Health care - administrative incompetence

[Architect]

Yes. More personal responsibility = less utilization = lower costs for all.

1. Healthcare ourcomes in UHC systems such as the UK and Canada are broadly equivalent to the US.

2. Healthcare in Canada and the UK covers all residents/nationals and cost is substantially less than the US - by around 50% in the case of my own country.

3. You would agree, I think, that UHC systems do not tend to rely on self provision or personal responsibility in the manner you mention.

4. Why, then, are our systems so much cheaper?

5. Likewise why should the US system not learn from, and incorporate the most successful elements of, those nations?

6. If you're not happy with the UK and Canada then I'm quite happy to throw in Germany, France, Australia, New Zealand, the Low Countries, and Scandanavia. Some of these do have insurance and private-sector involvement as part of their UHC systems.

 

[Ducky]

1. Healthcare ourcomes in UHC systems such as the UK and Canada are broadly equivalent to the US.

2. Healthcare in Canada and the UK covers all residents/nationals and cost is substantially less than the US - by around 50% in the case of my own country.

3. You would agree, I think, that UHC systems do not tend to rely on self provision or personal responsibility in the manner you mention.

4. Why, then, are our systems so much cheaper?

5. Likewise why should the US system not learn from, and incorporate the most successful elements of, those nations?

6. If you're not happy with the UK and Canada then I'm quite happy to throw in Germany, France, Australia, New Zealand, the Low Countries, and Scandanavia. Some of these do have insurance and private-sector involvement as part of their UHC systems.

Given my incurable cancer and future medical costs on top of my past ones for the american system I am in, I would prefer to have this discussion over elevenses after a checkup with a doctor in the UK.

At least then I could afford the biscuits and tea.

 

[blutoski]

Another relevant paper in AMJM (a top tier peer-reviewed journal): [Medical Bankruptcy in the United States, 2007: Results of a National Study]

This is a few years old, but it's interesting that they revealed medical costs are also a major component of US credit card debt for those who have not declared bankruptcy.

 

[Fiona]

How so? In a free market, if enough people choose not to buy commodity x because it's too expensive, then the price of commodity x has to come down.

Er....it cannot come down below cost. What sometimes happens is that it becomes a luxury item: higher unit price/ smaller target market. your faith in the free market is touching but health is not a free market, as has been pointed out. But even if it was your formula does not work so far as I can see

 

[xjx388]

This is why I like participating on discussion forums. It challenges what I believe. You guys have given me a lot food for thought and it's going to take some time to process.

My thinking was that individuals should be responsible for their routine care. From my experience as a FP clinic manager, I know what my costs would be if I didn't have to deal with the government and insurance plans. I think other docs and hospitals would realize the same cost-savings and pass them onto patients. Maybe this is idealistic and wrong. Maybe not. Most docs are compassionate people who genuinely want to help people.

So if an individual is responsible for their routine care and that care is cheaper, there's still the prospect of major illness and bills that exceed their ability to pay. That's where a catastrophic plan comes in. Yes, it's an insurance plan, but it's not an HMO, PPO or anything like that. People could buy these plans to match the highest amount they are able budget for health care per year. Say they can only afford to spend $10,000 per year on medical care. They purchase the catastrophic plan to cover them in the event their bills exceed this amount. It would be very rare that someone has medical costs over this amount, given that per capita spending is around $4000 in the US. It would be just like term life insurance. Couple that with tax incentives for saving towards healthcare along with making purchase of these plans mandatory. What's wrong with a plan like that?

 

[Uncayimmy]

How so? In a free market, if enough people choose not to buy commodity x because it's too expensive, then the price of commodity x has to come down.

Consider flu shots. If demand goes down, will the price come down? Maybe. Some people such as myself would be willing to pay more for them, so if they lose part of the market, it might make more financial sense to just raise the price to those who fully appreciate the value. You can get 44oz of Coke for $0.79 at a convenience store or $3.50 at a football game. If they scale back production, there could be a bidding war so to speak. The end result could be higher prices for vaccinations. It's actually hard to say.

Furthermore, consider that the cost of a flu shot is much less than the cost of treating pneumonia. I might "save" $25 by not getting the shot. If I get the flu, I lose a few days of work (self-employed people don't get paid). If it complicates, I could end up in the hospital. That's far more expensive for me as an individual. It also increases the demand for hospital services, which you seem think in your myopic way would increase the price in a free market.

Most importantly, no matter what we do, the damn flu virus is going to sweep across the country every year.

 

[Rolfe]

Oh dear, I'm tired and I've still got too many decorations to put on the damn tree.

It feels like Groundhog Day. We've had this discussion on several previous occasions, Dan Stanley for example, and it's just soul-destroying to start it all again from scratch with someone spouting the same dreck about "personal responsibility". The sheer disconnect from reality evidenced by this attitude is positively painful.

I like being the sort of moral degenerate whose taxes paid for Mr. Yaffle's cancer care (would that he could have had more of it) and Architect's busted knee and all the rest. I see all my friends, neighbours, relations, worst enemies, and people I don't know from Adam living securely in the knowledge that whatever their healthcare needs happen to be, they will be taken care of. It's natural and normal and nobody appears to be the worse for it. Just where this great gain is in "personal responsibility" escapes me completely.

Oh, it's too bad that committees of physicians looking at all available evidence and trying to come up with best-practice directives have agreed that antibiotics are not routinely necessary for simple throat infections. Hey, they might be doing it to save money! (Neatly overlooking the fact that the antibiotics cost about £2.50 and the flat-rate prescription tax is about £6.50.) But if we leave it up to the patient to pay from his own pocket, and he decides not to pay for the antibiotic (despite this not being an informed choice at all), hey that's great, it's the free market at work.

