Discussing the different ways of rationing medical care always brings out the hottest heads. For example:
- I can picture your health care world where the patients are huddled in a line frantically searching their minds for any indiscretions that might jeopardize their access...kinda of like Seinfeld's sponge worthy episode. Or perhaps a modern day Spanish inquisition...did you or did you not worship at the altar of the treadmill and raw vegetables? Albert Schweitzer, doctors without borders, I guess they're saps or enablers. To take your argument to the extreme. I guess you could just watch that COPDer suffocate to death and then sleep like a baby. No disagreement that medicare needs to be reworked and people should take more responsibility for their part of the health equation. But to sit as judge, jury and executioner, I don't think that was in the Hippocratic oath.
midwest women, you are angry at me when you should be angry at others. I am pointing out the inevitable. That rationing MUST occur on course we are heading. How we choose to ration care will be the debate of the century.
There used to be a time in the world were doctors were different. When doctors learned a special gift no others could. When doctors were respected for their sacrifices. When they were looked up to in communities for providing a gift no others could. That time is long gone. Not because doctors aren't still the sole providers of that gift for others. But because of the way doctors provide their gift.
Long before my time as a physician, there used to be a time where doctors charged patients, not third pary insurance companies. A time when doctors figured out how much money they needed to live the lifestyle they desired and charged patients accordingly. It was up to the doctor to decide how much money he or she wanted to charge.
There was a time when patients felt obligated to pay that amount out of gratitude. And patients would pay it graciously. As a thank you for helping them. And those that couldn't pay were forgiven of their debts out of grace.
That ended long ago when patients and doctors left that equation. Replaced with a centralized bureaucracy filled with government administrators and private insurance companies. A bureaucracy solidified by the tax structures that codify third party medicine.
And the people bought it hook line and sinker. Because FREE=MORE. They saw third party medicine as their golden ticket to the chocolate covered potato chips at the Willy Wonka factory of health care. And eventually, so did the medical community. The people, in their FREE=MORE mentality, now feel entitled to all the goods and services from the sweat of others. From the sweat of their physicians, a field once respected for providing a gift no others could (and still can't).
The people believe they are owed the services of others because they have pre paid for those services in the form of Medicare premiums and large $20,000 a year family deductibles. What the people fail to realize is that every penny spent on their insurances is less money in their pocket. There is no free money out there. You are paying for your premiums by way of lower salary and wages.
But the people don't care. They demand FREE=MORE because of their belief that they are OWED the services of others. This is the entitled mantra of socialism at its finest.
No longer does a physician feel the obligation to excuse those that cannot pay by allowing instead to have those that can subsidize those that can't.
The moment patients worked to get insurance coverage and the moment physicians worked to get insurance money is the moment the dynamics changed. The take it or leave it mentality of third parties has left the fee structure unacceptable for many physicians. In a sense, most physicians now view all third party money as charity care and feel no obligation to provide free care to those without insurance. Providing a gift became nothing more than a service with a defined value.
The real losers here are everyone. Everyone has become a slave to a system that codifies tax breaks for big business in order for them to decrease your take home wages to pay for your $20,000 health insurance premiums, or to a government that unilaterally takes money from all your income every month for your entire life to offer you FREE=MORE. This third party system has created a system of entitlement from patients who feel they are OWED medical care and physicians who are OWED insurance money.
I am not judger. I am not executioner. I am not jury. I am simply pointing out that the third party system is not sustainable because you, midwest women, feel entitled to everything health care as evidenced by your post, and physicians feel entitled to accept the stability of third party money to offer it back.
This is an unsustainable formula which cannot survive. I am pointing out the gut wrenching truth. That FREE=MORE will collapse. And no matter how you rearrange the deck on the Titanic, you will have to ration our modern day health care service because we simply cannot continue on the course for which we are heading.
Would I love to be a physician where physicians charged what they wanted, based on THEIR needs. Of course, as would you. As would everyone else in this word, who has a freedom to choose their price for their service. Would I love to write off the bills of those that cannot pay and allow those that can to subsidize MY needs and desires. Of course. I would love nothing more than to give away my service, when I felt my needs were met as well.
As it stands now, neither you nor physicians are willing to go down that route. Hospitals used to provide charity care for those less fortunate. Now they too rape the uninsured, charging them far higher rates than the fully insured. It's a backward system where those most in need are helped the least.
