Will ObamaCare Make Early Retirement More Difficult?

[Shane]

The insurance system is not the greatest. But you run into a lot of problems if you try to get away from it. One big problem is that consumers really don't know what they need. And it's not practical to expect them to be able to figure it out. You really need to have the years of education and practice that a physician has in order to make those judgments. And a lot of people will just not get needed care if they have a very large deductible. Whether it's because the don't have the money (either poverty or bad money management skills--prevalent in society) or because they don't want to spend the money or they don't have an accurate valuation of the benefit provided by the service. So you'll get a lot of people who will let problems go for too long and then end up with an amputation or some expensive hospitalization or totally preventable cancer, etc. I am very well educated about medical issues, but even I have trouble deciding when it's appropriate for me to get medical care when I have a high deductible plan. Part of that is that I don't know what things will cost. But part of that is the feeling that I'm likely wasting the money. Expecting the average not very educated person to make these decisions wisely is not realistic. And expecting the average not very fiscally responsible person to be able to manage the wild fluctuations in healthcare spending that might occur year-to-year is also not realistic. It's easy for those of us here with our disciplined (and incredibly rare) spending habits and larger than average incomes and 6 figure savings to write a $10k check if we needed to. Surveys indicate that most of the country couldn't get their hands on $2k if they needed it.

And this is just the beginning. I don't have the time to detail all the complications of changing to a pay-for-it-out-of-pocket system.

Capitalism is a really flawed, vicious, wasteful, and destructive system with lots of opportunities for the rich and powerful to abuse it to get richer and more powerful. But it's also pretty good at encouraging economic growth and distributing capital and flows of production, etc. We haven't found a system that works better in practice. I see health insurance the same way. I favor changing to a system similar to other industrialized nations. There are a number of different models that they use. And all work better than ours and cost much less. We're just doing it wrong here.

It seems pretty clear that the bolded part above is true. Every other rich, industrialized country in the world seems to be able to provide healthcare to its people for ~10% of GDP. Somehow, in the U.S. we are spending 17%+. It seems pretty clear we're doing something wrong and maybe we could learn something by studying how other countries manage to provide quality care for a lot less.

That we continue to allow private insurance companies to skim their profits out of the system makes absolutely no sense. If, collectively, we self insured and cut out the middleman, costs might go down. It seems to work fine in Europe and Japan. I've received healthcare in both of those places, and it was fine. The people I worked with there who have been using that model of healthcare all their lives looked pretty healthy to me, actually a lot healthier than the average Americans I see walking around in the U.S....

[beltim]

America's poor eating habits and expensive pharmaceuticals. That's what drives up healthcare costs.

Considering the total US spending on pharmaceuticals is 10% of health care costs, which is less than a lot of countries, this gets a big old WRONG.

And considering that the "poor eating habits" are only marginally worse than a few countries with half our health care costs, I strongly doubt that one as well.

[EnjoyIt]

America's poor eating habits and expensive pharmaceuticals. That's what drives up healthcare costs.

Considering the total US spending on pharmaceuticals is 10% of health care costs, which is less than a lot of countries, this gets a big old WRONG.

And considering that the "poor eating habits" are only marginally worse than a few countries with half our health care costs, I strongly doubt that one as well.

If we took away cigarettes and fast food I would happily be out of business.  People's life choices are appalling.  How is it right to keep treating the same person over and over again when they can't breath, yet continue to smoke with absolutely no interest in quitting. What about the 300 pound person in heart failure who would rather get bypass surgery with all its inherent complications instead of attempting diet an exercise?  The majority of people I see are overweight with high blood  pressure, diabetes and elevated cholesterol.  A good percentage of these people smoke.  I rarely see a thin person with minimal medical conditions with a heart attack or stroke.  it happens but it is rare.

[EnjoyIt]

The insurance system is not the greatest. But you run into a lot of problems if you try to get away from it. One big problem is that consumers really don't know what they need. And it's not practical to expect them to be able to figure it out. You really need to have the years of education and practice that a physician has in order to make those judgments. And a lot of people will just not get needed care if they have a very large deductible. Whether it's because the don't have the money (either poverty or bad money management skills--prevalent in society) or because they don't want to spend the money or they don't have an accurate valuation of the benefit provided by the service. So you'll get a lot of people who will let problems go for too long and then end up with an amputation or some expensive hospitalization or totally preventable cancer, etc. I am very well educated about medical issues, but even I have trouble deciding when it's appropriate for me to get medical care when I have a high deductible plan. Part of that is that I don't know what things will cost. But part of that is the feeling that I'm likely wasting the money. Expecting the average not very educated person to make these decisions wisely is not realistic. And expecting the average not very fiscally responsible person to be able to manage the wild fluctuations in healthcare spending that might occur year-to-year is also not realistic. It's easy for those of us here with our disciplined (and incredibly rare) spending habits and larger than average incomes and 6 figure savings to write a $10k check if we needed to. Surveys indicate that most of the country couldn't get their hands on $2k if they needed it.

And this is just the beginning. I don't have the time to detail all the complications of changing to a pay-for-it-out-of-pocket system.

Capitalism is a really flawed, vicious, wasteful, and destructive system with lots of opportunities for the rich and powerful to abuse it to get richer and more powerful. But it's also pretty good at encouraging economic growth and distributing capital and flows of production, etc. We haven't found a system that works better in practice. I see health insurance the same way. I favor changing to a system similar to other industrialized nations. There are a number of different models that they use. And all work better than ours and cost much less. We're just doing it wrong here.

You bring up 1 good point.  How does a patient know they need to pay for medical care?  A call center funded by government to ask questions. Followed by inexpensive and easy availability to primary care and clinics.

A few places do this:  Keiser has a setup like this where their members can call or see a representative that will send them to the appropriate medical facility or provider.

[onlykelsey]

America's poor eating habits and expensive pharmaceuticals. That's what drives up healthcare costs.

Considering the total US spending on pharmaceuticals is 10% of health care costs, which is less than a lot of countries, this gets a big old WRONG.

And considering that the "poor eating habits" are only marginally worse than a few countries with half our health care costs, I strongly doubt that one as well.

If we took away cigarettes and fast food I would happily be out of business.  People's life choices are appalling.  How is it right to keep treating the same person over and over again when they can't breath, yet continue to smoke with absolutely no interest in quitting. What about the 300 pound person in heart failure who would rather get bypass surgery with all its inherent complications instead of attempting diet an exercise?  The majority of people I see are overweight with high blood  pressure, diabetes and elevated cholesterol.  A good percentage of these people smoke.  I rarely see a thin person with minimal medical conditions with a heart attack or stroke.  it happens but it is rare.

Do you primarily treat cardiovascular issues?  I feel like my disastrously expensive medical events have not been behavior-related (that I can tell).  This year, for example, my body somehow lost my IUD, so I had to go in for multiple visits, and then get knocked out by an anesthesiologist and have it surgically removed to the tune of five figures.  A few years ago a colposcopy (which turned out not to be necessary) featuring an anesthesiologist that I specifically said I did not want to see and who did nothing except tell me his name cost me (really, my insurance plan) nearly 20K.  It seems absurd.  Nowhere else I've lived works like this.

[seattlecyclone]

It seems pretty clear that the bolded part above is true. Every other rich, industrialized country in the world seems to be able to provide healthcare to its people for ~10% of GDP. Somehow, in the U.S. we are spending 17%+. It seems pretty clear we're doing something wrong and maybe we could learn something by studying how other countries manage to provide quality care for a lot less.

That we continue to allow private insurance companies to skim their profits out of the system makes absolutely no sense. If, collectively, we self insured and cut out the middleman, costs might go down. It seems to work fine in Europe and Japan. I've received healthcare in both of those places, and it was fine. The people I worked with there who have been using that model of healthcare all their lives looked pretty healthy to me, actually a lot healthier than the average Americans I see walking around in the U.S....

