on collecting survey results and trying to improve them. Interestingly enough the way patient satisfaction works is that only the top hospitals get an extra few percent in reimbursement. Therefor the rest of the hospitals are just wasting their money.
Another example of waste is the time spent clicking away on a computer by the nurse. Nurses today must check so many boxes on a computer that they have less time to spend with patients. Therefor hospitals must hire more nurses and more techs to pick up the slack. Plus every nurse needs to have their own computer workstation which can cost as much as $10k for a portable workstation or (computer on wheels.)
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Another example of waste is the time spent clicking away on a computer by the nurse. Nurses today must check so many boxes on a computer that they have less time to spend with patients. Therefor hospitals must hire more nurses and more techs to pick up the slack. Plus every nurse needs to have their own computer workstation which can cost as much as $10k for a portable workstation or (computer on wheels.)
Agree, although you are not allowed to refer to them as COWs anymore because you might offend someone (I wish I was joking but I'm not). Anyway these are quickly being replaced with iPads.
Another source of nursing waste is to pay a nurse to do something an aide can do so that your hospital can brag about having better RN staffing ratios and get magnet status.
Also having layers of administration doesn't help.
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We need to fix the drug industry too.
It is ridiculous that it takes nearly a decade to bring a drug to the market with all of the meetings, tests, trials, more meetings.
If we want cheap drugs, we need cheap drug testing.
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I agree completely that the problem is not going to be solved by switching around insurance rules. Unfortunately, in the US we seem to believe that we should follow free market principles in everything we do. Thus, health care is designed as a capitalistic free-market system where insurance providers and hospitals supposedly compete to offer the best service at the lowest price. That sounds great until you realize that health care is not a free market system, rather, it is a captive market system. Yes, you can afford to be selective when it comes to more passive ailments like the flu or a broken bone, but people do not have the opportunity to shop around for the best price when they have a life-threatening emergency such as a heart attack, or God forbid, cancer. And sure enough, it is the larger life-threatening illnesses that will drive any ordinary person to bankruptcy without proper insurance. Given the nature of those illnesses, hospitals have no incentive to lower costs, as patients (or their insurance) will really have no choice but to pay whatever the hospital asks.
It's time we start looking at catastrophic health-care as a human right, similar to how we look at our needs for clean water, affordable electricity, available transportation, police and fire protection, and legal representation. Until we do, health care costs will continue to rise (in a similar fashion to college education costs) because people simply do not have the option of 'shopping around'.
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EnjoyIt for president!
I've been complaining (probably just to myself) about the insurance middleman for routine care for a long time.
I asked my chiropractor once why he doesn't just go cash only. He'd save money on extra computers and aides to manage insurance claims and cut his costs. He said many people won't go if it's not covered by insurance.
Same thing with some "alternative" care. People won't try going to get acupuncture or homeopathy or other things line that because "it's not covered by insurance", even though it may be more effective care for their particular condition, and in the long run cost less because it may actually fix their issue. (I have personal experience with this.)
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People talk about the high cost of healthcare all the time. Maybe you're not paying attention to those conversations, which often lose people when they veer into the highly technical, but it is not as if they aren't happening.
The challenge with implementing a blanket charge to reduce cost is that it is really, really, hard. There are thousands of unintended negative consequences that will come with a reduction of costs and people who work in healthcare policy absolutely know that and are thinking of that when they consider ways to reduce costs. This is why there is no straightforward answer for how we approach this problem.
One example of this: for whatever reason, in the U.S., we've decided that we want healthcare to be one of our main industries for employing people and paying them a livable wage. Now, you might not think that's right, but the fact is that is where we are at this point. Healthcare is a huge industry that supports middle-class (and up) wages that in turn support many other industries (e.g., real estate/housing, food service, transportation, construction/building, medical technologies, and on and on). A drastic and quick reduction in healthcare costs would lead to millions of people losing their jobs and many other experiencing a substantial decrease in pay and benefits, the effects of which would ripple out to many other industries not formally tied to healthcare. This would almost certainly throw our entire economy into a major recession.
So we know that reducing costs needs to happen gradually, using multiple methods that are implemented strategically so as not to shock the system in ways that lead to a huge economic downturn. One of the promising methods to reduce costs is an all-payer model. Maryland has successfully used such a model for decades. More recently, they've added a fixed revenue model to limit growth in costs. These methods have been very successful and hold great promise for reducing costs in other states.
That answer is probably not the passionate rallying cry you're looking for, but the truth is that in reality these are the kinds of boring policies that actually lead to cost reductions over time, without causing major economic upset.
If you're truly interested in this topic, I suggest you look at the Center for Medicare & Medicaid Innovation Center which promotes and conducts all sorts of research on this very topic. It's a great resource for learning more about what is going on at the federal and state levels to address this issue.
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From my understanding, as a former resident of a 'single payer system' country and as a person working in the health insurance industry, I believe it's a complicated situation that can't really be boiled down to a single line item. But I would suggest that one big issue seems to be economy of scale - or rather lack thereof.
In single payer systems the government has bulk buying power with pharmaceutical companies, hospitals, medical equipment providers and so on. Companies compete for the government contracts since the sheer scale of the contract makes it worth their while - even if the reimbursements/profit margins are lower than they would receive for individual or smaller contracts - on the that scale it makes them a profit. Medicaid/Medicare already does this.
The other issue seems to be that individual employers are forced to pick up the administration of benefits where in a single payer system the government would. I realize that there are doubts about the efficiency of government in the USA but bear with me a moment. In single payer systems you have, again, economy of scale. In the US system employers attempt to grasp at the economy of scale by employing middle men. Instead of employing 2 dozen HR personnel they can simply contract an HR Outsourcing firm at a lower cost. Instead of a doctor hiring ten receptionists they can simply contract a medical billing company at a lower cost. Due to the nature of private business each 'middle man' must, by necessity, take their cut. It wouldn't necessarily be cheaper for the employer to hire all those HR staff members.
I don't have a solution to this. Much smarter people than I have developed ideas and theories - I'm simply pointing out that there's many moving parts when talking about lowering cost to consumers for healthcare in the US.
The Atlantic claims US Healthcare costs are already down 2 Trillion (https://www.theatlantic.com/business/archive/2015/04/how-america-reduced-health-care-spending-by-2-trillion/390771/).
The Fiscal Times has a list (http://www.thefiscaltimes.com/2016/04/12/5-Ways-We-re-Bringing-Down-Cost-Healthcare) of things that are already happening to lower costs.
Harvard Business Review has this (https://hbr.org/2015/10/how-the-u-s-can-reduce-waste-in-health-care-spending-by-1-trillion) article about how much costs could be lowered via various avenues
This Fortune article (http://fortune.com/2015/01/12/how-to-cut-americas-crazy-high-health-care-costs/) seems to boil down to increasing Market Competition.
Take your pick - they're probably all worth a try.
At the end of the day I would keep in mind that healthcare is a social good. We don't let people die in the streets, instead we let the hospital go unpaid when they declare bankruptcy after receiving treatment which increases costs for those who can pay, and I doubt anyone is suggesting that we should withhold treatment. It's never going to be as easy as letting the free market decide - healthcare is not always something that one can shop around for (as in cases of life and death emergencies with the patient may not even be conscious) - but we can put systems in place to increase competition and pricing (and health outcome) transparency.
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Reducing costs in health care involves having difficult conversations that people don't want to have, because we don't deal with death very well in our culture. We see death as an abomination to be fought at all costs instead of a necessary part of life. I think something like 50% of your health care dollars are spent in the last 6 months of your life. I am all for doing something like this guy personally: https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/ (https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/)
Just making sure people make an end of life plan would save vast amounts of money without changing anything else. I don't want to spend the last few months or years of my life in a hospital undergoing procedures. Let me go.
But no. Then people start screaming about death panels.
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Last night I saw a commercial during the local news for a health care service company. Basically a no frills basic service in their clinic or through house calls with a set price list for basic labs/services. They don't take insurance and are selling that as their means of keeping costs low. From their website, it looks like they only treat basic ailments but it is an interesting concept and a hell of a lot cheaper than what my employer will be paying for the annual exam and labs that I just had. I'd be interested to see if this sort of thing catches on.
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We need to fix the drug industry too.
It is ridiculous that it takes nearly a decade to bring a drug to the market with all of the meetings, tests, trials, more meetings.
If we want cheap drugs, we need cheap drug testing.
I understand where you're coming from, but I think drug testing is one of those areas you really can't skimp out on. Remember thalidomide? Diethylstilbestrol? Without "all the meetings, tests, trials, more meetings" you can end up with drug products that permanently impact people, leave them disabled, at high risk of cancer, or who know what else, and continue to impact the and their families for generations after the fact. And that's just on the drug end of things. Without proper vetting, ethics, and oversight of the trials and experimentation, you end up with stuff like the Tuskegee syphillis experiment. Bad Shit has happened in the past, which is why we end up with so many rules and regs today.
More generally, it's easy to say things like "cut out all the onerous regulations and bureaucracy, nurses shouldn't have to check off so many ticky boxes instead of actually caring for their patients," and well... I get it. I'm not a nurse, but at my job I also have to check off many boxes to indicate that I've done X or Y, and sometimes end up spending more time "following procedure" than actually getting my job done. But if I don't check off a box and leave something undone, nobody will suffer, get sick, or die. My layman's understanding is the incorporation of checklists into hospitals and doctors' routines has actually served to streamline the process and save lives, because humans are fallible and checklists less so. What does it take to balance cost efficiency, practicality, and effectiveness with the truth that lives are on the line, and without regulation or oversight we've seen some pretty egregious breaches of trust and ethics, or less egregious breaches of just plain carelessness or human error.
I don't have any helpful answers to contribute, unfortunately, just the thought that the health care industry is one of the hardest industries to strip back in terms of regulation and bureaucracy, and there are both good and bad reasons for that.
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We need to fix the drug industry too.
It is ridiculous that it takes nearly a decade to bring a drug to the market with all of the meetings, tests, trials, more meetings.
If we want cheap drugs, we need cheap drug testing.
I understand where you're coming from, but I think drug testing is one of those areas you really can't skimp out on. Remember thalidomide? Diethylstilbestrol? Without "all the meetings, tests, trials, more meetings" you can end up with drug products that permanently impact people, leave them disabled, at high risk of cancer, or who know what else, and continue to impact the and their families for generations after the fact. And that's just on the drug end of things. Without proper vetting, ethics, and oversight of the trials and experimentation, you end up with stuff like the Tuskegee syphillis experiment. Bad Shit has happened in the past, which is why we end up with so many rules and regs today.
But Trump said drug prices are high and he is going to get cheap drugs. I was just giving a simple solution like his simple statement.
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But Trump said drug prices are high and he is going to get cheap drugs. I was just giving a simple solution like his simple statement.
Well shoot. If Trump says so, then consider all my concerns gone. :D
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What about HCAHPS. My hospital spends money on private rooms with 90 cable channels and room service in order to get 5% more reimbursement. They even have comment cards like you get at Denny's. This is despite the fact that patient satisfaction actually increases mortality. What if they spent that money on medical research that can actually help people?
I would argue that a lot of extras that hospitals have are because people want them, but don't fully understand how that affects cost.
There are a lot of easy ways to affect the cost of health care...or just pay for it out of pocket...
Private rooms? Going back to multiple room wards is the way.
HIPPA? I've heard privacy is dead anyway.
Gloves for procedures? Gone!
Free aromatherapy in the waiting room (I've heard of this) gone!
What? You want a TV in your room? All the rooms on your multiple bed ward now have just beds and curtains. Windows if you're lucky.
Free wifi? Gone!
If you want food, your family better bring it for you.
Same for extra blankets.
Get used to walking out to the bathroom. There's only a few on the floor you're on now.
Handicap access? There's only so many people with those problems, why build it in for convenience...that adds cost.
Ceiling lifts? If you're too big to be moved, I guess you just wont get the care you need.
CEO executive pay down to normal levels
I always like Back to the Future movies...why not do it with healthcare? Back to the 1950s...I can't wait!