And you can blame it all on the third party system where patients and physicians alike are entitled. You want to blame someone for a system that throws away those without money? Blame the government with their Medicare. Blame your employer for their giant tax breaks to give you less in take home pay to pay for your insurance premiums. Blame yourself for feeling entitled to the services of others with no regards to the sweat and tears of their labor. Blame physicians for taking the plunge and becoming slaves of third parties instead taking care of patients.
There is so much more to the equation than you give credit to. You choose the physician as the easy target because you know no other way to express your dissatisfaction. Some may feel entiteld to free care because they feel physicians are too rich (financially). Who cares how rich they are? Everyone has a right to charge what they want. Freedom allows one to get rich without feeling guilty.
In my heart of hearts, I have no doubt in my mind that IF we flipped a switch overnight and abandoned ALL third party medicine so that contracts of care were created in an individual basis between physician and patient, physician and hospital, patient and hospital, that the cost of delivering care in this country would plummet. That those capable of providing for their own health care would subsidize those that couldn't. And EVERYONE would be covered for the right care, not the most expensive care. That the enormous waste being provided on the backs of the Medicare National Bank and your tax sheltered employer would disappear.
The concerns you express, midwest women, are the same concerns we all express. But you blame me for telling it like it is, instead of blaming the culprit that destroyed health care.
Insurance. An insurance that someday may have to line people up like the Spanish inquisition, as you call it, and ration care based on choices that nobody wants to make. As long as you accept insurance as your health care savior you will be at the whim of a centralized planning power that will make unpopular choices and could potentially cause you harm.
If you can get the other 250 million Americans in this country to abandon their FREE=MORE mentality and to pay their bills without feeling entitled to the sweat of others, you would see a remarkable change in the dynamics of health care delivery in this country. Until then, we are all on a steam ahead course to the Land of the Screwed.
This is one of your best posts. It is an excellent synopsis of the current sad state of affairs.
ReplyDeleteI agree with Bad Medicine. That was very well articulated.
ReplyDeleteUnfortunately, members of the younger generation have grown up with government and parental bailouts, credit cards, home equity loans, bankruptcy, and second chances galore. The have no interest in anyone but themselves, and are completely unwilling to tell themselves "No", take no for an answer, or to vote anyone into office who will. To say they are entitled is an understatement. This is a generation who truly behaves as if their actions have no consequences, a lesson strongly reinforced over the past couple of months. I'm afraid, Happy, that your post explains only one of the symptoms of a larger problem. At the rate we're going, we're not just looking at the downfall of the healthcare system, but of the US itself. And, best of all, Americans absolutely refuse to believe such a scenario is remotely possible.
It isn't the younger generation that did this. It started with the baby boomers.
ReplyDeleteAnd our burdening future generations with the Medicare (soon to universal coverage) debt isn't more of the same. Blame it on whoever you want. The solution remains the same: Cut entitlement spending and increase taxes on EVERYONE to pay the debt we've amassed thus far.
ReplyDeleteMeant to say, burdening future generations with all this debt is more of the same...whoops.
ReplyDeleteHealth insurance is a damned if you do, damned if you don't proposition. If you lose coverage and cannot qualify for Medicare or Medicaid, say hello to the bankruptcy judge if some emergency befalls you - the amount of medical debt that triggers bankruptcy seems absurdly low, $10-20K IIRC. Decide whether to pay utility bills or buy meds you need for chronic condition(s), many of which are not available as $4 generics -asthmatics and others get screwed over this regularly. (I don't want to suck 2 puffs of Ventolin HFA 6 times a day; I'd rather be completely controlled on Advair 100/50 - can't wait until salmeterol and fluticasone go generic! Seems to me that a lot of $4 Rxs are for "old folks"). Wait for years - if you can get a job with group health insurance - to be covered for "pre-existing conditions". If you've been uninsured over 63 days, it'll be a cold day in Hell to get the insurance company to remove the waivers.
ReplyDeleteOK Happy, let's dump all 3rd party payers immediatelyexcept for catastrophic insurance! Standardize prices for all non-catastrophic health care- related goods and services at a reasonable rate, where "reasonable" means that 80% of the people requiring such goods or services can afford to and will pay said rate(s) at least 90% of the time. Sure, it's arbitrary, but you have to start somewhere!. Everybody pays up front, everybody pays the same price off the same menu, just like at McDonalds.