Europe is not a single country, nor do they have a single way of managing health care. In fact, Switzerland's system sounds very similar to Obamacare: everyone must buy insurance meeting government standards from a private company, the insurance has annual deductibles with coinsurance after that up to an out-of-pocket maximum, and there are income-based subsidies to keep the premiums at a set percentage of a person's income.

And yet their system also costs less than ours. Cheaper health care does not necessarily entail having the government operate the entire medical industry, or even the payment aspect of it.

[EnjoyIt]

America's poor eating habits and expensive pharmaceuticals. That's what drives up healthcare costs.

Considering the total US spending on pharmaceuticals is 10% of health care costs, which is less than a lot of countries, this gets a big old WRONG.

And considering that the "poor eating habits" are only marginally worse than a few countries with half our health care costs, I strongly doubt that one as well.

If we took away cigarettes and fast food I would happily be out of business.  People's life choices are appalling.  How is it right to keep treating the same person over and over again when they can't breath, yet continue to smoke with absolutely no interest in quitting. What about the 300 pound person in heart failure who would rather get bypass surgery with all its inherent complications instead of attempting diet an exercise?  The majority of people I see are overweight with high blood  pressure, diabetes and elevated cholesterol.  A good percentage of these people smoke.  I rarely see a thin person with minimal medical conditions with a heart attack or stroke.  it happens but it is rare.

Do you primarily treat cardiovascular issues?  I feel like my disastrously expensive medical events have not been behavior-related (that I can tell).  This year, for example, my body somehow lost my IUD, so I had to go in for multiple visits, and then get knocked out by an anesthesiologist and have it surgically removed to the tune of five figures.  A few years ago a colposcopy (which turned out not to be necessary) featuring an anesthesiologist that I specifically said I did not want to see and who did nothing except tell me his name cost me (really, my insurance plan) nearly 20K.  It seems absurd.  Nowhere else I've lived works like this.

I treat all sorts of diseases and conditions and I agree that your issues are likely not dependent on your lifestyle choices.  I  do agree that your medical situation and costs are a downright shame and failure of our system.  The colposcopy I don't know, if abnormal cells were seen on the original smear, then the only way to know is to take a sample and look at it.  These procedures are intended to detect cancer early and actually do save people's lives. 

[randymarsh]

America's poor eating habits and expensive pharmaceuticals. That's what drives up healthcare costs.

Considering the total US spending on pharmaceuticals is 10% of health care costs, which is less than a lot of countries, this gets a big old WRONG.

And considering that the "poor eating habits" are only marginally worse than a few countries with half our health care costs, I strongly doubt that one as well.

If we took away cigarettes and fast food I would happily be out of business.  People's life choices are appalling.  How is it right to keep treating the same person over and over again when they can't breath, yet continue to smoke with absolutely no interest in quitting.

I think treating them is the correct moral answer, but as far as policy is concerned cost shouldn't be ignored. A decent size chunk of the population refuses to make the right decisions with disastrous public health consequences, among others. But in a country that puts personal freedom above all else, what can you do? Soda taxes are met with disdain. The FTC tried to reign in food advertising to children in the ~80s and of course Big Sugar put a stop to that. Government is either vilified or toothless and consumers have clearly shown they're fine with a diet of coke and pizza rolls.

[Cassie]

My Dad had a big stroke that left him with brain damage at age 59 and was not overweight, did not have HBP, etc. They never figured out why it happened. I also worked with a thin guy with HBP, high cholesterol that did everything right. Sometimes things just happen.

[NoCreativity]

Europe is not a single country, nor do they have a single way of managing health care. In fact, Switzerland's system sounds very similar to Obamacare: everyone must buy insurance meeting government standards from a private company, the insurance has annual deductibles with coinsurance after that up to an out-of-pocket maximum, and there are income-based subsidies to keep the premiums at a set percentage of a person's income.

And yet their system also costs less than ours. Cheaper health care does not necessarily entail having the government operate the entire medical industry, or even the payment aspect of it.
[/quote]


I was in undergrad many years ago with a guy that had moved from Spain where there is (was?) apparently a mixed system of socialized care but you could buy additional private insurance for faster / better care. He seemed really happy with their system.

[Spork]

America's poor eating habits and expensive pharmaceuticals. That's what drives up healthcare costs.

Considering the total US spending on pharmaceuticals is 10% of health care costs, which is less than a lot of countries, this gets a big old WRONG.

And considering that the "poor eating habits" are only marginally worse than a few countries with half our health care costs, I strongly doubt that one as well.

If we took away cigarettes and fast food I would happily be out of business.  People's life choices are appalling.  How is it right to keep treating the same person over and over again when they can't breath, yet continue to smoke with absolutely no interest in quitting.

I think treating them is the correct moral answer, but as far as policy is concerned cost shouldn't be ignored. A decent size chunk of the population refuses to make the right decisions with disastrous public health consequences, among others. But in a country that puts personal freedom above all else, what can you do? Soda taxes are met with disdain. The FTC tried to reign in food advertising to children in the ~80s and of course Big Sugar put a stop to that. Government is either vilified or toothless and consumers have clearly shown they're fine with a diet of coke and pizza rolls.

Actually, the funny thing is that unhealthy lifestyle REDUCES a person's average lifetime health care costs.  And they do so by reducing life span.  Every one of us will have increasing health care costs as we age.  We will all have end-of-life health care costs.  That guy that smokes 3 packs a day and dies at 50 just seems like he uses more of the system.  But when averaged in, he uses less.

It seems counter intuitive... but people with shorter lives just use less.

[Shane]

It seems pretty clear that the bolded part above is true. Every other rich, industrialized country in the world seems to be able to provide healthcare to its people for ~10% of GDP. Somehow, in the U.S. we are spending 17%+. It seems pretty clear we're doing something wrong and maybe we could learn something by studying how other countries manage to provide quality care for a lot less.

That we continue to allow private insurance companies to skim their profits out of the system makes absolutely no sense. If, collectively, we self insured and cut out the middleman, costs might go down. It seems to work fine in Europe and Japan. I've received healthcare in both of those places, and it was fine. The people I worked with there who have been using that model of healthcare all their lives looked pretty healthy to me, actually a lot healthier than the average Americans I see walking around in the U.S....

Europe is not a single country, nor do they have a single way of managing health care. In fact, Switzerland's system sounds very similar to Obamacare: everyone must buy insurance meeting government standards from a private company, the insurance has annual deductibles with coinsurance after that up to an out-of-pocket maximum, and there are income-based subsidies to keep the premiums at a set percentage of a person's income.

And yet their system also costs less than ours. Cheaper health care does not necessarily entail having the government operate the entire medical industry, or even the payment aspect of it.

My experience with healthcare in Europe was during several years living in Switzerland's neighbor, Austria. My health insurance was a government plan that paid for everything I ever needed, minus small co-pays. In Austria, I was told that some people chose to pay extra to have supplementary private insurance that basically allowed them to "jump the line," and not have to wait as long to get to see a doctor or have an operation or whatever. I think it also entitled them to private rooms in the hospital, instead of sharing with other patients.

Above, someone suggested that the high cost of pharmaceuticals in the U.S. was one of the reasons for our unusually high healthcare costs, but @beltim said that's not it because pharmaceuticals only account for 10% of costs. I suggested cutting out private insurance companies and allowing the American people to self insure, basically Medicare for All. But apparently insurance companies skimming profits out of the system may not be the problem...