We can just go a little further and be like every third world public health care out there. And mostly just die. Think of the money we'll save in nursing home costs!
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I am a nurse in a hospital so in a way I am both a supplier and a consumer. I also feel there is no use focusing solely on how we "supply" the healthcare without addressing the cost of the healthcare. I don't think getting rid of insurance companies is going to help at all.
I recently had a $2300 bill for 3 stitches in the ER. I have a $1500 deductible. Had I known the stitches were going to cost that much I would not have gotten them. When you get a car repaired you get an estimate. You can decide what work you want done and what you can do without. When you go to the hospital you are given no choices on what tests you want and don't want and you have no idea what the bill is going to be. I drive a Honda Civic. I don't drive a Cadillac. I think you need some skin in the game. If you have insurance people don't care so much about costs. If you have to pay, you do. It is interesting to me that people will suddenly withdraw care for critically ill patients when they are out of Medicare days and they are suddenly going to be responsible for the bill. Then they suddenly care about what services they are using.
Also, I think one of the big problems is the way hospitals are reimbursed. Hospitals get paid partially on patient "satisfaction" scores. Some of the areas that are being measured are pain relief- leading to overmedication and drug addiction issues and if the people like the environment- leading to constant expensive unnecessary remodeling. The staff is actually being paid incentives to "be nice" to the patients and getting high satisfaction scores. We recently got new flooring but have really old EKG monitors. CEOs get raises and bodyguards. Hospitals are supposedly non profit and figure out ways to spend the money instead of lowering the costs.
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We need to fix the drug industry too.
It is ridiculous that it takes nearly a decade to bring a drug to the market with all of the meetings, tests, trials, more meetings.
If we want cheap drugs, we need cheap drug testing.
Reminds me of that sketch from Monty Python
Man loses his job, tells children:
"I've got no option but to sell you all for scientific experiments."
https://www.youtube.com/watch?v=ddN6WHBmBmI (https://www.youtube.com/watch?v=ddN6WHBmBmI)
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My employer just switched to a somewhat unique model. It is HDHP w/ an HRA but most coverage is through a concierge or direct primary care physician. DPC covers primary care and optionally pediatrics. They also dispense drugs at cost (supposedly). It is brand new so I cannot say much on how well it works. However, I found it very interesting that they only charge $50 per month for any joe off the street to sign up. This gives you access to the doctors by office visit, text, email, etc. An interesting model. I really think that this type of thinking is what is needed to fix healthcare in America.
I have been told that doctors charge the insurance companies several hundreds for a routine office visit. Obviously, $50 per month gets you that and more. Is the real cost $20 per visit, less? Also, DPC gets rids of the insurance and paperwork load on the doctor and (usually) required staff.
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I recently had a $2300 bill for 3 stitches in the ER. I have a $1500 deductible. Had I known the stitches were going to cost that much I would not have gotten them.
While I agree that $2300 seems like a lot of money for three stitches on it's face, you're not really paying for just 3 stitches with an emergency room visit.
You're paying for the emergency room to be staffed in order to triage and then see you in an expedient manner, staffed 24/7/365. Depending on the Trauma Level of the hospital, you're also paying that hospital to have all those other specialties staffed too.
You paid for the MD/PA 's time to see you and then stitch you up.
You paid for the sterile equipment used to stitch you up from drape to needle and whatever used to wash out the wound.
You paid for the person to sit there and triage you.
You paid for a nurse to see you.
You paid for someone to probably take your vital signs
You paid for maintenance of the facility, rooms parking lot, etc.
You paid a janitor or other to clean the room you stayed in. And the consumables such as chemicals etc. used.
You paid for salaries of executives/managers from the CEO down to the nurse manager and staffing office, security, valet parking attendants etc. etc. etc.
And probably more. The point is, it's not just three stitches built into that cost.
But I do agree that we should know how much things cost up front- hospitals and clinics should provide that information readily. But unless you're unconscious, you can nearly always tell them what tests/procedures you do or do not want done to you-sometimes not in your best interest to refuse though. I think the onus of knowing about insurance billing/pricing is already there if you have insurance by looking up what is and what is not covered prior to making an appointment. Otherwise you can get stuck paying large uncovered medical bills.
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I have been told that doctors charge the insurance companies several hundreds for a routine office visit. Obviously, $50 per month gets you that and more. Is the real cost $20 per visit, less? Also, DPC gets rids of the insurance and paperwork load on the doctor and (usually) required staff.
My doctor spent 15-20 minutes with me at my last routine visit.
Is that worth only $20?
My doctor's time is only worth $80?
Actually, $80 for a PCP, might be kind of close.
But that does not include, the nurse, assistant, receptionist, rent, electricity, heat, computers...etc.
My hour long dental appointment costs $250. That pays the dentist (who usually sees 2-3 patients in that time), two hygienists, the receptionist, rent, billing, heat, electricity, equipment...
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1) No incentive on the patients part to shop around
2) No incentives for patients to stay healthy and lower their premiums, or use lower cost options if available
3) The margins on health insurers are very low. They actually do the public a service and lower costs by negotiating with the providers.
4) Tort and other laws preventing cheap fix-it places from offering cheap visits
5) A sensible conversation about keeping a lid on costs for those with terminal illnesses near the end of their lives
I think we need a hybrid, one where we pay a insurance (or government taxes us on it) for a high deductible plan (say above $5k, and you could even get a rider for coverage above say $2k-$5k) and when you need something major done you go to an agent similar to a mortgage broker who shops around for you and presents various options.
Competition is exactly what lowers costs.
You don't use your car insurance monthly, or your home owners, why should health insurance be any different?
The R's have no clue how to fix the system and they KNOW taking away insurance now is slitting their own throats. It's almost comical watching what they are doing.
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1) No incentive on the patients part to shop around
Problem: How does one shop around when in an emergency medical situation?
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We need to fix the drug industry too.
It is ridiculous that it takes nearly a decade to bring a drug to the market with all of the meetings, tests, trials, more meetings.
If we want cheap drugs, we need cheap drug testing.
Not wo fast. We already have explosive cost growth for OLD medicines thanks to what can only be pricing collusion. Look up the price correlation plots for insulin as a prime example. Competitors track each other nearly perfectly for a medicine that has been around for many decades.
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Ever ask for a quote to patch you up while you're unable to walk and bleeding out? They look at you like you're crazy and if you persist tell you they can get a price within a couple weeks. Then they try to sell you some drugs and a wheelchair at 20x market rate on your way out.
Get government out of medicine and trauma treatment. Eliminate the AMA, all other lobbyist groups, eliminate all medical licensing, and get the government out of medical treatment altogether. That is the way to restore transparency in pricing and restore a price competitive market.
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I have been told that doctors charge the insurance companies several hundreds for a routine office visit. Obviously, $50 per month gets you that and more. Is the real cost $20 per visit, less? Also, DPC gets rids of the insurance and paperwork load on the doctor and (usually) required staff.
My doctor spent 15-20 minutes with me at my last routine visit.
Is that worth only $20?
My doctor's time is only worth $80?
Actually, $80 for a PCP, might be kind of close.
But that does not include, the nurse, assistant, receptionist, rent, electricity, heat, computers...etc.
My hour long dental appointment costs $250. That pays the dentist (who usually sees 2-3 patients in that time), two hygienists, the receptionist, rent, billing, heat, electricity, equipment...
It would be great if someone familiar with the real costs could chime in here.
What I have heard is that doctors are compensated to have you come in for everything. ie cold - gotta come in whereas most adults already know what is needed.
I was thinking then along the lines of $500 for a routine check-up. This is minimal time with the doctor as you mentioned. The doctor may do 15 of those in a day. $7,500 in a day billed to insurance. It gets negotiated down but that requires a lot of paperwork.
If we could get medicine to be more efficient, I wonder what the costs could be reduced to.
I completely agree with you that the doctor's time is valuable and they should be compensated. I wonder though how much fluff is added to the cost due to the 'system' - insurance, regulatory overhead, etc.
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Ever ask for a quote to patch you up while you're unable to walk and bleeding out? They look at you like you're crazy and if you persist tell you they can get a price within a couple weeks. Then they try to sell you some drugs and a wheelchair at 20x market rate on your way out.
Get government out of medicine and trauma treatment. Eliminate the AMA, all other lobbyist groups, eliminate all medical licensing, and get the government out of medical treatment altogether. That is the way to restore transparency in pricing and restore a price competitive market.
How does one restore a competitive market in the absence of regulation if the person responsible for making a price-conscious decision is unable to walk and currently bleeding out?
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1) No incentive on the patients part to shop around
Problem: How does one shop around when in an emergency medical situation?
I hear this complaint all the time, but the reality is that most people who need healthcare are not in an emergency situation. Most people are not having heart attacks or bleeding out of all their orifices. The reality is that most people have plenty of time to hit the internet and review their options. My nearby emergency department sees about 170 patients per day. 30 of which come by ambulance of those 30 only a small handful have a real emergency. The rest could have driven themselves or have a friend drive them. Which goes back to the point of insurance. It is those emergencies and very high unexpected costs that insurance should cover. That is by definition what insurance is. It is a policy you buy incase bad shit happens. Insurance is not to pay for everyday events.
Obamacare tried to create some incentive on the patient, but without true price transparency it is impossible to make a sensible decision.
As for your other comment on clicking boxes. Let me give you an example of useless clicking on my part. I am an ER physician. When I have a patient that does not meet criteria for getting thrombolyitic therapy (clot busting medication) for a stroke I must specifically document the words "medication not given due to . . . ." even though other areas of my chart document the same thing. Why? because the stroke regulatory body is filled with people who need to review my chart and it needs to be spelled out for them very very clearly. The facts are already in the history and physical exam. They are just too clueless regarding medicine to look there. Examples of more clueless clicking. If I do not specify minor items in my chart I get paid less for my work. For example if I have a patient with a heart attack but don't specify the severity of pain, I will get reimbursed about 60% less for that care. Idiotic waste of my time but I must make sure I click all the right boxes. Neither of the above improve patient outcomes they just take up my time and therefor decrease my time with patients. It has gotten so bad that many ER physicians hire scribes to help them keep up with the documentation burden. Who do you think pays for those scribes?
Also when 1 person makes a mistake then usually the next step is not fixing the nurse who made the mistake, but add extra steps in the process so that mistake can't be made. Although at first glance it might seam like a great idea, but overtime these extra steps and check boxes and clicks pile up. Before you know it nurses spend 80% of their day clicking on the computer making sure each and every step is properly documented. The better process would be to teach the 1st nurse how not to make that mistake and then if needed teach all the other nurses the same. We talk about lifestyle creep on this forum. I call it documentation creep and so far I see nothing stopping this juggernaut of waste.
I find it funny how some people agree with everything our bloated government wants to do. If the government dictates it must be correct and right unless its the other party and therefor everything is wrong. No, stop and evaluate each item yourself and let your brain make the decision as opposed to following party lines. Reality is that both parties are full of corruption and waste.
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I have been told that doctors charge the insurance companies several hundreds for a routine office visit. Obviously, $50 per month gets you that and more. Is the real cost $20 per visit, less? Also, DPC gets rids of the insurance and paperwork load on the doctor and (usually) required staff.
My doctor spent 15-20 minutes with me at my last routine visit.
Is that worth only $20?
My doctor's time is only worth $80?
Actually, $80 for a PCP, might be kind of close.
But that does not include, the nurse, assistant, receptionist, rent, electricity, heat, computers...etc.
My hour long dental appointment costs $250. That pays the dentist (who usually sees 2-3 patients in that time), two hygienists, the receptionist, rent, billing, heat, electricity, equipment...
It would be great if someone familiar with the real costs could chime in here.
What I have heard is that doctors are compensated to have you come in for everything. ie cold - gotta come in whereas most adults already know what is needed.
I was thinking then along the lines of $500 for a routine check-up. This is minimal time with the doctor as you mentioned. The doctor may do 15 of those in a day. $7,500 in a day billed to insurance. It gets negotiated down but that requires a lot of paperwork.