One of your previous posts mentioned the ludicrous amount Qwest Diagnostics billed BCBS for your TSH, and that BCBS paid $10-15 as the negotiated rate. Let there be one "negotiated rate", and let everybody pay it themselves. Personally, if I could pay the negotiated rate without having to buy insurance, I'd be money ahead (I'm in the state high risk pool - lucky me).
My comments came from the original post about non-compliant patients with frequent and costly admissions. I was just suggesting that ultimately, whether they're sick thru bad luck or bad choices, our only ethical choice is to treat. We're not in the business of judging behavior.
ReplyDeleteI'd like to hear your ideal system. And even tho our current system is flawed, what is wrong with the fundamental concept of a nation assisting in caring for the elderly's health needs in a reasonable manner? Or the poor?
There is nothing in my post to suggest I feel entitled. I work, have the company insurance which by the way doesn't cover much. An er visit with a fractured foot...an xray, a boot and 5 minutes with the doc..out of pocket I paid $400 bucks..if this is free=more, I'll pass
As an aside, I found your descriptions of yesteryear docs ironic. I grew up as the daughter of one...small town boy who went to med school on a scholarship and moved back to his hometown to take care of his friends and neighbors. An old fashioned GP with the black bag that made house calls. We ate food from farmers because he bartered his services, families were charged less for each subsequent baby delivered. I grew up in that long lost world. He worked hard and I can never remember him judging his patients. Ironically he left his private practice when Medicare reared its head in the early 70's...he saw it coming. He never got rich but made a decent living. He taught me compassion and he never judged a patient in his life, only the systems he had to operate in.
@ midwest woman
ReplyDeleteRemind me again why I should pay the same or more as the "the poor" who choose to risk stratify themselves by smoking,failing to worship at the altar of the treadmill, etc?
I am 44 years old; I have never been in the hospital, I take no medications.
I have kept detailed records since I started working full time twenty years ago.
And I have paid (as of 2008) out of pocket medical insurance of $194,000.
I have never filed a claim.Not one.
Two physicals in past 5 years, both paid cash as below deductible.
Now, once again,how much more would you like me to pay more to take care of the elderly and the poor?
Doesn't matter... I paid into Medicare. We won't see a dime's worth of care from it...
ReplyDeletestop the bleeding, you beter hope you're just dodging a bullet. You better hope you genetics are good, that your body doesn't wear out (because it will) and something catastrophic doesn't happen to you because you were in the wrong place at the wrong time. Then tell me how much you've paid in. I gaurantee what you paid in will get gobbled up in a week. Just be thankful you haven't had to use it.
ReplyDeleteGood posting, although I would like to suggest that rationing is a current concern. We currently see indications that we ration by ability to pay, thus, we see people putting off needed treatments, not getting RX filled or cutting pills in half.
ReplyDeleteAlso, I don't see insurance as the entire culprit, but rather the linking of said insurance to the workplace. Thus you get a rather large divorce from the consumer of health care and payer of the services. THIS is where the free part enters the equation. On-going reports from the Office of Actuary at CMS show that the percentage of out-of-pocket medical expense (including the o-o-p part of the premium) has fallen from around 50% in the 60s to less than 20% now. Although I really do need to sit down one day and run the numbers, I find it interesting that as the o-o-p went down sharply, the percent of GDP spent in health care went up sharply.
What we are seeing is what happens to demand when something is subsidized to the tune of 80%. Compounded by the high barriers to entry of new supply (since you just can't go out tomorrow and "build" a new doc). I find a special irony in certificate of need legislation in this context.
"OK Happy, let's dump all 3rd party payers immediatelyexcept for catastrophic insurance!"
ReplyDeleteBrilliant idea Anon, old Son. Another of the problems is that we don't have health "insurance" any more. Insurance is usually defined as taking an expensive, yet rare occurrence (say having a house catch fire) and spreading the risk among many people so that no one has to face the entire cost.