So, does anyone have any idea what it is that makes healthcare so expensive in the U.S.? Is the problem what @EnjoyIt suggested that doctors in the U.S. have to constantly be looking over their shoulders because they're worried a patient's family will sue them if they make a mistake? Is it that we allow patients' families to request and receive unreasonably high priced and ultimately ineffective end of life care for patients that would be better just getting much cheaper palliative care from Hospice?

So, where's the low-hanging fruit? What single thing could we do that would have the most positive impact on lowering healthcare costs in the U.S.?

[monstermonster]

A huge portion of the cost of pharmacy costs in the US now is biologicals. Mine costs $33,600 a year. That is low compared to some other biologicals.

Biologicals primarily manage diseases that are not someone's "fault" from unhealthy lifestyle: cancer, lupus, chrone's, arthritis, plaque psoriasis.

They are not yet available in a ton of other countries, which is part of why our prescription costs are so high.

I'm an outwardly appearing healthy, non-smoker, low alcohol, whole foods diet, works out 6 days a week, runs half-marathons. This is not a lifestyle problem. But I cost the average health insurance payer about $5-10/year in subsidies to my fucking prescription.

That's part of what we need to fix is the R&D cost for biologicals that get passed along at these crazy high rates.

[EnjoyIt]

America's poor eating habits and expensive pharmaceuticals. That's what drives up healthcare costs.

Considering the total US spending on pharmaceuticals is 10% of health care costs, which is less than a lot of countries, this gets a big old WRONG.

And considering that the "poor eating habits" are only marginally worse than a few countries with half our health care costs, I strongly doubt that one as well.

If we took away cigarettes and fast food I would happily be out of business.  People's life choices are appalling.  How is it right to keep treating the same person over and over again when they can't breath, yet continue to smoke with absolutely no interest in quitting.

I think treating them is the correct moral answer, but as far as policy is concerned cost shouldn't be ignored. A decent size chunk of the population refuses to make the right decisions with disastrous public health consequences, among others. But in a country that puts personal freedom above all else, what can you do? Soda taxes are met with disdain. The FTC tried to reign in food advertising to children in the ~80s and of course Big Sugar put a stop to that. Government is either vilified or toothless and consumers have clearly shown they're fine with a diet of coke and pizza rolls.

Actually, the funny thing is that unhealthy lifestyle REDUCES a person's average lifetime health care costs.  And they do so by reducing life span.  Every one of us will have increasing health care costs as we age.  We will all have end-of-life health care costs.  That guy that smokes 3 packs a day and dies at 50 just seems like he uses more of the system.  But when averaged in, he uses less.

It seems counter intuitive... but people with shorter lives just use less.

people with those severe unhealthy lifestyles although live shorter, constantly require medical care and attension.  Often ICU care, cancer care and so forth.  They are actually very high utilizers of health care dollars.

It seems pretty clear that the bolded part above is true. Every other rich, industrialized country in the world seems to be able to provide healthcare to its people for ~10% of GDP. Somehow, in the U.S. we are spending 17%+. It seems pretty clear we're doing something wrong and maybe we could learn something by studying how other countries manage to provide quality care for a lot less.

That we continue to allow private insurance companies to skim their profits out of the system makes absolutely no sense. If, collectively, we self insured and cut out the middleman, costs might go down. It seems to work fine in Europe and Japan. I've received healthcare in both of those places, and it was fine. The people I worked with there who have been using that model of healthcare all their lives looked pretty healthy to me, actually a lot healthier than the average Americans I see walking around in the U.S....

Europe is not a single country, nor do they have a single way of managing health care. In fact, Switzerland's system sounds very similar to Obamacare: everyone must buy insurance meeting government standards from a private company, the insurance has annual deductibles with coinsurance after that up to an out-of-pocket maximum, and there are income-based subsidies to keep the premiums at a set percentage of a person's income.

And yet their system also costs less than ours. Cheaper health care does not necessarily entail having the government operate the entire medical industry, or even the payment aspect of it.

My experience with healthcare in Europe was during several years living in Switzerland's neighbor, Austria. My health insurance was a government plan that paid for everything I ever needed, minus small co-pays. In Austria, I was told that some people chose to pay extra to have supplementary private insurance that basically allowed them to "jump the line," and not have to wait as long to get to see a doctor or have an operation or whatever. I think it also entitled them to private rooms in the hospital, instead of sharing with other patients.

Above, someone suggested that the high cost of pharmaceuticals in the U.S. was one of the reasons for our unusually high healthcare costs, but @beltim said that's not it because pharmaceuticals only account for 10% of costs. I suggested cutting out private insurance companies and allowing the American people to self insure, basically Medicare for All. But apparently insurance companies skimming profits out of the system may not be the problem...

So, does anyone have any idea what it is that makes healthcare so expensive in the U.S.? Is the problem what @EnjoyIt suggested that doctors in the U.S. have to constantly be looking over their shoulders because they're worried a patient's family will sue them if they make a mistake? Is it that we allow patients' families to request and receive unreasonably high priced and ultimately ineffective end of life care for patients that would be better just getting much cheaper palliative care from Hospice?

So, where's the low-hanging fruit? What single thing could we do that would have the most positive impact on lowering healthcare costs in the U.S.?

I don't think it is any one thing, but a conglomeration of multiple issues:

1) Our pharmaceuticals cost more because of the high cost of R&D and the FDA approval process.
2) Regulatory burdens for collection of billing
3) Absurd JHACO regulations costing millions to reach compliance
4) American's who demand the most cutting edge therapies and medications regardless of cost
5) End of life care
6) Cover your ass medicine and cost of malpractice insurance
7) Malpractice insurance for hospitals as well
8) Primary care doctors who are too busy to see patients in a timely fashion and instead recommend they go to the Emergency Department.
9) Our current medical system where the cost of healthcare is seemingly free to most of the end consumer since they have health insurance forcing little to no downward pressure in cost.

I'm sure there is more but that is all I can think of right now.

[MoonShadow]

So, does anyone have any idea what it is that makes healthcare so expensive in the U.S.? Is the problem what @EnjoyIt suggested that doctors in the U.S. have to constantly be looking over their shoulders because they're worried a patient's family will sue them if they make a mistake? Is it that we allow patients' families to request and receive unreasonably high priced and ultimately ineffective end of life care for patients that would be better just getting much cheaper palliative care from Hospice?

It's a combination of many factors, but the tendency to over-prescribe testing is a part of it.  Bigger, I think, is the middle-man overhead that may layers of payment processing & regulation that increases the costs by including way more employees into the system than just the medical service providers & medical infrastructure costs.  Another contributing factor is likely to be that Americans are used to very high quality care in a timely fashion; which despite claims to the contrary, is not always the case in many European systems.

So, where's the low-hanging fruit? What single thing could we do that would have the most positive impact on lowering healthcare costs in the U.S.?

HSAs for everyone.  Once the concept that the funds are personally owned, the patient/payer naturally becomes much more cost conscious.  Since switching to an HSA for my family, we have switched doctor's offices; from a normal one with more employees for payment & records than doctors & nurses, to one with a single doctor & a single nurse whom refuse to process any insurance claims whatsoever.  I pay $1200 per year "membership" for my wife & myself (the kids would be an extra $10 per month, each, but they still go to their old pediatrician's office) and that covers every single visit during the year, period.  It would be higher if I was over 50, and lower if I was under 30, so it's somewhat based upon age.

[MoonShadow]

people with those severe unhealthy lifestyles although live shorter, constantly require medical care and attension.  Often ICU care, cancer care and so forth.  They are actually very high utilizers of health care dollars.

This is all true, but on average, even the most healthy person will eventually degrade until they need all these things as well.  The stats are unambiguous, a person who declines early and dies at 50 will consume less medical care over a lifetime than the person who does the same at 80.  So a 'life cycle' based single payer health care system is, automatically, predisposed to favor an early death of covered citizens.  It reminds me of an Onion article....