If we could get medicine to be more efficient, I wonder what the costs could be reduced to.
I completely agree with you that the doctor's time is valuable and they should be compensated. I wonder though how much fluff is added to the cost due to the 'system' - insurance, regulatory overhead, etc.
I am an ER doctor and can only talk about the ER with confidence. Let talk about the person above with the $2250 bill for 3 stitches. If that same person went into an urgent care and saw a nurse practitioner or PA their bill would probably have been closer to $200. Urgent cares have lower overhead and less regulations. Plus since you are paying cash or by credit card they don't need to deal with insurance companies. If that person went to a free standing ER the price would have been ~$1k. They would have seen an ER physician who costs more as well as pay for the increased overhead of a free standing emergency department which usually do deal with insurance companies. Lets be honest. This patient had a cut that was maybe 1-2cm in length. They were not bleeding all over the place, and had plenty of time to review all their options. Unfortunately there is little price transparency in the hospital and most patients do not know how to figure out their options. So like many others they head to their nearest big hospital emergency department and get stuck with a $2250 bill. For the record, depending on the location of the cut, how complex it is, the ER doctor would get anywhere from $35-$150 for the repair. This does not include the physician's overhead costs such as billing and coding and administrative costs which may be as high as 20%
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I find it funny how some people agree with everything our bloated government wants to do. If the government dictates it must be correct and right unless its the other party and therefor everything is wrong. No, stop and evaluate each item yourself and let your brain make the decision as opposed to following party lines. Reality is that both parties are full of corruption and waste.
That's true. Both parties have their corruption and waste. But there are real differences between the two majority parties. However, that's beyond the scope of this thread. For the record though, I agree with the majority of principles of the representatives I voted for.
It is a policy you buy incase bad shit happens. Insurance is not to pay for everyday events.
An excellent argument for a universal health system. Get rid of insurance altogether. Brilliant!
As far as shopping around for care, I agree EDs are really majority non-emergency care. But there will always be people who can neither afford the ED, nor urgent care.
As another one who does and has done many of those clicks, MDs may know about why they're clicking what they're clicking, but as an RN, I have no idea what relates to reimbursement or regulation. If there isn't time to chart, patient care comes first. If something important happens, I do something or there is a change that gets charted, but otherwise the vast majority of the charting for inpatient care is repetitive and I believe quite unnecessary. Filling in boxes to fill in boxes.
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My employer just switched to a somewhat unique model. It is HDHP w/ an HRA but most coverage is through a concierge or direct primary care physician. DPC covers primary care and optionally pediatrics. They also dispense drugs at cost (supposedly). It is brand new so I cannot say much on how well it works. However, I found it very interesting that they only charge $50 per month for any joe off the street to sign up. This gives you access to the doctors by office visit, text, email, etc. An interesting model. I really think that this type of thinking is what is needed to fix healthcare in America.
I have been told that doctors charge the insurance companies several hundreds for a routine office visit. Obviously, $50 per month gets you that and more. Is the real cost $20 per visit, less? Also, DPC gets rids of the insurance and paperwork load on the doctor and (usually) required staff.
There was another thread a while ago on "Direct Primary Care" and I think it's an innovative, free market model that should be expanded. Of course, the insurance lobby is not a fan; but, if you can charge $50-$100 per month for expanded primary care that includes more personalized care and emphasizes prevention I'm all for it. And, the docs who have gone this direction seem to make equal to or more $ than in a traditional setting where they see 4-5x more patients. I think a DPC model with an overriding catastrophic insurance policy is a model worth looking at and, in fact, what health care looked like when insurance was first introduced in the early-mid 1900's where you paid the family doc cash and then had a hospital (catastrophic) policy
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Some good responses so far! I'll add my two cents:
First, I happen to disagree that obtaining care given or paid for by others is some kind of right. You never have the right to take another's money to pay for your care or to demand that health practitioners service you for free. Thus, the solutions I tend to gravitate toward are health education, prevention (diet & exercise), and market based reforms when it comes to care and financing care.
The folly of the current healthcare debate to me is that the current problematic system is a result of government regulation gone wrong. They regulate what drugs are available, who can provide medical services (licensing, accreditation, etc.), what insurance policies are available and where they can be sold, malpractice & tort policy, etc. All of this has led to complexity and high cost. Now, instead of recognizing the root of the problem and letting the market sort it out, we're choosing to employ the same politicians who created the mess to fix it via new, gargantuan government run programs.
- Core to the k-12 curriculum should be health education (screw you Doritos and Mountain Dew manufacturers!)
- Medical training and education opportunities should be expanded, more doctors = more competition
- Unleash the entrepreneurs! Direct Primary Care is one example; but, I can only imagine what new healthcare models could be concocted if allowed by the government
- The test for tort cases should be limited to gross negligence
- Insurance should be reserved for catastrophic events
- People in a modern society should voluntarily agree to help poor people obtain decent care when needed and I think there are some great private charities that can handle the administration of these programs better than any elected or appointed official. At the same time, I would choose to send 50 underprivileged kids to college before I'd give a 95 year old millions in cancer treatments.
I think some core MMM principles apply to healthcare: take care of yourself through proper diet and exercise and your healthcare expenses will be less, educate yourself and shop around for the best deals, learn to do some things yourself when practical, etc. The successful Mustachian doesn't accept the typical "system" as gospel, so I am a bit surprised when I see some posts advocating for one government run system or another. Good topic, good debate!
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I'll give some recent examples about waste. Husband went for annual physical. While waiting, he had to fill out forms. One was a "depression screen." What he didn't know was that he was charged for filling out that form--$40! Yikes!
I refused to fill it out. Insurance got billed the $40 anyway because my doctor literally said "Do you ever feel down? You know you can always come to me if depression becomes an issue" Or something to that effect, but about as subtle. $40, ka-ching! I love my primary care physician otherwise so I'm going to hold him blameless.
I was so mad after I got the EOB, even though I didn't have to pay it, that I looked up the reason for this. It's a current preventative recommendation and might have something to do with a standard of care that gives funding credits.
Next year I am going to preempt by asking about it and refusing the whole thing outright before the exam.
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Yes, agree very much. There shouldn't be a "co-pay" if I can simply walk into the doctor for an office visit, pay him directly, and not have to run anything through insurance. I simply pay him the $20 or $30 or whatever he/she would charge. I don't need it to be run through insurance. Because realistically, a doctor visit is not worth $100 that is charged---it's because insurance is in the middle of it trying to make their profit.
So when you need a $50,000 operation, how are you going to pay for that? You'll probably need a cashier's check.
Also, if you think you are going to get a doctor appointment for $20, you're crazy. If you don't think it is worth $100, I guess you'll just have to stay at home and hope for the beset?
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My employer just switched to a somewhat unique model. It is HDHP w/ an HRA but most coverage is through a concierge or direct primary care physician. DPC covers primary care and optionally pediatrics. They also dispense drugs at cost (supposedly). It is brand new so I cannot say much on how well it works. However, I found it very interesting that they only charge $50 per month for any joe off the street to sign up. This gives you access to the doctors by office visit, text, email, etc. An interesting model. I really think that this type of thinking is what is needed to fix healthcare in America.
I have been told that doctors charge the insurance companies several hundreds for a routine office visit. Obviously, $50 per month gets you that and more. Is the real cost $20 per visit, less? Also, DPC gets rids of the insurance and paperwork load on the doctor and (usually) required staff.
There was another thread a while ago on "Direct Primary Care" and I think it's an innovative, free market model that should be expanded. Of course, the insurance lobby is not a fan; but, if you can charge $50-$100 per month for expanded primary care that includes more personalized care and emphasizes prevention I'm all for it. And, the docs who have gone this direction seem to make equal to or more $ than in a traditional setting where they see 4-5x more patients. I think a DPC model with an overriding catastrophic insurance policy is a model worth looking at and, in fact, what health care looked like when insurance was first introduced in the early-mid 1900's where you paid the family doc cash and then had a hospital (catastrophic) policy
That is my understanding of this outfit we're using. As long as they can get to a certain # of patients, their financial needs are met. They provide better, more personalized care to the smaller number of patients.
Your comment about the early-mid 1900's is interesting to me. It really does seem that going back to a simpler model would save a lot of costs and headaches.
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Enjoyit, thank you for your perspective. It is always good to hear a Dr.s opinion, since they are in the middle of the whole thing.
As for your other comment on clicking boxes. Let me give you an example of useless clicking on my part. I am an ER physician. When I have a patient that does not meet criteria for getting thrombolyitic therapy (clot busting medication) for a stroke I must specifically document the words "medication not given due to . . . ." even though other areas of my chart document the same thing. Why? because the stroke regulatory body is filled with people who need to review my chart and it needs to be spelled out for them very very clearly. The facts are already in the history and physical exam. They are just too clueless regarding medicine to look there. Examples of more clueless clicking. If I do not specify minor items in my chart I get paid less for my work. For example if I have a patient with a heart attack but don't specify the severity of pain, I will get reimbursed about 60% less for that care. Idiotic waste of my time but I must make sure I click all the right boxes. Neither of the above improve patient outcomes they just take up my time and therefor decrease my time with patients. It has gotten so bad that many ER physicians hire scribes to help them keep up with the documentation burden. Who do you think pays for those scribes?
Also when 1 person makes a mistake then usually the next step is not fixing the nurse who made the mistake, but add extra steps in the process so that mistake can't be made. Although at first glance it might seam like a great idea, but overtime these extra steps and check boxes and clicks pile up. Before you know it nurses spend 80% of their day clicking on the computer making sure each and every step is properly documented. The better process would be to teach the 1st nurse how not to make that mistake and then if needed teach all the other nurses the same. We talk about lifestyle creep on this forum. I call it documentation creep and so far I see nothing stopping this juggernaut of waste.
I assure you, this isn't just a problem in the medical field. In my tech company, we have a system of cumbersome procedures in place in order to make sure that people don't make mistakes. It takes several full time people to maintain this system and a good portion of people's work day is spent dealing with logistics programs and procedures.
I see this more of a civilization complexity problem, and we definitely could use less cumbersome ways of reducing human error. However, as a patient, it comforts me to know that things are being double and triple checked so that nothing happens to me during a procedure, so part of me is okay with this, despite increased cost.
I am an ER doctor and can only talk about the ER with confidence. Let talk about the person above with the $2250 bill for 3 stitches. If that same person went into an urgent care and saw a nurse practitioner or PA their bill would probably have been closer to $200. Urgent cares have lower overhead and less regulations. Plus since you are paying cash or by credit card they don't need to deal with insurance companies. If that person went to a free standing ER the price would have been ~$1k. They would have seen an ER physician who costs more as well as pay for the increased overhead of a free standing emergency department which usually do deal with insurance companies. Lets be honest. This patient had a cut that was maybe 1-2cm in length. They were not bleeding all over the place, and had plenty of time to review all their options. Unfortunately there is little price transparency in the hospital and most patients do not know how to figure out their options. So like many others they head to their nearest big hospital emergency department and get stuck with a $2250 bill. For the record, depending on the location of the cut, how complex it is, the ER doctor would get anywhere from $35-$150 for the repair. This does not include the physician's overhead costs such as billing and coding and administrative costs which may be as high as 20%
Oh man, preaching to the choir here. The use of the ER as an urgent care clinic needs to stop. Not only is it costly, but it really is an unpleasant patient experience to wait in an ER for hours for something relatively minor because you don't have any other options. We just had a private urgent care clinic open in our town. The one at our local hospital has extremely limited hours, so you often end up going to the ER. There needs to be a better solution across the board for when you have something that needs drop in care but not full ER services.
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Reducing costs in health care involves having difficult conversations that people don't want to have, because we don't deal with death very well in our culture. We see death as an abomination to be fought at all costs instead of a necessary part of life. I think something like 50% of your health care dollars are spent in the last 6 months of your life. I am all for doing something like this guy personally: https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/ (https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/)
Just making sure people make an end of life plan would save vast amounts of money without changing anything else. I don't want to spend the last few months or years of my life in a hospital undergoing procedures. Let me go.