Health insurance, on the other hand, has become a rather Frankensteinian concoction where you take a (realtively) inexpensive and very common occurrence (saying going to the doctor)and try to spread that out around many people. But instead of maybe one or two people in pool having a house fire, a large percentage of the pool go see the doc and have a claim.
I would submit that we haven't had a true insurance system since the days of BC/BS and Major Medical.
Can't create a doc overnight, but plenty of well-off hospitals, including non-profits, are expanding and creating demand that way. Got to fill up the extra beds and run tons of procedures and imaging with the new machines and the docs are in on that.
ReplyDelete"Can't create a doc overnight, but plenty of well-off hospitals, including non-profits, are expanding and creating demand that way. Got to fill up the extra beds and run tons of procedures and imaging with the new machines and the docs are in on that."
ReplyDeleteThe last time I took a close look at that in '07, the studies were fairly evenly divided into the camp indicating that these were major drivers of new money and the camp that felt it was more rearranging the deck chairs on the Titanic. (Personal aside, the studies showing the impact of specialty hospitals siphoning off high ticket patients from general hospitals tend to reinforce the Titanic camp to my mind).
However, even assuming the former, this is merely just another indication that a part of the excess demand is being taken up and, if anything, would tend to reinforce the contention that demand continues to outstrip supply.
This post makes no sense to me. If "contracts of care were created in an individual basis between physician and patient, physician and hospital, patient and hospital" how would that help people who have cancer? They'd still go bankrupt - most people can't afford the treatment and no doctor is going to comp them.
ReplyDeleteIf you're going to come up with a system, it has to make sure that people get treatment for cancer regardless of their ability to pay.
I'm inclined to dismiss a lot of what you say.
ReplyDeleteWhat glory days of early medicine? You mean the Hippocratic Oath, that chauvinist creed so the members of the profession could protect their secrets?
And health insurance doesn't seem to be the problem, rather, the implementation seems to be the problem.
I also don't particularly like it when physicians or soon to be physicians speak of the medical profession as if it was capitalist. Its not. It is a cartel. Admission to medical school is limited. Access to residency is limited. Numbers of physicians are kept artificially low.
Medicine is not capitalist. There is demand for primary care, and yet compensation does not go up. There is demand for dermatology, and yet supply does not go up. If we want to make the system capitalist, fine, I'm all for that. But anyone should be able to take the licensing tests for any specialty.
Or we can try to efficiently socialize it. But right now medicine is an unholy hybrid between the worst aspects of capitalism and socialism and we're surprised it doesn't work?
Fair disclaimer: As a medical student I fully recognize that I'm talking out of my ass, and that there probably is a great deal that I don't know yet.
"From the sweat of their physicians, a field once respected for providing a gift no others could (and still can't)."
ReplyDelete.. First, physicians have lost respect due to a lot more than insurance reasons. The medical industry has killed about half of my immediate family through mis-diagnosis and administration of wrong medications.
.. I carry insurance "just in case" but my entire family knows that if they EVER take me to a hospital, I had better not be comming out again or I'll kill the idiot who authorized it.
4 years ago, I had a (litteral) ton of hay fall on my head and my employer demanded that I get xrays... $900 later (yes, I was FULLY INSURED) they gave me vicodin and told me to sleep it off. They gave me NOTHING to assist my body in healing, simply pushed masking drugs that kept me unconcious for the first day and was immobile from pain w/out them.
Instead on continuing with that crap, I used herbs that actually aid the healing process and was better in one more day (compared to the 10 days the glorious physician predicted) and back to work in three.
Unless I'm litterally squirting blood and can't find the source, there is no reason to see any physician who's main goals these days seems to be to push masking drugs and use expensive equipment.
You want to ration health care, go for it, you'll quickly find out that there are MANY people willing to FREELY share THEIR GIFT of the knowledge of hebal remedies.
Health care will never be rationed because there is too much money in it for pharmaceutical companies. If doctors actually cared about patient's well being (instead of their wallets) they'd think for themselves instead of trying to suck every dollar they can out of each patient.
Don't agree? Then tell me why a "patient advocate" is assigned to every patient to ensure their coverage is fully utilized and how patients suddently get "healthy" when their insurance is about to run out? I've audited hospitals for over five years and the entire industry is disgusting.
PLEASE ration healthcare... it will save MANY MANY lives!