[NoCreativity]

So, does anyone have any idea what it is that makes healthcare so expensive in the U.S.? Is the problem what @EnjoyIt suggested that doctors in the U.S. have to constantly be looking over their shoulders because they're worried a patient's family will sue them if they make a mistake? Is it that we allow patients' families to request and receive unreasonably high priced and ultimately ineffective end of life care for patients that would be better just getting much cheaper palliative care from Hospice?

It's a combination of many factors, but the tendency to over-prescribe testing is a part of it.  Bigger, I think, is the middle-man overhead that may layers of payment processing & regulation that increases the costs by including way more employees into the system than just the medical service providers & medical infrastructure costs.  Another contributing factor is likely to be that Americans are used to very high quality care in a timely fashion; which despite claims to the contrary, is not always the case in many European systems.

So, where's the low-hanging fruit? What single thing could we do that would have the most positive impact on lowering healthcare costs in the U.S.?

HSAs for everyone.  Once the concept that the funds are personally owned, the patient/payer naturally becomes much more cost conscious.  Since switching to an HSA for my family, we have switched doctor's offices; from a normal one with more employees for payment & records than doctors & nurses, to one with a single doctor & a single nurse whom refuse to process any insurance claims whatsoever.  I pay $1200 per year "membership" for my wife & myself (the kids would be an extra $10 per month, each, but they still go to their old pediatrician's office) and that covers every single visit during the year, period.  It would be higher if I was over 50, and lower if I was under 30, so it's somewhat based upon age.

I think that's the way the whole system is currently moving. To a dichotomy of sorts where most people get care under a VERY managed single system, much like the Veterans Administration. And another group thatpay for services like mdvip and ZDoggMD's progect in Las Vegas - http://turntablehealth.com/

[Spork]

people with those severe unhealthy lifestyles although live shorter, constantly require medical care and attension.  Often ICU care, cancer care and so forth.  They are actually very high utilizers of health care dollars.

This is all true, but on average, even the most healthy person will eventually degrade until they need all these things as well.  The stats are unambiguous, a person who declines early and dies at 50 will consume less medical care over a lifetime than the person who does the same at 80.  So a 'life cycle' based single payer health care system is, automatically, predisposed to favor an early death of covered citizens.  It reminds me of an Onion article....

In the Onion article, did the government realize the savings and start to subsidize and promote unhealthy food alternatives like wheat and corn?  Oh wait.  No, that's not the Onion.

[Yaeger]

If you look at the healthcare costs by age across the different countries, it's very clear where the healthcare cost increases are coming from. We just need to halt the increases going to those 60+. If only we had a government program that controlled medical costs for that age group...

[MoonShadow]

http://www.theonion.com/video/social-security-reform-bill-encourages-americans-t-21006

This one is the one that I was thinking of, but the principle still applies.

[MoonShadow]

If you look at the healthcare costs by age across the different countries, it's very clear where the healthcare cost increases are coming from. We just need to halt the increases going to those 60+. If only we had a government program that controlled medical costs for that age group...

So, Yaeger, is it your opinion that repealing Medicare would result in the problem self-correcting within a decade or so?

[Yaeger]

If you look at the healthcare costs by age across the different countries, it's very clear where the healthcare cost increases are coming from. We just need to halt the increases going to those 60+. If only we had a government program that controlled medical costs for that age group...

So, Yaeger, is it your opinion that repealing Medicare would result in the problem self-correcting within a decade or so?

Ultimately, yes. Creating a market mechanism that restores the linkage between costs and medical outcomes is an essential part of controlling healthcare costs for a specific group, and ultimately for an entire population. Bringing the costs closer to the decision-makers (patients) is essential. However, I think it'd be incredibly destructive to do so without allowing for stopgap programs to wean people off of government dependency, but I think a goal of privatizing our healthcare market would do wonders for reducing the unsustainable growth of healthcare spending on a shrinking workforce and a growing percentage of elderly.

[randymarsh]

That graphic is very telling. I keep hearing that Medicare payments aren't that high though, so I don't understand why the spending skyrockets? Seems like the problem might be less Medicare itself and our obsession with keeping old patients alive? If Medicare payments aren't that generous, it makes sense that a large volume of tests/procedures/surgeries would result in the huge discrepancy between other countries.

[Spitfire]

That graphic is very telling. I keep hearing that Medicare payments aren't that high though, so I don't understand why the spending skyrockets? Seems like the problem might be less Medicare itself and our obsession with keeping old patients alive? If Medicare payments aren't that generous, it makes sense that a large volume of tests/procedures/surgeries would result in the huge discrepancy between other countries.

Beat me to it. If the resident doc here is saying Medicare doesn't pay enough, what gives with these old age costs in the US?

[Yaeger]

Beat me to it. If the resident doc here is saying Medicare doesn't pay enough, what gives with these old age costs in the US?

I'm not sure, but three things come to mind (doc feel free to correct me): inability for Medicare to negotiate drug prices, an increased number of unnecessary procedures and tests, and the inability for doctors to deny high-cost emergent care on chronically ill patients.

[seattlecyclone]

That graphic is very telling. I keep hearing that Medicare payments aren't that high though, so I don't understand why the spending skyrockets? Seems like the problem might be less Medicare itself and our obsession with keeping old patients alive? If Medicare payments aren't that generous, it makes sense that a large volume of tests/procedures/surgeries would result in the huge discrepancy between other countries.

Beat me to it. If the resident doc here is saying Medicare doesn't pay enough, what gives with these old age costs in the US?

Maybe it has to do with the quantity of procedures that it covers for an average senior citizen. The payments might not be as high per procedure as private insurance pays, but they still add up. Perhaps Medicare is willing to cover procedures with a higher dollar cost per quality-adjusted life year than other countries will.

[MoonShadow]

That graphic is very telling. I keep hearing that Medicare payments aren't that high though, so I don't understand why the spending skyrockets? Seems like the problem might be less Medicare itself and our obsession with keeping old patients alive? If Medicare payments aren't that generous, it makes sense that a large volume of tests/procedures/surgeries would result in the huge discrepancy between other countries.

Beat me to it. If the resident doc here is saying Medicare doesn't pay enough, what gives with these old age costs in the US?

Part of that is just volume.  Medicare payments still represent about half of all the medical care in the US, by price.  Part of it is, likely, a tendency for hospitals that do take medicare to make up losses on the sly, by regularly charging for associated services that may or may not have actually been provided.

[EnjoyIt]

people with those severe unhealthy lifestyles although live shorter, constantly require medical care and attension.  Often ICU care, cancer care and so forth.  They are actually very high utilizers of health care dollars.

This is all true, but on average, even the most healthy person will eventually degrade until they need all these things as well.  The stats are unambiguous, a person who declines early and dies at 50 will consume less medical care over a lifetime than the person who does the same at 80.  So a 'life cycle' based single payer health care system is, automatically, predisposed to favor an early death of covered citizens.  It reminds me of an Onion article....

Please share this unambiguous statistic.  I would really like to see it.  I just see several high utilizers of medical care and they are the very unhealthy.  They don't just utilizing care for being old.  They utilize care for all those ailments that led them there.  Such as the diabetic you becomes a dialysis patient for the next 15 years, or the smoker who ends up in the hospital once a month.  Or the alcoholic who needs his stomach drained every month.  I can go on so I am very curious regarding this statistic.

[EnjoyIt]

Beat me to it. If the resident doc here is saying Medicare doesn't pay enough, what gives with these old age costs in the US?