But no. Then people start screaming about death panels.
I was thinking about your post last night while taking care of a basically brain dead patient, the family who wants everything done to keep them alive because they hope they might....I dunno...have some kinda miracle? The patient will end up at a nursing home, probably eventually with recurrent pneumonias and more hospital stays in the ICU since they'll probably be vent dependent to breathe. A slow death.
Something that hasn't been mentioned is the rationing of care. I know I know, but I'll argue that we already ration care. What is the point of keeping a human only physically alive? I know that could turn into a slippery slope...but I think our society needs to talk about it. They do this in other countries with universal health care especially with certain surgeries and organ transplants.
A coworker mentioned that we should all have this discussion at least yearly when we visit our primary. I've discussed with my wife: If i come to the point of not being able to communicate, feed myself or wipe my ass...let me die. I don't want to be a vegetable. Not a quad either, thank you.
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First, I happen to disagree that obtaining care given or paid for by others is some kind of right. You never have the right to take another's money to pay for your care or to demand that health practitioners service you for free.
The government does have the right to take your money and use it to pay for things other people need. It is called society.
You go to private school. The government takes your money from property tax and pays for some other person's child to go to public school.
You have an extensive Kindle library. The government takes your money and uses it to build a library to provide free books for other people.
They do these things to make society seem like a better option.
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Oh man, preaching to the choir here. The use of the ER as an urgent care clinic needs to stop. Not only is it costly, but it really is an unpleasant patient experience to wait in an ER for hours for something relatively minor because you don't have any other options. We just had a private urgent care clinic open in our town. The one at our local hospital has extremely limited hours, so you often end up going to the ER. There needs to be a better solution across the board for when you have something that needs drop in care but not full ER services.
Our current model pays our primary care physicians too little for what is expected of them. Therefor most doctors these days specialize and we ended up with a shortage of primary care. Not to mention their days are so busy clicking all the right boxes that they just don't have the time to add another patient to their day and tell them to go to the ER. Their reimbursement has been cut for decades while their cost of operation increases so they end up billing insurance companies for depression counseling and smoking cessation counseling and anything else they can do to bring their paychecks back to what they used to make even 5 years ago.
In 2017 a new reimbursement structure has come out and it dictates that doctors need to meet certain measures such as have the correct expensive computer software, talk about certain health issues with patients, and a few other metrics. The top percent of doctors that are willing to spend the money and learn all the steps will get up to a 9% increase in reimbursement. Sounds great right? Well all the other docs will get nothing or worse get reimbursement cut by 9%. 9% can be the difference between keeping your doors open and forced into retirement. CMS believes that about 10% of small practice physicians will be able to comply with these regulations so they should expect a 9% payout but 2020. This new reimbursement structure will be putting physicians out of business.
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First, I happen to disagree that obtaining care given or paid for by others is some kind of right. You never have the right to take another's money to pay for your care or to demand that health practitioners service you for free.
The government does have the right to take your money and use it to pay for things other people need. It is called society.
You go to private school. The government takes your money from property tax and pays for some other person's child to go to public school.
You have an extensive Kindle library. The government takes your money and uses it to build a library to provide free books for other people.
They do these things to make society seem like a better option.
I don't see anything wrong with healthcare being accessible for those that can't afford it. Actually I think we as a rich society should go out of our way to provide medical care for every American. Though I strongly disagree that those who can't afford it should have the same expectations as those who pay. There is no reason why free care needs to happen immediately unless it is a medical emergency. There is no reason why those receiving free care need to have private rooms with cable television. There is no reason why free care needs to have the latest robotic procedures available to them when lower cost options are just as good or close to it. There is no reason why we need to perform expensive therapies on patients who have minimal brain function with no quality of life. There is no reason why anyone can force me to give you my most undivided attention for free. I am happy to help those in need and currently provide about 25% of my care for free. But I sure as hell don't owe anything to these people other than what I want to give. Well, except the government has created laws that actually force me to take care of every patient. Even when they curse or spit or are drug addicts trying to fool me into getting them high.
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The problem we have here seems to be that rich people want to be treated special.
If everyone has healthcare, they worry they will not have special treatment.
So we could maybe have a two tier healthcare system sort of like flying coach and flying first class.
Everyone gets coach healthcare which includes basics and uses drugs that have gone generic.
If you upgrade to first class healthcare, you get the private room, nurse in short skirt, latte flavored jello
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The problem we have here seems to be that rich people want to be treated special.
If everyone has healthcare, they worry they will not have special treatment.
So we could maybe have a two tier healthcare system sort of like flying coach and flying first class.
Everyone gets coach healthcare which includes basics and uses drugs that have gone generic.
If you upgrade to first class healthcare, you get the private room, nurse in short skirt, latte flavored jello
My hospital actually has a VIP unit with gold plated everything. Floated there once and they even have nicer toilet paper. Regular rooms are really nice too (100 cable channels, mini fridge, pullout couch for the family) and we have better staffing ratios than most places. I still wish the $$ would be spent on research instead of cable TV and room service.
I am for universal Medicare ( not good for me now, but great if I FIRE).
To really fix healthcare, we need to spend $ to avoid spending $$$$ down the road. This will also not be an overnight fix.
Here are some ideas, feel free to add to the list:
Increase funding for education for poor children, including health literacy. Why not throw in some financial education while we're at it and turn everyone into badass mustachians. Higher literacy (measured by grade level) directly impacts chronic disease burden and life expectancy. Why not also instill a sense of public mindedness ("I should not go to the ER for my poison ivy because it will take the Dr's time away from someone who is really sick").
Encourage people to improve their health rather than treating disease down the road. Provide preventive care and chronic disease management. Insulin is much cheaper than dialysis. BP meds are cheaper than putting a 30 year old in a nursing home because of a stroke.
Provide basic dental care for low income people. It costs millions to take care of one guy with a brain abscess from a tooth. Also it would cut down on frivolous ER visits.
Cut off a-holes who abuse the system.
Do not admit people to the hospital for being drunk. Or for headaches, or back pain, or the flu unless they are actually at risk of dying.
Get rid of f***ing Press-Ganey.
Giving free, accessible, and private birth control to all women and girls would placate both sides of the abortion debate.
Increase research into finding the most cost effective way to solve a problem. Fund more studies for prevention, vaccines, and cures.
Use evidence based treatments. Sometimes lower tech has better outcomes than higher tech.
Bargain with the drug companies for a cheaper price like every other country does. Ban advertising for prescription drugs. Punish Pharma-bro and his ilk.
Look at what other countries are doing instead of trying to reinvent the wheel. Cuba has the same life expectancy as the US, and lower infant mortality.
Edit: forgot to add that we should encourage everyone to have the end of life conversation before it is needed. Maybe we should make it a form at the DMV. I have seen many people kept alive when I wouldn't want to be if I were in their situation.
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I know several have mentioned this, but we really need to cut down on ICU use and third-line chemotherapy, etc for terminally ill people. How we define terminally ill is something to be addressed as a society, but everyone in the healthcare industry profits off the backs of Medicare and private insurers by providing essentially futile care to minimally prolong the life of someone (usually at high cost to quality of life). This costs a thousand times more than whether your anti-hypertensive medication is $50 or $5 a month, or if your hospital has crappy floors or nice floors. Unfortunately I doubt this will be addressed. Why? 1: No one has any interest in addressing this because it reeks of "death panels" and is a form of rationing. 2: If there's one thing everyone on this board can agree on, it's that the average America hates talk of fiscal discipline, regardless of the cost to themselves or society.
Our ICUs are full of 70+ year olds who have had high risk operations or other interventions with minimal gains in quality of life, low expectations of recovery and are now suffering the expected complications of the end stages of their specific chronic diseases. That's on us as physicians for not setting realistic expectations early and a society for expecting miracles.
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If you upgrade to first class healthcare, you get the private room, nurse in short skirt, latte flavored jello
You really want me in a skirt? Ok...but I'm a dude with skinny and hairy legs. Not to mention the possibility of body fluids on your legs. Gross.
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I know several have mentioned this, but we really need to cut down on ICU use and third-line chemotherapy, etc for terminally ill people. How we define terminally ill is something to be addressed as a society, but everyone in the healthcare industry profits off the backs of Medicare and private insurers by providing essentially futile care to minimally prolong the life of someone (usually at high cost to quality of life).
This is all well and good...but a lot of times when it comes down to it, people do not have the capacity to say no to more medicine and interventions. It's going to take time to change society's perspective.
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Giving free, accessible, and private birth control to all women and girls would placate both sides of the abortion debate.
I agree with everything you said...but this one is a real sticking point. We can't even agree on how to educate on sex education let alone giving free birth control to females. Conservatives will always be against this. If it's not because of religion, then because they don't want anybody to get anything "free" even if it saves money down the road. They're big on principles even if it means shooting themselves in the foot.
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I know several have mentioned this, but we really need to cut down on ICU use and third-line chemotherapy, etc for terminally ill people. How we define terminally ill is something to be addressed as a society, but everyone in the healthcare industry profits off the backs of Medicare and private insurers by providing essentially futile care to minimally prolong the life of someone (usually at high cost to quality of life).
This is all well and good...but a lot of times when it comes down to it, people do not have the capacity to say no to more medicine and interventions. It's going to take time to change society's perspective.
I agree, and mention that in the second half of my post. However I think it'll take more scarcity of resources to change perspective rather than time alone. We are in the phase of healthcare just past the upswing in quality. Just 40 years ago, people routinely died of major heart attacks because of limited technology to treat them, for example. Or many cancers, even. Now we've plateaued in healthcare improvement with technology and are relying on societal changes, which is of course a lot harder. Unfortunately, we are far behind in understanding the utility of certain technologies on a societal level. A good example is the expanded use of cardiac stents from their original indication (heart attacks) to other symptoms (intermittent chest pain, or even asymptomatic narrowing of the arteries). Approximately 5 million stents later, a trial demonstrated no benefit to stenting for these other indications. Yet, it is still commonly done. Why? Greed, expectations, inertia?
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Much of the ridiculous cost for healthcare at hospitals doesn't come from regulations. It comes from having to make up for the cost of uninsured patients. Before the ACA, poor people wouldn't get preventative care and then when the situation got really bad they would go to the emergency room with no insurance and get healthcare for free. Well, technically, they were billed for it, but then they would declare bankruptcy since they couldn't afford the bills and the debt would be wiped out. The hospitals still need to pay for the services, so they raise the bills for everyone else. The ACA mostly put an end to that, which is why health costs weren't increasing anywhere near as quickly over the past few years.
Soon, that will be a thing of the past, though, because my fellow White Trash voted to outlaw the ACA. They don't really understand healthcare. They don't get that the ACA did more good than harm.
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Much of the ridiculous cost for healthcare at hospitals doesn't come from regulations. It comes from having to make up for the cost of uninsured patients. Before the ACA, poor people wouldn't get preventative care and then when the situation got really bad they would go to the emergency room with no insurance and get healthcare for free. Well, technically, they were billed for it, but then they would declare bankruptcy since they couldn't afford the bills and the debt would be wiped out. The hospitals still need to pay for the services, so they raise the bills for everyone else. The ACA mostly put an end to that, which is why health costs weren't increasing anywhere near as quickly over the past few years.
Soon, that will be a thing of the past, though, because my fellow White Trash voted to outlaw the ACA. They don't really understand healthcare. They don't get that the ACA did more good than harm.
Although I agree that hospitals cover the cost of uncompensated care via increasing the cost to the insured and self pay patients that actually pay, but the ACA did not make the cost of going to the Emergency Room free. Looking at the balance sheet of my hospital I see plenty of people with insurance who do not pay their very high deductible. It is as if the insurance did nothing for them except line the pockets of the insurance company. This may be why the cost of healthcare has not risen at the same rate these last 3 years. People are now willing to ration their own expenses to keep their own costs down.