BTW: I'm late 40's, not a worshiper of any treadmill or vegetable and not on any drugs (nor do I need them!) Yet, all my contemporaries who use the healthcare system seem to be on at least three medications. You tell me which is better? A system that wants to put you on medications that destroy your kidneys and liver or natural care that works with the whole body for HEALING instead of masking?
I would also like to mention that I completely agree with the tail-end of your other post.
ReplyDeleteActually, I'm convinced that most health outcomes are influenced by environment, personal decisions, and genetics far more than they are anything that docs can do.
If we want to save the system, here is what we do:
-Stop the subsidies on meat, dairy, etc.
-Tax unhealthy food. What is "unhealthy"? A quick way to do it would be to apply a tax that was inversely related to caloric density. Thus, high fat foods are expensive. Use this money to subsidize fresh fruits, vegetables, whole grains, etc.
-Mandate health insurance, but provide discounts to people who can prove they lead a healthy lifestyle. Say insurance starts out at 1000 bucks (unrealistic, I know). If you can prove that you don't smoke, by submitting to a random nicotine screen 2x per year, you get 100 bucks off. BMIs below 25 get a $100 discount/month, BMI below 30 get 50 bucks off, etc.
-Easier said than done, but we need to overhaul the primary care system and encourage more early interventions.
If we can influence lifestyle and environment, the burden on the health care system will be infinitely more manageable...
Anonymous,
ReplyDeleteWhen you start noticing red spots in your stools later in life, and you ignore them for months, or try to heal it with herbal remedies...
...don't blame the doctors when your stage IV colorectal cancer cannot be treated.
There are a lot of foolish things that doctors do. And there are a lot of bad doctors. But people who dismiss the health care system completely and rely on herbal remedies are going to end up with Darwin Awards because they ignored some easily cured disease until it was too late. I've seen it so many times already, and I've been on the wards less than a year.
Nicholas wrote: "Or we can try to efficiently socialize it. But right now medicine is an unholy hybrid between the worst aspects of capitalism and socialism and we're surprised it doesn't work?"
ReplyDeleteIt's not even that. Like you said earlier, its a cartel. If I, as a patient, see a physician who says take medication xyz and I refuse, then the insurance company will refuse to pay for anything else associated with that illness.
As an example, 10+ years ago I went in for what was suspected to be kidney stones... doctor want to do ??scan. I asked what would be first treatment if they were there. He said water/fluids for 10 days. So I told him I'd to water/fluid for 10 days and come back if nothing changed. HE dumped ME as a paitent. Fine with me, but I wasn't going to mis another day of work to go get him a kick back of some new machine the hospital just bought.
So, while you're worried that its not "capitalistic" so you can get a big salary... how about patients who don't have any say in their own treatment. What if they don't want to risk the side effects of certain drugs? What if they don't want certain tests that won't really tell you anything anyway?
I rehab horses, occasionally I break little bones here and there... people ask me why I don't go to a doctor... well, because they don't do anything. I'd get radiated, wrapped, handed vicadine and then billed by at least six different companies I had no say in hiring or dealing with. (And that's with FULL insurance) Well, I can feel the bone moving, so don't need radiated, I can wrap my own self up and I can actually treat it to aid/speed healing instead of just masking pain so that I'm back to full speed sooner. All that for about $10 instead of $1000 deductable.
Good for you becoming a doctor... but I hope the new generation gets their head out of their bank account and learns more than what the pharmaceutical companies want to teach them!
" going to end up with Darwin Awards because they ignored some easily cured disease "
ReplyDelete... yup, I'm too stupid to have a say in my own body or what I'm willing to do or not do. Lets see how many drugs you're pushing because some phram rep talked you into it by the time you graduate.
BTW - taxation should be directly proportionate to processing, not "fats" or "sugars". Fats are not bad, look at nuts, very high density fat but not bad. Red meats are not half as bad as preservatives.
If a product hasn't been processed or cooked, then no tax. As soon as its processed (more than one ingredient) then tax. As soon as you ad sucrose (of any type) then double tax. Tripple tax on any resteraunts. Quadruple tax on fast food. And a $10 idot tax on alcohol and tobacco.
You want to change health care? Start shipping fresh vegetables into the inner city poor, make FRESH (not the about to go rotten crap in grocery stores) vegetables freely available to them and teach them how to cook even simple rice based dishes for their kids.