I'm not sure, but three things come to mind (doc feel free to correct me): inability for Medicare to negotiate drug prices, an increased number of unnecessary procedures and tests, and the inability for doctors to deny high-cost emergent care on chronically ill patients.

Just one correction, medicaid pays less than Medicare.  Medicaid pays out about 80% of what it costs to provide the service.  Medicare is more reasonable.

I would agree with all three of the above as well as the regulatory burden medicare imposes on hospitals and physicians.  This cost is then passed on back to CMS.  If an office needs to higher 2 people to make sure they can get all the proper information and bill medicare and then make sure they collect everything from medicare, who pays for those 2 people?  What about the whole office of people in hospitals that are required to comply with all these regulations.

Go into any ICU in the country and look at who is there.  I would bet at any one time you will find a minimum of 1 person who has been there for weeks with no quality of life.  They are a brain dead vegetable yet we are not allowed to let them die.  Eventually if they get stable enough they rot away in a skilled nursing facility until they get sick again and come right back to the hospital.  These patients easily cost $250k-$500k a year to treat.  Multiply that by every hospital and skilled nursing facility in the country and we can easily see where a huge chunk of our money is going.

Lastly, older people have a higher incidence of disease and therefor we do more testing.  For one, hospitals today get some reimbursement based on patient satisfaction, and lose money if the scores are very poor.  Doctors are pushed to make sure patients are happy and we all know if a patient does not get their test in a timely manor, they are not happy.  If they don't get their CT or MRI they are unhappy.  So we find ourselves ordering more tests and succumbing to patient demands.  Add in the training we all received while residents from mentors that practice defensive medicine, older patients inadvertently get more testing.  BTW, more testing leads to false positives which leads to more procedures and increased risk of complications.  But hey, CMS believes happy patients receive better care :roll eyes: 

Just an interesting tidbit about patient satisfaction scores.  It doesn't matter what your scores are, it matters what your scores are compared to other hospitals.  Top hospitals get extra cash, middle hospitals get no cash, and poor hospitals lose cash.  If a middle hospital moves up to a top hospital, that means one of the top hospitals gets dropped down to middle and they don't get paid.  Therefor the competition is very fierce since everyone can not be at the top.  It is a bullshit system that costs a crap load of money to track those surveys and also to work on improving them.

[seattlecyclone]

people with those severe unhealthy lifestyles although live shorter, constantly require medical care and attension.  Often ICU care, cancer care and so forth.  They are actually very high utilizers of health care dollars.

This is all true, but on average, even the most healthy person will eventually degrade until they need all these things as well.  The stats are unambiguous, a person who declines early and dies at 50 will consume less medical care over a lifetime than the person who does the same at 80.  So a 'life cycle' based single payer health care system is, automatically, predisposed to favor an early death of covered citizens.  It reminds me of an Onion article....

Please share this unambiguous statistic.  I would really like to see it.  I just see several high utilizers of medical care and they are the very unhealthy.  They don't just utilizing care for being old.  They utilize care for all those ailments that led them there.  Such as the diabetic you becomes a dialysis patient for the next 15 years, or the smoker who ends up in the hospital once a month.  Or the alcoholic who needs his stomach drained every month.  I can go on so I am very curious regarding this statistic.

Here's a link to a New York Times article about the study that the Dutch government did. Turns out that at least in the Netherlands, smokers and obese people cost less to treat over the course of a lifetime because they die sooner. They're also more likely to die of heart disease, which is probably cheaper than slowly fading away from dementia over a number of years (for example).

[EnjoyIt]

people with those severe unhealthy lifestyles although live shorter, constantly require medical care and attension.  Often ICU care, cancer care and so forth.  They are actually very high utilizers of health care dollars.

This is all true, but on average, even the most healthy person will eventually degrade until they need all these things as well.  The stats are unambiguous, a person who declines early and dies at 50 will consume less medical care over a lifetime than the person who does the same at 80.  So a 'life cycle' based single payer health care system is, automatically, predisposed to favor an early death of covered citizens.  It reminds me of an Onion article....

Please share this unambiguous statistic.  I would really like to see it.  I just see several high utilizers of medical care and they are the very unhealthy.  They don't just utilizing care for being old.  They utilize care for all those ailments that led them there.  Such as the diabetic you becomes a dialysis patient for the next 15 years, or the smoker who ends up in the hospital once a month.  Or the alcoholic who needs his stomach drained every month.  I can go on so I am very curious regarding this statistic.

Here's a link to a New York Times article about the study that the Dutch government did. Turns out that at least in the Netherlands, smokers and obese people cost less to treat over the course of a lifetime because they die sooner. They're also more likely to die of heart disease, which is probably cheaper than slowly fading away from dementia over a number of years (for example).

Please don't tale offense, but any study that is not US based can't possibly reflect the realities of the US.  After all the US spends so much more in healthcare per capita compared to the Netherlands.

I can tell you this much.  CMS has its own thoughts and has decided that preventative care and allowing patients to live longer may be cheaper.  Therefor they mandated for insurance to offer free yearly physicals including screening exams.  I assume the thinking behind this is that catching disease early and prolonging a patient's life costs less than treating the disease after it has progressed.  I know, this is kind of an apples vs oranges comparison.  Also government has decided to pay physicians for trying to get people to change their lifestyle.  You get to bill for smoking, drug and alcohol cessation counseling. I assume it costs less to get them to stop.

I'm not sure how much chemo and radiation costs in the Netherlands, but treating lung cancer costs a fortune in the US. I am also curious how expensive dialysis is compared to the US.  Dialysis patients live a long time, many on disability, have a medicaid cab pick them up and drive them to their dialysis center and then home 3 days a week.  Those patients are also very prone to complications and infections.  I can't imagine that is cheap. Don't get me wrong, people with appropriate life choices can still get those diseases, it is just much more frequent in the smokers, and the over-eaters.

[Daleth]

You mentioned negligence higher up.  Lets talk about negligence and talk about bad doctors.  Physicians are human and humans will always make mistakes.  There is absolutely no alternative it will happen to every physician.  Some mistakes are very minor while others may have catastrophic results.  A physician who made a mistake is not necessarily a bad physician, they may have made a choice on treatment options, that choice was not the best option and unfortunately a patient suffers the consequence.

Yeah, no. Some doctors are worse or more careless than others, and the threat of malpractice suits gives them a massive financial incentive to get better at their jobs, whether through continuing education, creating protocols to prevent certain mistakes and problems, or what have you. For that incentive to exist, negligence has to be the standard.

Sometimes medical negligence is leaving a surgical instrument or roll of gauze inside a patient's body. That IS a bad doctor, because part of being a good doctor is having protocols in place (or following the ones your hospital put in place) to prevent stupid mistakes like that from happening. Sometimes negligence is neglecting to wash your hands, change your gloves between patients, etc. If malicious intent is the standard, then a patient left with a sponge or tool inside him after surgery has no recourse: he has to pay for corrective surgery himself, he has to eat the cost of taking time off work, and he has to suffer (the pain caused by the original negligence plus the pain of the extra surgery) for nothing. None of that gets any compensation unless negligence is the standard. Similarly, if hospitals couldn't get sued for spreading infections through bad hygiene practices, that would basically be a license to be careless--in fact it would be a license to get paid MORE for being careless, since patients who get infections need more medical care as a result.

  I will give you a very common example:  A patient sees their doctor with belly pain.  The doctor evaluates the patient, gets labs, and treats the pain.  The patient feels better and goes home.  The doctor chose not to get the CT scan since that imaging carries is a high radiation dose and comes with its own risk.  The patient goes home and turns out the physician missed an appendicitis which ruptures.  The patient has a bad outcome requiring surgery and extensive in-hospital stay.  Is this negligence?  I don't think so.  It is a bad outcome though in many states this is a lawsuit that the patient will win.