I agree, and mention that in the second half of my post. However I think it'll take more scarcity of resources to change perspective rather than time alone. We are in the phase of healthcare just past the upswing in quality. Just 40 years ago, people routinely died of major heart attacks because of limited technology to treat them, for example. Or many cancers, even. Now we've plateaued in healthcare improvement with technology and are relying on societal changes, which is of course a lot harder. Unfortunately, we are far behind in understanding the utility of certain technologies on a societal level. A good example is the expanded use of cardiac stents from their original indication (heart attacks) to other symptoms (intermittent chest pain, or even asymptomatic narrowing of the arteries). Approximately 5 million stents later, a trial demonstrated no benefit to stenting for these other indications. Yet, it is still commonly done. Why? Greed, expectations, inertia?
Scarcity of resources is the reality. People expect everything for everyone and they expect it immediately. The reality is that we do not have those resources to have everything. People just don't realize that. People thing we can just tax the person making a little more than them to cover all those extra costs. There is a limit to this strategy.
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Much of the ridiculous cost for healthcare at hospitals doesn't come from regulations. It comes from having to make up for the cost of uninsured patients. Before the ACA, poor people wouldn't get preventative care and then when the situation got really bad they would go to the emergency room with no insurance and get healthcare for free. Well, technically, they were billed for it, but then they would declare bankruptcy since they couldn't afford the bills and the debt would be wiped out. The hospitals still need to pay for the services, so they raise the bills for everyone else. The ACA mostly put an end to that, which is why health costs weren't increasing anywhere near as quickly over the past few years.
Soon, that will be a thing of the past, though, because my fellow White Trash voted to outlaw the ACA. They don't really understand healthcare. They don't get that the ACA did more good than harm.
Although I agree that hospitals cover the cost of uncompensated care via increasing the cost to the insured and self pay patients that actually pay, but the ACA did not make the cost of going to the Emergency Room free. Looking at the balance sheet of my hospital I see plenty of people with insurance who do not pay their very high deductible. It is as if the insurance did nothing for them except line the pockets of the insurance company. This may be why the cost of healthcare has not risen at the same rate these last 3 years. People are now willing to ration their own expenses to keep their own costs down.
Out of interest, what fraction of ICU care at your hospital gets covered by insurance? Also, what's your ICU/floor ratio for beds? Ours is close to 20%, which I think is egregious but the ICUs are always full...mostly it seems Medicare is picking up the tab since they are mostly 70+ year olds.
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Our ICU seams to be about 15% of the hospital beds but when you add step down or IMCU that number doubles. I honestly do not know he percentage, but sicker patients tend to be over 65 and therefor Medicare.
We are really good at moving them out quickly. Since length of stay costs money and the hospital pushes the intensivists to move them out ASAP. Obviously when they are stable. Bounce backs from floor to ICU are also counted and are rare.
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Soon, that will be a thing of the past, though, because my fellow White Trash voted to outlaw the ACA. They don't really understand healthcare. They don't get that the ACA did more good than harm.
This is a one-dimensional view of a complex and difficult issue. Someone always pays for healthcare. Of course ACA benefitted some, I mean you spend $1 trillion of taxpayer funds, someone will be helped.
But many many others (private sector workers who don't qualify for subsidies) are seeing premiums & copays double and triple and coverage cut. And businesses are burdened, can't grow or hire full time for same reasons. ACA is overall a costly burden on the economy.
But I think this insightful post is about the actual insane *cost* and how much goes to the middleman, the onerous regulations (many just political in nature), and sheer dumb waste. It's a lot.
And the profiteering insurers and big pharma etc, are not letting their golden goose die. It doesn't matter Obamacare vs Trumpcare vs Ryancare. Their armies of lobbyists are fighting tooth and nail to ensure the status quo stays.
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Soon, that will be a thing of the past, though, because my fellow White Trash voted to outlaw the ACA. They don't really understand healthcare. They don't get that the ACA did more good than harm.
This is a one-dimensional view of a complex and difficult issue. Someone always pays for healthcare. Of course ACA benefitted some, I mean you spend $1 trillion of taxpayer funds, someone will be helped.
But many many others (private sector workers who don't qualify for subsidies) are seeing premiums & copays double and triple and coverage cut. And businesses are burdened, can't grow or hire full time for same reasons. ACA is overall a costly burden on the economy.
But I think this insightful post is about the actual insane *cost* and how much goes to the middleman, the onerous regulations (many just political in nature), and sheer dumb waste. It's a lot.
And the profiteering insurers and big pharma etc, are not letting their golden goose die. It doesn't matter Obamacare vs Trumpcare vs Ryancare. Their armies of lobbyists are fighting tooth and nail to ensure the status quo stays.
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Exactly, while we quibble over who pays for health care, those big industries are continuing to laugh their way to the bank. Just think about how much less expensive healthcare would be to deliver if you remove the middle man from the majority of non catastrophic issues. Even if the middle man is the government, it costs a lot of money to hire people and comply with billing and coding regulations to bill the government. It then costs the government lots of money to hire people to review all the billing and coding, have panels to review, evaluate and deny claims, and send checks to biller.
So many people think that government should do all these amazing things, but they just don't realize that the healthcare dollar is finite and therefor you have to ration utilization and decrease cost. That is what socialized medicine in other countries do. They ration utilization.
Something as simple as getting a prescription costs way to much money to operate. The pharmacy needs to hire a person who will look at every script and send it to either the government or the insurance company for approval. Someone at the government and at the insurance company needs to evaluate that script and approve payment. Only then can the pharmacist fill it. All those people, computers, and software that are involved costs money and are wasteful. Not to mention the insurance company needs to make a profit on the transaction also adding to the cost. So instead of paying $7 for a prescription, you are now paying $10. There is no need for the insurance or government middleman in this process. On the other hand if you require $250/day medication, for the rest of your life, well then insurance and/or government can step in to reimburse you for your cost.
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If you were to redesign the health care system from scratch, how would you design it?
I really feel like much of the medical system is just run plain inefficiently. I hate going to the doctor where they make me fill out the same form every time. I also hate that half the time I go to the doctor, I end up getting sick afterwards from something I picked up while there. I hate talking to my doctor, because he or she seems really overwhelmed and unempathetic most of the time. I don't blame them, I just think they are overloaded.
If I have something minor, like bronchitis or a UTI, what I realized is that the worst part of it is that I have to haul my uncomfortable ass to the doctor, talk to them for 15 minutes, maybe do a test, and then get a prescription or a note to give my employer. I am sure I probably have made other people sick doing this. (As an aside, I always wonder how doctors and nurses avoid just being sick all the time) I end up having to be annoyed for 3-4 hours instead of being home resting. Maybe there is no way around this, but it sure is annoying. They just opened up one of those urgent care clinics across town - maybe that is a better option now.
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I am a nurse in a hospital so in a way I am both a supplier and a consumer. I also feel there is no use focusing solely on how we "supply" the healthcare without addressing the cost of the healthcare. I don't think getting rid of insurance companies is going to help at all.
I recently had a $2300 bill for 3 stitches in the ER. I have a $1500 deductible. Had I known the stitches were going to cost that much I would not have gotten them.
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Those stiches would have cost you $250 in Canada if you didn't have insurance. i.e. didn't have your health card with you from another province or were from out of Country. Not trying to get into the debate about what system is better/best - just showing you an example of bloated costs, likely due to insurance companies being involved.
(Our doctors are still rich. Our nurses well paid.)
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We need to fix the drug industry too.
It is ridiculous that it takes nearly a decade to bring a drug to the market with all of the meetings, tests, trials, more meetings.
If we want cheap drugs, we need cheap drug testing.
It's getting cheaper every day to bring a drug to market. Companies can do it faster, with less overhead (thanks to single use technologies - there are a lot of virtual companies that get it done using contract manufacturing), and more reliably as well.
The issue is as we get better in understanding how these drugs are working, we're making drugs that are more complex which require better/more extensive testing to show that Drug A = Drug A = Drug A. I don't see a good solution for it especially if I'm going to be getting injected with it.
Pills are a different matter since that's just basically baking.
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If you were to redesign the health care system from scratch, how would you design it?
I really feel like much of the medical system is just run plain inefficiently. I hate going to the doctor where they make me fill out the same form every time. I also hate that half the time I go to the doctor, I end up getting sick afterwards from something I picked up while there. I hate talking to my doctor, because he or she seems really overwhelmed and unempathetic most of the time. I don't blame them, I just think they are overloaded.
If I have something minor, like bronchitis or a UTI, what I realized is that the worst part of it is that I have to haul my uncomfortable ass to the doctor, talk to them for 15 minutes, maybe do a test, and then get a prescription or a note to give my employer. I am sure I probably have made other people sick doing this. (As an aside, I always wonder how doctors and nurses avoid just being sick all the time) I end up having to be annoyed for 3-4 hours instead of being home resting. Maybe there is no way around this, but it sure is annoying. They just opened up one of those urgent care clinics across town - maybe that is a better option now.
My thoughts:
-everyone is required to have a catastrophic plan. Yearly stop-loss of $10,000. Maybe even nationalize this part. 1 preventative checkup per year, zero help with costs until the $10,000 mark. Maybe make costs the same, per person, no matter what, perhaps?
-Requirements for insurance policies are standardized across all 50 states. These policies ought to be cheap, I mean they only have to cover up to $10,000 per year.
-It will become illegal for employers to do anything but provide a voucher that the employee can use to secure their own coverage.
-You can deny coverage for pre-existing conditions again, and the ratio of cost to young/old can increase a bit so we aren't forcing the young to subsidize the old. (fuck you baby boomers, you've looted this country enough.)
I'm not sure how to do it exactly, but I'd like to see more transparency in pricing for care. Emergency procedure's are a whole 'nother kettle of fish, but for non-emergency stuff certain should be do-able. Ideally people would be given enough information to make healthcare consumption decisions, while also feeling the economic impact of those decisions, to make this market work a bit more efficiently.
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preventative checkup per year, zero help with costs until the $10,000 mark. Maybe make costs the same, per person, no matter what, perhaps?
Out of curiosity, what happens to a family of 4 who only makes $40k per year?
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-everyone is required to have a catastrophic plan. Yearly stop-loss of $10,000. Maybe even nationalize this part. 1 preventative checkup per year, zero help with costs until the $10,000 mark. Maybe make costs the same, per person, no matter what, perhaps?
-Requirements for insurance policies are standardized across all 50 states. These policies ought to be cheap, I mean they only have to cover up to $10,000 per year.
-It will become illegal for employers to do anything but provide a voucher that the employee can use to secure their own coverage.
-You can deny coverage for pre-existing conditions again, and the ratio of cost to young/old can increase a bit so we aren't forcing the young to subsidize the old. (fuck you baby boomers, you've looted this country enough.)
I like parts of this, but the last caveat is troublesome, mostly because I have kids who have pre-existing conditions, and for them to be penalized through no fault of their own seems like they will be put at a disadvantage.
Also, I have a feeling that the effect of this is that many procedures will suddenly rise in price to $10,001 in order to soak the cap. Not sure what can be done about this though.
i'd also pair this with death panels so that we aren't incentivized to pump money into the last 6 months of a persons life.
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Politicians don't want to try to fix the 3,000 pound gorilla in the room- obesity. Poor diet and poorly designed car reliant suburbs means the US has a terribly unhealthy population.
Also, the government over regulates the actual business of healthcare. Ask any doctor or any hospital. The cost to comply and buy malpractice insurance is sky high. Ever heard of a certificate of need in retail? Healthcare has these all over the place, you can't even open up a hospital without one. The government must "certify" the need??? WTF? That's not freedom.
I say go self pay, with a health sharing plan instead. Self pay isn't scary if you lead a healthy lifestyle. Outside of having babies, we've never come close to meeting our deductibles.
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No one in the government negotiates with the drug companies, we just keep paying whatever it is. Trump said he was going to negotiate with them, and this is something I actually agreed with him on, but he hasn't done anything. He's only made them benefit more. I'm not surprised.