If knocked down buildings were turned into gardening lots, there would be a huge positive influence on the local residents. I haul compost into the city near me so they can set up gardening plots and I hope they get hundreds of them througout the city. Every K-12 school should be outfitted with a green house to grow foods for the students.
Don't worry, I don't blame doctors because you're a product of the school system and process you go through. Not different than politicians.
I have to think there is something naive in your sepia-toned description of the way medicine was in yesteryear. Big government beaurocracies don't grow by themselves for no reason. They usually grow out of a need to address a very real problem. Whether or not they address that problem the effectively or in the best way possible is open to debate, but my suspicion is that a lot of elderly and poor were not getting medical care prior to medicare and medicaid, because they could not pay for it and could not find doctors who would treat them as charity cases. A program as big as medicare would not have grown without some impetus from those not being well served by the current system.
ReplyDeleteTake the current state of dental care. As was noted in the rationing post, dentists charge cash for service - they rely little if at all on dental insurance. Dental care access for the poor is atrocious as a result.
Few dentists accept medicare payments because they are too low. The middle class and wealthy, who can afford to pay out of pocket, get excellent care, but the poor largely go without even if they have a serious condition like an abcess, because they can't afford to pay the dentist and public subsidies are inadequate.
I have no doubt that there are plenty of dentists out there who take on charity cases, but no where near enough to provide everyone, especially the poor, with even minimal dental care. In the DC area where I live there was recently a young boy who died because of a dental abscess that infected his brain. Where was the charitable dentist willing to remove his infected tooth free of charge, because he could recoup costs by soaking one of his rich clients? He was either treating one of those rich clients, shopping for a new Benz, or at the golf course.
My suspicion is that there was a lot of that kind of thing going on in the 30s and 40s for access to medical care, and that is why we got the system we did. It was a response to a real need - maybe not the most well informed or effective response, but it was an honest try.
I agree with your original post - rationing will be necessary. However, I disagree that FREE=MORE is the prime culprit in driving up medical costs. Medical costs are reasonable in France, and everyone seems to get pretty good care there, and they don't pay that much for it on a per capita basis when compared to the US. Vast sums of money are disappearing into the American medical system and someone is getting filthy rich because of it.
An appendectimy costs tens of thousands of dollars these days. In inflation adjusted terms the proceedure would only be $1,470 if the cost of the proceedure in 1956 ($150) is used as an estimate of the true cost. Why has the cost increased a thousand percent or more since the 1950s? Are appendectimies a thousand times better than they were back then? Why is health care the only area where a service has gotten more expensive rather than cheaper over time? These are the questions that need answering if we are to control health care costs. Rationing may be part of it, but many countries in Europe are doing well with the FREE=MORE model. We need to look at how they are doing it and pick the from the best models there, or we will go back to the good old days which were probably not all that good unless you were wealthy enough to be able to afford care.
isn't healthcare cost going up because healthcare is improving? we have this boom of technology and everyone feels entitled to top notch medical care. well, there's not enough money for EVERYONE to get the BEST healthcare, it's just not possible. why can't we all drive luxury cars and live in mansions? well not everyone can afford it. why is healthcare different? why do we feel that everyone has a right to the most advanced healthcare, whether or not they can afford it? why have we put healthcare on this pedestal? people get sick, people die, this is life. we can't prolong everybody's life span. if you want to make bad health choices and you can afford the best healthcare, well good for you. if you can't, then you made your bed and now lie in it. we cannot sustain the ideal that we must save everyone from everything. there just aren't enough resources out there. we need stratified healthcare, not rationed healthcare, because then everyone loses, including the advancement of healthcare.
ReplyDeleteanon 9:52, you're the voice crying out in the wilderness. Not sure the punishment fit the crime but there were serious abuses that needed to be addressed.My first job was at the dump hospital and "diversion" had a whole different meaning back then (the late 70's). As for dizzying acceleration in costs. Family member severs thumb attached only by scant piece of tissue which was reattached by hand surgeon in the late 80's Succesful outcome...total surgeon's bill..$875. We had no insurance so we arranged monthly payments and paid out of pocket. I couln't translate this scenario into the 21st century.
ReplyDelete