The reason the patient will win is because in your example, the doctor actually was negligent. What you're describing isn't the standard of care. The doctor should have palpated the patient's belly to see if there was pain in the area of the appendix, should have done blood tests that check whether the patient was fighting an infection, and if the tests were positive the physician should have followed up with an ultrasound. A CT can diagnose appendicitis but an ultrasound can too, with no radiation and at a far lower cost. If the patient for some reason refused an ultrasound, the doctor should then have warned him what the risk was and suggested keeping him overnight for evaluation. If the patient refused that too, the doctor should've warned him of the risk again--by that point most patients would listen to their doctors, and those who don't listen even after all that are not going to win a malpractice suit.

[Spork]

people with those severe unhealthy lifestyles although live shorter, constantly require medical care and attension.  Often ICU care, cancer care and so forth.  They are actually very high utilizers of health care dollars.

This is all true, but on average, even the most healthy person will eventually degrade until they need all these things as well.  The stats are unambiguous, a person who declines early and dies at 50 will consume less medical care over a lifetime than the person who does the same at 80.  So a 'life cycle' based single payer health care system is, automatically, predisposed to favor an early death of covered citizens.  It reminds me of an Onion article....

Please share this unambiguous statistic.  I would really like to see it.  I just see several high utilizers of medical care and they are the very unhealthy.  They don't just utilizing care for being old.  They utilize care for all those ailments that led them there.  Such as the diabetic you becomes a dialysis patient for the next 15 years, or the smoker who ends up in the hospital once a month.  Or the alcoholic who needs his stomach drained every month.  I can go on so I am very curious regarding this statistic.

Here's a link to a New York Times article about the study that the Dutch government did. Turns out that at least in the Netherlands, smokers and obese people cost less to treat over the course of a lifetime because they die sooner. They're also more likely to die of heart disease, which is probably cheaper than slowly fading away from dementia over a number of years (for example).

Please don't tale offense, but any study that is not US based can't possibly reflect the realities of the US.  After all the US spends so much more in healthcare per capita compared to the Netherlands.

I can tell you this much.  CMS has its own thoughts and has decided that preventative care and allowing patients to live longer may be cheaper.  Therefor they mandated for insurance to offer free yearly physicals including screening exams.  I assume the thinking behind this is that catching disease early and prolonging a patient's life costs less than treating the disease after it has progressed.  I know, this is kind of an apples vs oranges comparison.  Also government has decided to pay physicians for trying to get people to change their lifestyle.  You get to bill for smoking, drug and alcohol cessation counseling. I assume it costs less to get them to stop.

I'm not sure how much chemo and radiation costs in the Netherlands, but treating lung cancer costs a fortune in the US. I am also curious how expensive dialysis is compared to the US.  Dialysis patients live a long time, many on disability, have a medicaid cab pick them up and drive them to their dialysis center and then home 3 days a week.  Those patients are also very prone to complications and infections.  I can't imagine that is cheap. Don't get me wrong, people with appropriate life choices can still get those diseases, it is just much more frequent in the smokers, and the over-eaters.

Give me a guestimate of costs to treat these 2 patients over a lifetime:
Patient 1: unhealthy lifestyle.  Gets lung cancer at 47.  Expensive treatment.  Dies at 50.
Patient 2: moderately healthy lifestyle.  Coronary bypass at 47 (probably due to family history, stressful job and terrible advice on how eating healthy constitutes low fat/high carb diets).  Liver cancer diagnosed in his 50s and a lobe of the liver removed (but was found not to be cancerous by pathology). Experimental kidney stone extraction done in 50s that failed and likely damaged kidney.  Cancer of that same kidney diagnosed in his 60s and nephrectomy was done.  Starts having CHF at 82.  Has about 20 incidents of atrial fibrillation which are treated with cardioversion, medication, ablation ... none of which work.  Gets an experimental heart valve repair at 85 which doesn't really work.  Gets a valve replacement at 86 which works, but has complications leaving him in an ICU for 6 weeks on a vent and on dialysis, followed by 6 weeks of LTAC care, followed by a week of hospice.  Dies at 86.

[seattlecyclone]

Please don't tale offense, but any study that is not US based can't possibly reflect the realities of the US.  After all the US spends so much more in healthcare per capita compared to the Netherlands.

I can tell you this much.  CMS has its own thoughts and has decided that preventative care and allowing patients to live longer may be cheaper.  Therefor they mandated for insurance to offer free yearly physicals including screening exams.  I assume the thinking behind this is that catching disease early and prolonging a patient's life costs less than treating the disease after it has progressed.  I know, this is kind of an apples vs oranges comparison.  Also government has decided to pay physicians for trying to get people to change their lifestyle.  You get to bill for smoking, drug and alcohol cessation counseling. I assume it costs less to get them to stop.

I'm not sure how much chemo and radiation costs in the Netherlands, but treating lung cancer costs a fortune in the US. I am also curious how expensive dialysis is compared to the US.  Dialysis patients live a long time, many on disability, have a medicaid cab pick them up and drive them to their dialysis center and then home 3 days a week.  Those patients are also very prone to complications and infections.  I can't imagine that is cheap. Don't get me wrong, people with appropriate life choices can still get those diseases, it is just much more frequent in the smokers, and the over-eaters.

Sure, I'll grant that there are differences in cost between the Netherlands and the US. If I knew of a US-based study I would have linked it. We already know that overall costs are higher here than in the Netherlands. It seems that for a US-based study to get a contrary result from the Netherlands one, the cost differential for the care smokers and obese people require would need to be vastly higher than the cost differential for other types of care. Yes, treating lung cancer here is expensive. It's expensive over there too! The point is that when someone dies of lung cancer at a young age, they don't live long enough to get other diseases in old age that are often even more expensive to treat.

Some of those regulations you mention (required preventive care coverage, smoking cessation programs) might not be for cost-related reasons at all, but rather because the people in charge think it's good to have access to this stuff because it makes peoples' lives longer even if it ends up costing more. Heck, maybe these regulations do save money for the insurance companies because pushing expensive end-of-life care off past age 65 shifts the cost burden from them to Medicare.

[EnjoyIt]

You mentioned negligence higher up.  Lets talk about negligence and talk about bad doctors.  Physicians are human and humans will always make mistakes.  There is absolutely no alternative it will happen to every physician.  Some mistakes are very minor while others may have catastrophic results.  A physician who made a mistake is not necessarily a bad physician, they may have made a choice on treatment options, that choice was not the best option and unfortunately a patient suffers the consequence.

Yeah, no. Some doctors are worse or more careless than others, and the threat of malpractice suits gives them a massive financial incentive to get better at their jobs, whether through continuing education, creating protocols to prevent certain mistakes and problems, or what have you. For that incentive to exist, negligence has to be the standard.

Sometimes medical negligence is leaving a surgical instrument or roll of gauze inside a patient's body. That IS a bad doctor, because part of being a good doctor is having protocols in place (or following the ones your hospital put in place) to prevent stupid mistakes like that from happening. Sometimes negligence is neglecting to wash your hands, change your gloves between patients, etc. If malicious intent is the standard, then a patient left with a sponge or tool inside him after surgery has no recourse: he has to pay for corrective surgery himself, he has to eat the cost of taking time off work, and he has to suffer (the pain caused by the original negligence plus the pain of the extra surgery) for nothing. None of that gets any compensation unless negligence is the standard. Similarly, if hospitals couldn't get sued for spreading infections through bad hygiene practices, that would basically be a license to be careless--in fact it would be a license to get paid MORE for being careless, since patients who get infections need more medical care as a result.