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I agree with most of what's been said so far. I'm with the OP, get rid of the insurance company middle-man in its current form and save 20% on insurance premiums. In various cities across the country I see large hospital systems buying up smaller hospitals, practices, etc. Maybe what could happen is that we start paying directly into the hospital system for our care, similar to the Kaiser system, eliminating insurance companies in their current form. Most people I've talked to (patients and providers) in the Kaiser system don't have complaints and Kaiser seems to do ok financially, yet in my area the plans they offer are about 20% less than a comparable plan from a private insurance company. Each city could have a few hospital systems from which patients can pay into and receive all their care from. They compete on price, quality and services. Coordination would likely improve, physician autonomy may decrease, but they'd likely be better supported. Maybe can even throw in a universal healthcare component where government finances (but doesn't run) these hospitals. Of course this is on top of reducing drug prices, tort reform, end of life care, etc.
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i'd also pair this with death panels so that we aren't incentivized to pump money into the last 6 months of a persons life.
Hey this is interesting. The idea of death panels is controversial at best, and viewed as repugnant by many. I'm surprised to see it here.
Does anyone else like the idea of death panels? I don't think that I do, although they may come to pass over the next 20 to 30 years.
Personally, there's absolutely no way I want to spend my last years in a nursing home or a palliative care ward.
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i'd also pair this with death panels so that we aren't incentivized to pump money into the last 6 months of a persons life.
Hey this is interesting. The idea of death panels is controversial at best, and viewed as repugnant by many. I'm surprised to see it here.
Does anyone else like the idea of death panels? I don't think that I do, although they may come to pass over the next 20 to 30 years.
Personally, there's absolutely no way I want to spend my last years in a nursing home or a palliative care ward.
I believe that it is a completely rational thing to do, when an individual is in their 80s, to determine a limit on what lengths we will go to prolong one's existence. It's going to be icky work, and I'll probably feel differently about it when it's my parents. And that's not to say a family can't pay with their own money, the exorbitant costs of those last few days, if it's worth it to them. (Of course, when a republican suggests this, I'll be because they want to kill the poor or something.)
Out of curiosity, what happens to a family of 4 who only makes $40k per year?
since a supplemental policy to bridge the gap between 0 and 10,000 ought to be fairly cheap, they'd... get one of those.
I like parts of this, but the last caveat is troublesome, mostly because I have kids who have pre-existing conditions, and for them to be penalized through no fault of their own seems like they will be put at a disadvantage.
Also, I have a feeling that the effect of this is that many procedures will suddenly rise in price to $10,001 in order to soak the cap. Not sure what can be done about this though.
i'd also pair this with death panels so that we aren't incentivized to pump money into the last 6 months of a persons life.
The catastrophic policy wouldn't have that caveat. And decoupling insurance from employment ought to mean less of those changes. But it would create an incentive with teeth to keep people from joining the plans that bridge the 0 to 10K gap after a diagnosis and causing the adverse selection death spiral.
And, as I said, I'm in support of some control on end-of-life spending.
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Giving free, accessible, and private birth control to all women and girls would placate both sides of the abortion debate.
I agree with everything you said...but this one is a real sticking point. We can't even agree on how to educate on sex education let alone giving free birth control to females. Conservatives will always be against this. If it's not because of religion, then because they don't want anybody to get anything "free" even if it saves money down the road. They're big on principles even if it means shooting themselves in the foot.
Good lord! In a thread on what's wrong with the cost of health care comes this, which could be exhibit A for how to reduce costs. Please, don't let yourself be brainwashed by the lefty echo chamber who've had this stunningly, ridiculously wrong. Making it "free" costs many multiples more than it would if it were simply OTC as it is for millions of women around the world in China, India & Mexico.
"Free" is not at all without cost. It's a very high cost because of insurance overhead, not just for the drugs themselves, but for the entirely unrelated exam that comes with a prescription renewal. It is also not "free" to the woman if it involves time off of work, getting a babysitter for other kids and transportation to submit to a pelvic exam lest her prescription for something unrelated is held hostage by a system of spiralling out of control costs. You want birth control to be cheapest and most accessible, you make it OTC and let Wall Mart stick it on their shelves next to Ibuprofen and Claritin. The market will cause the price to drop to around $9/month.
The unintended benefits include undocumented, uninsured or traveling women can purchase without missing a beat. A woman who doesn't want her employer or partner to know what she takes by having it appear on an EOB statement can do so privately by paying cash.
The other unintended benefit for the rest of Americans waiting for doctors appointments is that your doctor isn't busy giving an unrelated exam in exchange for a prescription. That is where patients save time and insurers and taxpayers would save money. Because the real waste in health care resources is when well people are taking up time in doctor's offices.
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My thoughts:
-everyone is required to have a catastrophic plan. Yearly stop-loss of $10,000. Maybe even nationalize this part. 1 preventative checkup per year, zero help with costs until the $10,000 mark. Maybe make costs the same, per person, no matter what, perhaps?
-Requirements for insurance policies are standardized across all 50 states. These policies ought to be cheap, I mean they only have to cover up to $10,000 per year.
-It will become illegal for employers to do anything but provide a voucher that the employee can use to secure their own coverage.
-You can deny coverage for pre-existing conditions again, and the ratio of cost to young/old can increase a bit so we aren't forcing the young to subsidize the old. (fuck you baby boomers, you've looted this country enough.)
I'm not sure how to do it exactly, but I'd like to see more transparency in pricing for care. Emergency procedure's are a whole 'nother kettle of fish, but for non-emergency stuff certain should be do-able. Ideally people would be given enough information to make healthcare consumption decisions, while also feeling the economic impact of those decisions, to make this market work a bit more efficiently.
Now we are finally talking...a conversation on actually decreasing the cost of care.
1) I fully agree with insurance being completely removed from most of our healthcare expenditures. Also have individuals buy catastrophic plans as you described above. yes there will be a very sticky transition point regarding what is covered by the catastrophic plan and what the limit is. These plans should be priced fairly. it should be less expensive for the healthier population but still have their premiums slightly higher to help offset the cost for the sicker and older population.
2) I also fully agree with cutting off futile care to the brain dead or those that will receive no improvement in quality of life. Families have the right to spend their own money if they desire.
3) Remove the massive bureaucracy out of health care. Stop forcing physicians to document useless nonsense for coding purposes as well as stop forcing us to use ICD-10 coding system for billing purposes.
4) Minimize lawsuits by placing caps as well as stopping lawsuits from poor outcomes. If we can't sue doctors and hospitals we must have the ability to remove poor performers from providing medical services to protect people.
5) Decrease some of the hoops the FDA forces drug companies to go through. The process to approve a new medication is much more onerous in the US as compared to many other countries. For example there is a new drug developed that can stop the bleeding for patients on a particular class of blood thinners. This has never existed and can really save lives. Plenty of trials have proven its efficacy but the FDA has delayed this drug going to market because they wanted more documentation despite the positive trials. This company was forced to take out a loan to continue operations until this drug is approved. Needles waste that not only costs money, but costs lives.
6) All medications and procedures need to have their costs easily listed and accessible. I should know exactly how much it will cost to remove my gallbladder or to have my cholesterol checked. There will never be cost reduction if there is no price transparency and competition.
7) We will also need to provide a way for the poor to be able to access healthcare. The best way for this is though community clinics and community hospitals. They will get free healthcare, but they will also have to wait. Lines will be longer unless you have an emergency. No private rooms in the hospital. But the medical care will be exactly the same if they paid for it. Good free care that is appropriately rationed just like in other countries with socialized healthcare.
I truly believe implementing all those changes above should cut the cost of healthcare by more than half. While still provide plenty of incentive for innovation. These steps need to be implemented over 10 years as making all those changes at once would put 100,000s of people out of work as they are all part of the middle man process. I would start with the most important which is mandatory price transparency.
Hey this is interesting. The idea of death panels is controversial at best, and viewed as repugnant by many. I'm surprised to see it here.
Does anyone else like the idea of death panels? I don't think that I do, although they may come to pass over the next 20 to 30 years.
Personally, there's absolutely no way I want to spend my last years in a nursing home or a palliative care ward.
Unfortunately there is a limit on how much we can spend on healthcare. Spending money on keeping the braindead alive is a waste of a very limited resource. I think if we chose a different name other than death panels it would not sound so evil. How about we call it "compassionate care." Allowing the very sick to die with dignity and comfort instead of continued pocking, probing and painful procedures that add nothing but suffering to our loved ones. Believe me, I truly believe what some people are forcing unto their very sick loved ones is awful and cruel.
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Soo solution?
Don't get healthcare :)
I have had jaw sugar (major), wisdom teeth removed, and my nuts slightly snipped. All without insurance and all of it being a fair price.
Many doctors are willing to work with you if you say you don't have insurance but can pay all cash up front.
My vasectomy was 750$ with ins, without, 125$
My wisdom teeth removal? They said it would be 250$ each tooth, so 1000$. Only charged me 250$ for all 4, that was including the pain meds.
Jaw surgery was est to be around 50k, in the end, i paid 10k....
I actually now carry HDHP, but even then i really don't even mention that i have it. I only have it due to major health issues that will get me sooner or later
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Giving free, accessible, and private birth control to all women and girls would placate both sides of the abortion debate.
I agree with everything you said...but this one is a real sticking point. We can't even agree on how to educate on sex education let alone giving free birth control to females. Conservatives will always be against this. If it's not because of religion, then because they don't want anybody to get anything "free" even if it saves money down the road. They're big on principles even if it means shooting themselves in the foot.
Good lord! In a thread on what's wrong with the cost of health care comes this, which could be exhibit A for how to reduce costs. Please, don't let yourself be brainwashed by the lefty echo chamber who've had this stunningly, ridiculously wrong. Making it "free" costs many multiples more than it would if it were simply OTC as it is for millions of women around the world in China, India & Mexico.
"Free" is not at all without cost. It's a very high cost because of insurance overhead, not just for the drugs themselves, but for the entirely unrelated exam that comes with a prescription renewal. It is also not "free" to the woman if it involves time off of work, getting a babysitter for other kids and transportation to submit to a pelvic exam lest her prescription for something unrelated is held hostage by a system of spiralling out of control costs. You want birth control to be cheapest and most accessible, you make it OTC and let Wall Mart stick it on their shelves next to Ibuprofen and Claritin. The market will cause the price to drop to around $9/month.
The unintended benefits include undocumented, uninsured or traveling women can purchase without missing a beat. A woman who doesn't want her employer or partner to know what she takes by having it appear on an EOB statement can do so privately by paying cash.
The other unintended benefit for the rest of Americans waiting for doctors appointments is that your doctor isn't busy giving an unrelated exam in exchange for a prescription. That is where patients save time and insurers and taxpayers would save money. Because the real waste in health care resources is when well people are taking up time in doctor's offices.
+1
This is a great example of one of the many things that's wrong with our health system.
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Insurance does not seem the best conveyance method for recurring commodities that are super cheap anyway. I get that we don't want cost to be a barrier to people controlling their reproduction, but there has to be a way to directly subsidize those costs without an insurance company skimming off the top or a gov't bureaucracy regulating it.
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Just to get some real numbers in here, my insurance pays $131.70 for a 99215 (high complexity return patient office visit). Medicare pays $111.78 for the same code. Medicaid in my state pays $46.70 for that code, which shows how much cross subsidization already exists in our system.
Our health care system is wildly expensive, and why that is the case is a very complex issue. I have a Masters degree in health policy and work in the field, which is enough to know that there are no easy answers and anyone who claims there are probably shouldn't be believed.
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Because realistically, a doctor visit is not worth $100 that is charged
I disagree. You're paying to see an expert who has invested many years/much money preparing to diagnose your ear infection. Why shouldn't that expert be paid well?
and asked him if he knows how to read food labels.
Most people don't understand how to read food labels.
I recently had a $2300 bill for 3 stitches in the ER. I have a $1500 deductible. Had I known the stitches were going to cost that much I would not have gotten them.