  I will give you a very common example:  A patient sees their doctor with belly pain.  The doctor evaluates the patient, gets labs, and treats the pain.  The patient feels better and goes home.  The doctor chose not to get the CT scan since that imaging carries is a high radiation dose and comes with its own risk.  The patient goes home and turns out the physician missed an appendicitis which ruptures.  The patient has a bad outcome requiring surgery and extensive in-hospital stay.  Is this negligence?  I don't think so.  It is a bad outcome though in many states this is a lawsuit that the patient will win.

The reason the patient will win is because in your example, the doctor actually was negligent. What you're describing isn't the standard of care. The doctor should have palpated the patient's belly to see if there was pain in the area of the appendix, should have done blood tests that check whether the patient was fighting an infection, and if the tests were positive the physician should have followed up with an ultrasound. A CT can diagnose appendicitis but an ultrasound can too, with no radiation and at a far lower cost. If the patient for some reason refused an ultrasound, the doctor should then have warned him what the risk was and suggested keeping him overnight for evaluation. If the patient refused that too, the doctor should've warned him of the risk again--by that point most patients would listen to their doctors, and those who don't listen even after all that are not going to win a malpractice suit.

Thanks for bringing the discussion to the table:

Not all patients like to read the textbook and present with classic signs of appendicitis.  White count does not rule in or rule out the disease.  Also, an early retorocecal inflamed appendix will not present with right lower quadrant abdominal pain.  Lastly ultrasound although is able to rule in an appendicitis, it is very technician dependent.  I know very few technicians who I would trust to make that diagnosis and refuse to rely on it as a modality except for kids with an obvious appendicitis to avoid unnecessary radiation.  The patient I described above I have seen on several occasions.  I have seen the CT done and I have also seen the CT not done and the patient comes back.  We have to remember that a poor outcome is not negligence.  We can not scan every person who has some belly pain.  Just as equally I have seen doctors get burned and order CTs almost 100% of the time whenever there is abdominal discomfort which is equally wrong.

Negligence and fear of lawsuits does not make you a better doctor.  It makes you a defensive doctor which actually brings higher risk to the patient through over testing.  Peer review makes you a good doctor.  Your practice being scrutinized by a group of physicians who tell you that you are wrong and need to get better educated or else lose your privileges or worse your license.  This process really works.

Lastly, a pice of gauze left in the abdomen.  How does this happen? A difficult procedure with a lot of oozing due to patient's disease process which requires tons of gauze.  The process for hospitals is to open up a package and count the gauze as well as instruments.  When the procedure is done before closing the technician counts the gauze and instruments again.  If we don't have a match the surgeon looks for the missing equipment.  If it is not found an X-ray is performed to try and localize it.  Now what happens if the technicians who counts the gauze made a mistake.  No search is performed and the patient goes home and gets sick.  This was not a bad doctor.  This was a failed process instituted by the hospital.  In cases like this the patient's bill is waived.  Yes there should be covered compensation for lost time off work. But it should not be millions and the lawyer should not get millions either. It should not be the doctor who covers that bill.  This is the reason why I practice in a state with tort reform. There are lawyers that provide a needed service for society, but the malpractice lawyers are leeches looking for any underhanded way to make a lot of money on the suffering of others. They are scum and give good lawyers a bad reputation. These lawyers have little business in my state.  Only real cases go to court here.  The gauze case above is a done deal and paid out by the hospital without even having to go to court.  the appy case I described above doesn't even get past the lawyers office since it is not worth their time to take the case.

[EnjoyIt]

Give me a guestimate of costs to treat these 2 patients over a lifetime:
Patient 1: unhealthy lifestyle.  Gets lung cancer at 47.  Expensive treatment.  Dies at 50.
Patient 2: moderately healthy lifestyle.  Coronary bypass at 47 (probably due to family history, stressful job and terrible advice on how eating healthy constitutes low fat/high carb diets).  Liver cancer diagnosed in his 50s and a lobe of the liver removed (but was found not to be cancerous by pathology). Experimental kidney stone extraction done in 50s that failed and likely damaged kidney.  Cancer of that same kidney diagnosed in his 60s and nephrectomy was done.  Starts having CHF at 82.  Has about 20 incidents of atrial fibrillation which are treated with cardioversion, medication, ablation ... none of which work.  Gets an experimental heart valve repair at 85 which doesn't really work.  Gets a valve replacement at 86 which works, but has complications leaving him in an ICU for 6 weeks on a vent and on dialysis, followed by 6 weeks of LTAC care, followed by a week of hospice.  Dies at 86.

Both cost a fortune though a 47 year old who dies before 65 does not hit the government dollars unless they were poor and on medicaid.  Therefor by shear nature the 86 year old costs more to the government.  I would also like to point out that the cancer patient who survives past 65 will likely be in the hospital often for respiratory issues.

Requiring bypass in a healthy lifestyle individual at 47 is very likely genetic and bad luck.  Based on the explicit details I assume this is someone you know.  Having CHF and A-fib and then getting valve replacement surgery at 86 concerns me a little.  Why go through that surgery unless quality of life is still excellent at 86 and the body is still healthy?  My grandfather was diagnosed with colon cancer at 94, had a hemi-colectomy (part of his colon removed.) Although the surgery went well, he was never the same and died shortly afterwards never leaving the rehab facility other than back and forth to the hospital.  If I knew then what I know now, I would have adamantly tried to educate and prevent the surgery from happening.  Better to live another year or two with family and with cancer followed by hospice than to put up with what he did in the last few months of his life.  Both of our examples are an utter waste of our healthcare dollars and actually shortened the life of our loved ones. 

[Spork]

Give me a guestimate of costs to treat these 2 patients over a lifetime:
Patient 1: unhealthy lifestyle.  Gets lung cancer at 47.  Expensive treatment.  Dies at 50.
Patient 2: moderately healthy lifestyle.  Coronary bypass at 47 (probably due to family history, stressful job and terrible advice on how eating healthy constitutes low fat/high carb diets).  Liver cancer diagnosed in his 50s and a lobe of the liver removed (but was found not to be cancerous by pathology). Experimental kidney stone extraction done in 50s that failed and likely damaged kidney.  Cancer of that same kidney diagnosed in his 60s and nephrectomy was done.  Starts having CHF at 82.  Has about 20 incidents of atrial fibrillation which are treated with cardioversion, medication, ablation ... none of which work.  Gets an experimental heart valve repair at 85 which doesn't really work.  Gets a valve replacement at 86 which works, but has complications leaving him in an ICU for 6 weeks on a vent and on dialysis, followed by 6 weeks of LTAC care, followed by a week of hospice.  Dies at 86.

Both cost a fortune though a 47 year old who dies before 65 does not hit the government dollars unless they were poor and on medicaid.  Therefor by shear nature the 86 year old costs more to the government.  I would also like to point out that the cancer patient who survives past 65 will likely be in the hospital often for respiratory issues.

Requiring bypass in a healthy lifestyle individual at 47 is very likely genetic and bad luck.  Based on the explicit details I assume this is someone you know.  Having CHF and A-fib and then getting valve replacement surgery at 86 concerns me a little.  Why go through that surgery unless quality of life is still excellent at 86 and the body is still healthy?  My grandfather was diagnosed with colon cancer at 94, had a hemi-colectomy (part of his colon removed.) Although the surgery went well, he was never the same and died shortly afterwards never leaving the rehab facility other than back and forth to the hospital.  If I knew then what I know now, I would have adamantly tried to educate and prevent the surgery from happening.  Better to live another year or two with family and with cancer followed by hospice than to put up with what he did in the last few months of his life.  Both of our examples are an utter waste of our healthcare dollars and actually shortened the life of our loved ones.