While I agree that $2300 seems like a lot of money for three stitches on it's face, you're not really paying for just 3 stitches with an emergency room visit.
You're paying for the emergency room to be staffed in order to triage and then see you in an expedient manner, staffed 24/7/365. Depending on the Trauma Level of the hospital, you're also paying that hospital to have all those other specialties staffed too.
You paid for the MD/PA 's time to see you and then stitch you up.
You paid for the sterile equipment used to stitch you up from drape to needle and whatever used to wash out the wound.
You paid for the person to sit there and triage you.
You paid for a nurse to see you.
You paid for someone to probably take your vital signs
You paid for maintenance of the facility, rooms parking lot, etc.
You paid a janitor or other to clean the room you stayed in. And the consumables such as chemicals etc. used.
You paid for salaries of executives/managers from the CEO down to the nurse manager and staffing office, security, valet parking attendants etc. etc. etc.
And probably more. The point is, it's not just three stitches built into that cost.
But I do agree that we should know how much things cost up front- hospitals and clinics should provide that information readily. But unless you're unconscious, you can nearly always tell them what tests/procedures you do or do not want done to you-sometimes not in your best interest to refuse though. I think the onus of knowing about insurance billing/pricing is already there if you have insurance by looking up what is and what is not covered prior to making an appointment. Otherwise you can get stuck paying large uncovered medical bills.
Good point -- all those things cost money.
Problem: How does one shop around when in an emergency medical situation?
Actually, I heard something on that subject years ago -- it may be a bit off topic: I attended a grand opening of a new hospital -- they opened the doors and let the general public come in and have a look at their new facilities. I found it interesting.
Anyway, when we toured the maternity ward, the host told us that they'd splurged on private rooms, fancy this and that -- not medically necessary things, mind you, but things to make new moms choose their hospital instead of another. They explained that this wasn't entirely altruistic; rather, they said that new mothers tend to take lots of time choosing where they'll give birth ... but then when a crisis comes along, the new mother automatically comes to "her hospital".
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Insurance does not seem the best conveyance method for recurring commodities that are super cheap anyway. I get that we don't want cost to be a barrier to people controlling their reproduction, but there has to be a way to directly subsidize those costs without an insurance company skimming off the top or a gov't bureaucracy regulating it.
We already have the perfect mechanism to subsidize that gives maximum autonomy to individuals: the tax code. If you are fortunate enough to be in a higher tax bracket -- should your birth-control be subsidized at all? I don't think so. If you are middle-class, it can be deductible or a tax credit. If you are poor, it can be a line-item credit added to the EITC. Alternatively, it can be an allowable purchase on EBT cards. In fact, there is no reason that an EBT card can't have a non-food balance for a number of things that are tax-deductible to the middle-class. The same logic that sorts purchases into payable by FSA/HSA debit cards for the middle-class ought to do it. It's already sorting your grocery bill (if you pay with EBT) into allowed & disallowed items.
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Just to get some real numbers in here, my insurance pays $131.70 for a 99215 (high complexity return patient office visit). Medicare pays $111.78 for the same code. Medicaid in my state pays $46.70 for that code, which shows how much cross subsidization already exists in our system.
Our health care system is wildly expensive, and why that is the case is a very complex issue. I have a Masters degree in health policy and work in the field, which is enough to know that there are no easy answers and anyone who claims there are probably shouldn't be believed.
You are right. There is no easy fix. My biggest gripe about the whole thing is that our politicians have us arguing about who will pay as opposed to actually trying to do something about cost. Is it really worth your time to see medicaid patients? I dunno maybe it is and maybe it isn't. What do you think the percentage of your reimbursement is overhead? How much time do you spend with a level 5 Medicaid patient?
But wouldn't you rather just charge much less, get cash and fire your coder/biller, fire your collections agency, fire your IT guy and just have you and a nurse manage all your patients? Don't you wish you did not have to try and get every chart up to a level 5 to squeeze every penny out of the insurance company or CMS? Don't you wish you did not have to waste valuable time documenting useless nonsense just so you can get paid. Basic medical care should be a cash business that would instantly decrease the cost for everyone.
Emergency care is a whole other story. As well as medical care for those who can not afford to pay cash as described in my example a few posts up.
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I am a nurse in a hospital so in a way I am both a supplier and a consumer. I also feel there is no use focusing solely on how we "supply" the healthcare without addressing the cost of the healthcare. I don't think getting rid of insurance companies is going to help at all.
I recently had a $2300 bill for 3 stitches in the ER. I have a $1500 deductible. Had I known the stitches were going to cost that much I would not have gotten them.
On a similar vein - I went to the ER because I almost cut off the tips of two of my fingers. It wasn't a big deal in the end and the nurse bandaged it up and as I was walking out, he handed me two metal finger protectors and said something to the effect of "Here, these might be useful." They didn't actually fit over the bandages though, and I never used them.
When the bill came, those two metal thingies had a price tag of $20 each. $40 as an afterthought that was 100% not requested, required, or useful.
But I don't think the nurse was being malicious or anything. He probably had no idea I was going to get changed $40 for that. I doubt he would have offered them to me if he'd known. And I doubt he'll ever find out. He's completely disconnected from the billing process, which is completely disconnected from my actual visit.
There are two easy ways to have lowered by bill by $40: If the nurse knew what those things cost, he may not have even offered them. If the bill was presented me before I exited the building, I could have declined them. But neither the supplier of that item nor the purchaser of that item knows the price of that item is so we never get the opportunity to address the price.
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I am a nurse in a hospital so in a way I am both a supplier and a consumer. I also feel there is no use focusing solely on how we "supply" the healthcare without addressing the cost of the healthcare. I don't think getting rid of insurance companies is going to help at all.
I recently had a $2300 bill for 3 stitches in the ER. I have a $1500 deductible. Had I known the stitches were going to cost that much I would not have gotten them.
On a similar vein - I went to the ER because I almost cut off the tips of two of my fingers. It wasn't a big deal in the end and the nurse bandaged it up and as I was walking out, he handed me two metal finger protectors and said something to the effect of "Here, these might be useful." They didn't actually fit over the bandages though, and I never used them.
When the bill came, those two metal thingies had a price tag of $20 each. $40 as an afterthought that was 100% not requested, required, or useful.
But I don't think the nurse was being malicious or anything. He probably had no idea I was going to get changed $40 for that. I doubt he would have offered them to me if he'd known. And I doubt he'll ever find out. He's completely disconnected from the billing process, which is completely disconnected from my actual visit.
There are two easy ways to have lowered by bill by $40: If the nurse knew what those things cost, he may not have even offered them. If the bill was presented me before I exited the building, I could have declined them. But neither the supplier of that item nor the purchaser of that item knows the price of that item is so we never get the opportunity to address the price.
I'll make you even more angry they cost only $2 each and probably much less in bulk. I'll make you even angrier. If a provider applied the splint they can bill your insurance for the application of it. How much they bill is a complete mystery of course but I am guessing Medicaid would pay about $30 for the application of each splint.
http://www.shoplet.com/Djo-Global-Finger-Splint-PROCARE-Frog-Style-Aluminum-Foam-Left-or-Right-Hand-Silver-Blue-Large/MCK19673000/spdv?gclid=CjwKEAjwqZ7GBRC1srKSv9TV_iwSJADKTjaDDRGtb_KBbn_SElt9rycCSoCYVY-JEr2BO_nH2qiKBBoCodjw_wcB
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I saw this article yesterday and found rather interesting. What Hospitals Waste (https://www.propublica.org/article/what-hospitals-waste)
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I saw this article yesterday and found rather interesting. What Hospitals Waste (https://www.propublica.org/article/what-hospitals-waste)
Great article and an awesome woman. Thanks for the link/read.
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If you were to redesign the health care system from scratch, how would you design it?
I really feel like much of the medical system is just run plain inefficiently. I hate going to the doctor where they make me fill out the same form every time. I also hate that half the time I go to the doctor, I end up getting sick afterwards from something I picked up while there. I hate talking to my doctor, because he or she seems really overwhelmed and unempathetic most of the time. I don't blame them, I just think they are overloaded.
If I have something minor, like bronchitis or a UTI, what I realized is that the worst part of it is that I have to haul my uncomfortable ass to the doctor, talk to them for 15 minutes, maybe do a test, and then get a prescription or a note to give my employer. I am sure I probably have made other people sick doing this. (As an aside, I always wonder how doctors and nurses avoid just being sick all the time) I end up having to be annoyed for 3-4 hours instead of being home resting. Maybe there is no way around this, but it sure is annoying. They just opened up one of those urgent care clinics across town - maybe that is a better option now.
A national health insurance policy that covers expenses over 10% of your income. In 2013, 10% was roughly the income the average person was spending on premiums and deductibles. This means everyone can afford healthcare for those of us who believe it should be part of the social compact, and there is still incentive to shop around for those of us who believe in the free market. If you want some kind of gap insurance for below that, it's fine, but it's not tax-deductible.
A lot of people trod out the unconscious man rushed in the ambulance as why the free market won't work for health care. Most of health care isn't like that. Providers just compete on things other than price, because most don't self-pay. ERs compete on wait-times (many hospitals have billboards with their current wait-times). Websites exist that have grades and reviews of doctors. Word-of-mouth of who's good. People don't normally end up consuming healthcare with no choice.
People will demand lower-cost solutions to common health issues. Physician assistants and nurse practitioners for colds and flus. Midwives for births. Maybe people will become more involved with their own care of "Do I really need that test/treatment/drug?" And you don't need everybody to participate in aggressive price shopping. As long as some critical mass does providers will start competing on costs.
Expensive treatments like cancer and end-of-life care will still probably expensive. We can't afford the best for everyone. We can either ration it by cost or by some government committee ("Death panels"). Government can't cover everything. Kidney transplant for a 68-year-old? Better be able to pay out of pocket or have private insurance. But I'd hope this plan will bend the cost curve for a lot of medical care and provide some modicum of affordable care for the poor.
Also, insurance is for unexpected costs. Car insurance covers accidents, not oil changes. Home insurance covers tornadoes, not replacing your 30-year-old roof because it's time. Health insurance shouldn't cover well-patient exams, colds, flu, labor and delivery, contraception. Those are all normal things. We're not insuring against them, we're just financing it differently. (This is what vision and dental "insurance" is, and if you look at the full cost of the policies, you're normally not saving much, if any, money.)
Preventive care is not the panacea people thought it would be. If it was, insurance companies would have to be told to cover it. People don't neglect contraception, because of the cost. Condoms are cheap/free. People don't accept some probability of an abortion/unwanted pregnancy because of the minimal cost of contraception. Making the pill OTC is a better idea and would be more effective.
Edit: Re: your last paragraph. My company offers Tel-A-Doc as benefit. You can phone the doctor, and the doctor will even phone in a prescription for you. There are other similar services and apps. Now, we just need an UberPrescriptions.
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If you were to redesign the health care system from scratch, how would you design it?
I really feel like much of the medical system is just run plain inefficiently. I hate going to the doctor where they make me fill out the same form every time. I also hate that half the time I go to the doctor, I end up getting sick afterwards from something I picked up while there. I hate talking to my doctor, because he or she seems really overwhelmed and unempathetic most of the time. I don't blame them, I just think they are overloaded.
If I have something minor, like bronchitis or a UTI, what I realized is that the worst part of it is that I have to haul my uncomfortable ass to the doctor, talk to them for 15 minutes, maybe do a test, and then get a prescription or a note to give my employer. I am sure I probably have made other people sick doing this. (As an aside, I always wonder how doctors and nurses avoid just being sick all the time) I end up having to be annoyed for 3-4 hours instead of being home resting. Maybe there is no way around this, but it sure is annoying. They just opened up one of those urgent care clinics across town - maybe that is a better option now.
A national health insurance policy that covers expenses over 10% of your income. In 2013, 10% was roughly the income the average person was spending on premiums and deductibles. This means everyone can afford healthcare for those of us who believe it should be part of the social compact, and there is still incentive to shop around for those of us who believe in the free market. If you want some kind of gap insurance for below that, it's fine, but it's not tax-deductible.
A lot of people trod out the unconscious man rushed in the ambulance as why the free market won't work for health care. Most of health care isn't like that. Providers just compete on things other than price, because most don't self-pay. ERs compete on wait-times (many hospitals have billboards with their current wait-times). Websites exist that have grades and reviews of doctors. Word-of-mouth of who's good. People don't normally end up consuming healthcare with no choice.
People will demand lower-cost solutions to common health issues. Physician assistants and nurse practitioners for colds and flus. Midwives for births. Maybe people will become more involved with their own care of "Do I really need that test/treatment/drug?" And you don't need everybody to participate in aggressive price shopping. As long as some critical mass does providers will start competing on costs.
Expensive treatments like cancer and end-of-life care will still probably expensive. We can't afford the best for everyone. We can either ration it by cost or by some government committee ("Death panels"). Government can't cover everything. Kidney transplant for a 68-year-old? Better be able to pay out of pocket or have private insurance. But I'd hope this plan will bend the cost curve for a lot of medical care and provide some modicum of affordable care for the poor.
Also, insurance is for unexpected costs. Car insurance covers accidents, not oil changes. Home insurance covers tornadoes, not replacing your 30-year-old roof because it's time. Health insurance shouldn't cover well-patient exams, colds, flu, labor and delivery, contraception. Those are all normal things. We're not insuring against them, we're just financing it differently. (This is what vision and dental "insurance" is, and if you look at the full cost of the policies, you're normally not saving much, if any, money.)
Preventive care is not the panacea people thought it would be. If it was, insurance companies would have to be told to cover it. People don't neglect contraception, because of the cost. Condoms are cheap/free. People don't accept some probability of an abortion/unwanted pregnancy because of the minimal cost of contraception. Making the pill OTC is a better idea and would be more effective.
Edit: Re: your last paragraph. My company offers Tel-A-Doc as benefit. You can phone the doctor, and the doctor will even phone in a prescription for you. There are other similar services and apps. Now, we just need an UberPrescriptions.
Very interesting take on this. I've been trying to become more knowledgeable about health care to form a solid opinion. Thank you for posting.
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The reason costs are so high in this country is that we are paying for socialized health care AND our own health care system. Bayer, Merck, Medtronic et al are global companies. Their goal is to make more money each year. It doesn't matter where that money comes from. So every time Germany decides they are only going to pay 20% of the asking price for drug X, Pfizer says, "OK. We will accept that." The companies roll over pretty much any time a country demands a lower price. Why would they do that? They run the numbers and see the price break will cost them $10mm so they look elsewhere to make up that revenue. Can they make that up in France? Nope, they limit costs. UK? Canada? Japan? Australia? No to all of those. Costs are limited there. The US? Winner winner chicken dinner! The government is specifically required NOT to negotiate lower prices. It's so easy to jack prices up in the US that it's not worth fighting for higher prices elsewhere. Insurance companies just want to take their cut of the pie so higher prices don't bother them as long as there is enough reserves coming in each year. It's playing a game of whack-a-mole except all but one mole is permanently forced down so only one can go up. That is us. Every time a country around the world limits their expenses, the US makes up for the lost revenue.
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Just to get some real numbers in here, my insurance pays $131.70 for a 99215 (high complexity return patient office visit). Medicare pays $111.78 for the same code. Medicaid in my state pays $46.70 for that code, which shows how much cross subsidization already exists in our system.
Our health care system is wildly expensive, and why that is the case is a very complex issue. I have a Masters degree in health policy and work in the field, which is enough to know that there are no easy answers and anyone who claims there are probably shouldn't be believed.
You are right. There is no easy fix. My biggest gripe about the whole thing is that our politicians have us arguing about who will pay as opposed to actually trying to do something about cost. Is it really worth your time to see medicaid patients? I dunno maybe it is and maybe it isn't. What do you think the percentage of your reimbursement is overhead? How much time do you spend with a level 5 Medicaid patient?
But wouldn't you rather just charge much less, get cash and fire your coder/biller, fire your collections agency, fire your IT guy and just have you and a nurse manage all your patients? Don't you wish you did not have to try and get every chart up to a level 5 to squeeze every penny out of the insurance company or CMS? Don't you wish you did not have to waste valuable time documenting useless nonsense just so you can get paid. Basic medical care should be a cash business that would instantly decrease the cost for everyone.
Emergency care is a whole other story. As well as medical care for those who can not afford to pay cash as described in my example a few posts up.
I'm not a provider, but I love hearing your thoughts on this. I work at a large academic medical center that tends to want to be a leader and therefore signs up for every new CMS program. And I totally agree that the level of overhead and bureaucracy are insane. We are accredited by a national accreditation body for our specialty, plus certified as part of a specialty-specific quality program, and participate in a CMS demonstration project for our specialty. That's three sets of reporting requirements just for specialty specific programs. And none of this reporting is automatically supported by our EMR, even though the alleged point of meaningful use is to enable data-driven decision making. And ultimately we participate in these programs for some combination of marketing and "it's the right thing to do".
I absolutely agree that we're way past the point of needing to talk about how to contain cost. And the answers are uncomfortable for a lot of patients and providers. People think in absolutes so often (this treatment is better!) instead of relatively (this treatment is slightly better for 10x the cost) and it makes rational decision making hard. To some extent who is paying has an influence on the tools available to address costs, but no matter how we pay, cost must be addressed.
Unfortunately I think people raise a great point about how we've chosen to make the healthcare industry 17% of our economy and it's hard to undo that. Healthcare supplies a ton of jobs, and we may not have the political will to rock the boat.
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The reason costs are so high in this country is that we are paying for socialized health care AND our own health care system. Bayer, Merck, Medtronic et al are global companies. Their goal is to make more money each year. It doesn't matter where that money comes from. So every time Germany decides they are only going to pay 20% of the asking price for drug X, Pfizer says, "OK. We will accept that." The companies roll over pretty much any time a country demands a lower price. Why would they do that? They run the numbers and see the price break will cost them $10mm so they look elsewhere to make up that revenue. Can they make that up in France? Nope, they limit costs. UK? Canada? Japan? Australia? No to all of those. Costs are limited there. The US? Winner winner chicken dinner! The government is specifically required NOT to negotiate lower prices. It's so easy to jack prices up in the US that it's not worth fighting for higher prices elsewhere. Insurance companies just want to take their cut of the pie so higher prices don't bother them as long as there is enough reserves coming in each year. It's playing a game of whack-a-mole except all but one mole is permanently forced down so only one can go up. That is us. Every time a country around the world limits their expenses, the US makes up for the lost revenue.
Very solid point. The thing is, Trump said he would negotiate with the companies. He never did, lol, he only made it better for them.
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The Market for Medical Care Should Work Like Cosmetic Surgery: http://www.ncpa.org/pdfs/st349.pdf (http://www.ncpa.org/pdfs/st349.pdf)
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Anyway, when we toured the maternity ward, the host told us that they'd splurged on private rooms, fancy this and that -- not medically necessary things, mind you, but things to make new moms choose their hospital instead of another. They explained that this wasn't entirely altruistic; rather, they said that new mothers tend to take lots of time choosing where they'll give birth ... but then when a crisis comes along, the new mother automatically comes to "her hospital".
There are some good points in this thread, but there is a fundamental assumption about how people buy medical care that is wrong. The whole idea that we would rationally choose cheaper care if only the costs and options were more open is transparent is crazy. When you are sick, you are also stressed, also emotional, not in a frame of mind to rationally compare options.
Maybe the mustashians here, but isn't the whole idea behind this forum that most people don't act in this way? I quoted the above bc the one medical area I know many do shop around for in advance is maternity care. And what do new moms want? Fancy services.
In other areas, we can't think rationally bc we are too stressed. My newborn daughter was born premature and spent two weeks in NICU. Do you think I was in a state of mind to calmly review our options? Even if I was by the second week, do you think I had the medical knowledge to question the doctor about necessity of treatment? If the doctor said XYZ is needed, I went along. Or the emotional state to do something like: the hospital down the street charges less for NICU, so I'm going to move her there.
As for end of life care, it is one thing to say, without the stress of the situation, that it does not make sense. It is another to have yourself, your spouse, your parent facing a situation. How do you know that THIS hospital visit is it for them, and they won't get better and have many years to come? I've had relatives with severe illnesses, spend a long time in hospitals, put DNR orders on them, but they recovered and now have a happy life.
We are not rational actors that a market based approach assumes. Not for many issues, but especially not medical care when we may literally be talking life and death. Trying to use market mechanisms to lower cost of health care is not going to solve the problem.
Sent from my iPhone using Tapatalk
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Anyway, when we toured the maternity ward, the host told us that they'd splurged on private rooms, fancy this and that -- not medically necessary things, mind you, but things to make new moms choose their hospital instead of another. They explained that this wasn't entirely altruistic; rather, they said that new mothers tend to take lots of time choosing where they'll give birth ... but then when a crisis comes along, the new mother automatically comes to "her hospital".
There are some good points in this thread, but there is a fundamental assumption about how people buy medical care that is wrong. The whole idea that we would rationally choose cheaper care if only the costs and options were more open is transparent is crazy. When you are sick, you are also stressed, also emotional, not in a frame of mind to rationally compare options.
Maybe the mustashians here, but isn't the whole idea behind this forum that most people don't act in this way? I quoted the above bc the one medical area I know many do shop around for in advance is maternity care. And what do new moms want? Fancy services.
In other areas, we can't think rationally bc we are too stressed. My newborn daughter was born premature and spent two weeks in NICU. Do you think I was in a state of mind to calmly review our options? Even if I was by the second week, do you think I had the medical knowledge to question the doctor about necessity of treatment? If the doctor said XYZ is needed, I went along. Or the emotional state to do something like: the hospital down the street charges less for NICU, so I'm going to move her there.
As for end of life care, it is one thing to say, without the stress of the situation, that it does not make sense. It is another to have yourself, your spouse, your parent facing a situation. How do you know that THIS hospital visit is it for them, and they won't get better and have many years to come? I've had relatives with severe illnesses, spend a long time in hospitals, put DNR orders on them, but they recovered and now have a happy life.
We are not rational actors that a market based approach assumes. Not for many issues, but especially not medical care when we may literally be talking life and death. Trying to use market mechanisms to lower cost of health care is not going to solve the problem.
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Your NICU example is a great one. I doubt anyone would seriously contemplate a NICU transfer after a traumatic birth. I know time in the NICU is really expensive, and I don't have any ideas on how to solve it.
I also think we overestimate how much healthcare is like the NICU where we wouldn't be capable of shopping around, and we also estimate how many people need to shop around for there to be a benefit. Would some cancer patients hear that their oncologist is only the second-best in the state and demand the top oncologist even if she costs $75,000 more over the course of their treatment? Yes, but as long as some cancer patients think "I'm going to go with cheaper, average oncologist and buy an Escalade with the leftover money), you're going to have some oncologists competing on price. Those price-competitive oncologists find cheaper ways to do things, and everyone benefits as their practices spread.
I hate that poor people can't get the healthcare they need. It's not that I love the idea of the "undeserving poor" suffering and support free-market healthcare for that reason. It's because I believe prices send important information about what people want and value. So I think it would be a great idea if the government funded HSAs and acted as a catastrophic insurer, but if people want a solution where they can waltz in and out of the hospital without seeing a bill... I think we're losing really important information.
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Sorry to say I think the real mistake we are all making is thinking things will ever actually get any better. There may be some small things here and there that may make it seem like it's getting better but nothing will ever change in any meaningful way. I know that sounds very negative but it's how I feel.
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If you upgrade to first class healthcare, you get the private room, nurse in short skirt, latte flavored jello
You really want me in a skirt? Ok...but I'm a dude with skinny and hairy legs. Not to mention the possibility of body fluids on your legs. Gross.
Well we're obviously slotting you for coach class care...
:)