My point is:  More often than not, unhealthy lifestyles utilize less medical care over their lifetime.  The end-of-life care (either at 86 or 50) is ridiculously expensive.  But if you die at 50, you're not getting 30 years of checkups, mammograms, colonoscopies, etc.  After you're dead, you're at extremely low risk of getting treated for kidney stones, gall stones, appendectomies, etc.  You're very unlikely to be in a car accident and require emergency attention.

In short: It's not the cost of the end-of-life care, it's the 30-40 years of care you're NOT GOING TO GET that makes unhealthy people use less healthcare over their life span.

[Shane]

I agree with Dr. EnjoyIt. Doctors are human beings and will inevitably make mistakes sometimes. In the event that a doctor inadvertently causes injury to a patient, it makes sense that the doctor and/or hospital's insurance company should compensate the patient in some way, but they don't necessarily deserve to get $millions. I'm fine with giving up my current rights to sue doctors and hospitals that accidentally harm me in exchange for lower prices on healthcare. Doctors shouldn't have to worry that if they make a mistake they will lose their house!

[Cassie]

In the studies comparing US to other countries does it take into account that the US has a much bigger population then most European countries? I would never waive my right to sue for lower costs. I have never sued anyone but if a doctor caused a loved one to die or be severely disabled because of negligence I would want to retain that ability.

[randymarsh]

In the studies comparing US to other countries does it take into account that the US has a much bigger population then most European countries? I would never waive my right to sue for lower costs. I have never sued anyone but if a doctor caused a loved one to die or be severely disabled because of negligence I would want to retain that ability.

What's the connection between population and lawsuits? I would argue that US per capita costs should be lower than European countries because of scale.

[Cassie]

No connection. I was saying that if you are comparing health care costs for US versus smaller countries then of course we would spend more. Lawsuits are a separate issue.

[tonysemail]

Do doctors really lose their houses to lawsuits?
I always assumed doctors buy enough commercial umbrella insurance that the financial stress is much less impact than the emotional stress.

http://www.medscape.com/viewarticle/861612
"It's a myth that lives on, despite the fact that it happens so rarely," said Michael Sacopulos, a defense attorney in Terre Haute, Indiana. "First of all, two thirds of malpractice claims are dropped or dismissed, and physicians win 90% of cases that go to trial. Almost all cases that reach a verdict are settled by the insurer without the doctor spending a penny of his or her own money."

[Schaefer Light]

Do doctors really lose their houses to lawsuits?
I always assumed doctors buy enough commercial umbrella insurance that the financial stress is much less impact than the emotional stress.

http://www.medscape.com/viewarticle/861612
"It's a myth that lives on, despite the fact that it happens so rarely," said Michael Sacopulos, a defense attorney in Terre Haute, Indiana. "First of all, two thirds of malpractice claims are dropped or dismissed, and physicians win 90% of cases that go to trial. Almost all cases that reach a verdict are settled by the insurer without the doctor spending a penny of his or her own money."

But the insurer has to pay its lawyers...thus driving up the cost of insurance.

[thd7t]

Do doctors really lose their houses to lawsuits?
I always assumed doctors buy enough commercial umbrella insurance that the financial stress is much less impact than the emotional stress.

http://www.medscape.com/viewarticle/861612
"It's a myth that lives on, despite the fact that it happens so rarely," said Michael Sacopulos, a defense attorney in Terre Haute, Indiana. "First of all, two thirds of malpractice claims are dropped or dismissed, and physicians win 90% of cases that go to trial. Almost all cases that reach a verdict are settled by the insurer without the doctor spending a penny of his or her own money."

But the insurer has to pay its lawyers...thus driving up the cost of insurance.

Are you saying that the cost of malpractice insurance is causing doctors to lose their houses? If that were true, doctors would forgo insurance, bringing the market back down.

[Schaefer Light]

Do doctors really lose their houses to lawsuits?
I always assumed doctors buy enough commercial umbrella insurance that the financial stress is much less impact than the emotional stress.

http://www.medscape.com/viewarticle/861612
"It's a myth that lives on, despite the fact that it happens so rarely," said Michael Sacopulos, a defense attorney in Terre Haute, Indiana. "First of all, two thirds of malpractice claims are dropped or dismissed, and physicians win 90% of cases that go to trial. Almost all cases that reach a verdict are settled by the insurer without the doctor spending a penny of his or her own money."

But the insurer has to pay its lawyers...thus driving up the cost of insurance.

Are you saying that the cost of malpractice insurance is causing doctors to lose their houses? If that were true, doctors would forgo insurance, bringing the market back down.

No, I'm saying that the lawyers involved are making health care more expensive than it needs to be.

[forummm]

Lastly, insurance companies follow suit of CMS because CMS constantly is trying to cut costs and decrease payments.  private insurance wants to pay out less so they follow whatever CMS does.

So if both CMS and private insurers think XYZ will save money--why are you against it? I get that it could be personally bothersome as a physician. But I mean from a societal perspective.

[forummm]

America's poor eating habits and expensive pharmaceuticals. That's what drives up healthcare costs.

Considering the total US spending on pharmaceuticals is 10% of health care costs, which is less than a lot of countries, this gets a big old WRONG.

And considering that the "poor eating habits" are only marginally worse than a few countries with half our health care costs, I strongly doubt that one as well.

If we took away cigarettes and fast food I would happily be out of business.  People's life choices are appalling.  How is it right to keep treating the same person over and over again when they can't breath, yet continue to smoke with absolutely no interest in quitting. What about the 300 pound person in heart failure who would rather get bypass surgery with all its inherent complications instead of attempting diet an exercise?  The majority of people I see are overweight with high blood  pressure, diabetes and elevated cholesterol.  A good percentage of these people smoke.  I rarely see a thin person with minimal medical conditions with a heart attack or stroke.  it happens but it is rare.

The rest of the industrialized world still has a diet significantly better than the US. But our diet is catching on abroad, and the people there are developing our diseases more and more as well. I agree that diet, exercise, and tobacco are huge problems. Alcohol is another (sure the Germans also have beer as a big part of their culture, and the French have wine, but Americans drink to excess and have other harmful behaviors like driving afterwards).

Poverty and lack of access to good medical care from early on in their lives is another problem. Poor people in the US let things get really bad before they seek care. And then they have so many other problems in their lives that just throwing some healthcare at them won't do the trick. A coworker prescribed insulin for a diabetic. And spent many office visits with him afterwards, wondering why he wasn't getting better. The patient didn't have a refrigerator to keep the insulin in.

[Paul der Krake]

In the studies comparing US to other countries does it take into account that the US has a much bigger population then most European countries?

Unless you get your policy research from 4th graders, the concept of normalizing numbers per capita has been around for quite a while.

[forummm]

Europe is not a single country, nor do they have a single way of managing health care. In fact, Switzerland's system sounds very similar to Obamacare: everyone must buy insurance meeting government standards from a private company, the insurance has annual deductibles with coinsurance after that up to an out-of-pocket maximum, and there are income-based subsidies to keep the premiums at a set percentage of a person's income.

Switzerland's is also the 2nd most expensive system in the world (behind US). Private insurance is not the best way to go. Other countries do private insurance better than we do. But it's still inefficient and expensive.

[forummm]

Actually, the funny thing is that unhealthy lifestyle REDUCES a person's average lifetime health care costs.  And they do so by reducing life span.  Every one of us will have increasing health care costs as we age.  We will all have end-of-life health care costs.  That guy that smokes 3 packs a day and dies at 50 just seems like he uses more of the system.  But when averaged in, he uses less.

It seems counter intuitive... but people with shorter lives just use less.

Yes, possibly, their lifetime healthcare costs. But not their per capita annual healthcare costs. I forget the exact numbers, but smoking and diabetes each add thousands of dollars per year in average healthcare costs.