Anybody see the double standard here?

We seem to be back to the weird disconnect I noticed in earlier discussions of this nature. On the one hand America is the Promised Land, where the standard of living is amazing and where everyone of course would want to live if they had the chance. (Not on a bet, actually.) US citizens, we're told, have access to luxuries and lifestyle choices we can only dream about. US incomes are the envy of the world. And so on.

And then when we start to talk about healthcare, suddenly the assumption is that nobody should have any luxuries at all. Every penny beyond the bare necessities of life should be laid aside for that possible big healthcare need that might or might not be along.

Wow, what an enviable lifestyle!

Here, even the poorest person can buy a cinema ticket or a box of chocolates or a gift for a child, and know that the purchase won't at any point make the difference between life and death. So the sellers of cinema tickets and chocolate and children's toys stay in business and the economy keeps going. (Those of us a bit further up the pecking order could even pay an Architect to plan the re-design of their houses, hint, hint....)

Imagine, if everyone lived the most frugal of lives, saving every spare penny in case of the myeloma or the triple bypass or the insulin. What the hell would the economy look like? I dread to think.

Oh, but it's only the poor you want to condemn to such misery, maybe? Well, how rich do you have to be, to feel that you have accumulated enough savings to be sure you can pay for anything you or your dependants might need, healthcare-wise? Look at what Ducky found he needed! And how are you going to get that money, if you're (say) a music producer, but nobody is buying music because it's a luxury item they have to forego to save for their own possible healthcare needs?

You're advocating a system where everyone, individually, has to save a massive amount of money and sequester it from circulation, even though only a small proportion of these people will actually need that money. It's economic insanity.

And it's a miserable life. And it's not even possible.

Rolfe.

 

[xjx388]

Oh dear, I'm tired and I've still got too many decorations to put on the damn tree.

It feels like Groundhog Day. We've had this discussion on several previous occasions, Dan Stanley for example, and it's just soul-destroying to start it all again from scratch with someone spouting the same dreck about "personal responsibility". The sheer disconnect from reality evidenced by this attitude is positively painful.

I like being the sort of moral degenerate whose taxes paid for Mr. Yaffle's cancer care (would that he could have had more of it) and Architect's busted knee and all the rest. I see all my friends, neighbours, relations, worst enemies, and people I don't know from Adam living securely in the knowledge that whatever their healthcare needs happen to be, they will be taken care of. It's natural and normal and nobody appears to be the worse for it. Just where this great gain is in "personal responsibility" escapes me completely.

We seem to be back to the weird disconnect I noticed in earlier discussions of this nature. On the one hand America is the Promised Land, where the standard of living is amazing and where everyone of course would want to live if they had the chance. (Not on a bet, actually.) US citizens, we're told, have access to luxuries and lifestyle choices we can only dream about. US incomes are the envy of the world. And so on.

And then when we start to talk about healthcare, suddenly the assumption is that nobody should have any luxuries at all. Every penny beyond the bare necessities of life should be laid aside for that possible big healthcare need that might or might not be along.

Wow, what an enviable lifestyle!

Here, even the poorest person can buy a cinema ticket or a box of chocolates or a gift for a child, and know that the purchase won't at any point make the difference between life and death. So the sellers of cinema tickets and chocolate and children's toys stay in business and the economy keeps going. (Those of us a bit further up the pecking order could even pay an Architect to plan the re-design of their houses, hint, hint....)

Imagine, if everyone lived the most frugal of lives, saving every spare penny in case of the myeloma or the triple bypass or the insulin. What the hell would the economy look like? I dread to think.

Oh, but it's only the poor you want to condemn to such misery, maybe? Well, how rich do you have to be, to feel that you have accumulated enough savings to be sure you can pay for anything you or your dependants might need, healthcare-wise? Look at what Ducky found he needed! And how are you going to get that money, if you're (say) a music producer, but nobody is buying music because it's a luxury item they have to forego to save for their own possible healthcare needs?

You're advocating a system where everyone, individually, has to save a massive amount of money and sequester it from circulation, even though only a small proportion of these people will actually need that money. It's economic insanity.

And it's a miserable life. And it's not even possible.

Rolfe.

Oh geez... This is why I dislike debates on discussion boards. Someone always has to make it personal or emotional. Why can't people just argue the facts and ideas dispassionately?

Your utopian vision of brotherly love and compassion and rosy cheeked common folk enjoying a show at the cinema is appealing, but we both know the world doesn't work that way.

 

[Ducky]

This is why I like participating on discussion forums. It challenges what I believe. You guys have given me a lot food for thought and it's going to take some time to process.

My thinking was that individuals should be responsible for their routine care. From my experience as a FP clinic manager, I know what my costs would be if I didn't have to deal with the government and insurance plans. I think other docs and hospitals would realize the same cost-savings and pass them onto patients. Maybe this is idealistic and wrong. Maybe not. Most docs are compassionate people who genuinely want to help people.

So if an individual is responsible for their routine care and that care is cheaper, there's still the prospect of major illness and bills that exceed their ability to pay. That's where a catastrophic plan comes in. Yes, it's an insurance plan, but it's not an HMO, PPO or anything like that. People could buy these plans to match the highest amount they are able budget for health care per year. Say they can only afford to spend $10,000 per year on medical care. They purchase the catastrophic plan to cover them in the event their bills exceed this amount. It would be very rare that someone has medical costs over this amount, given that per capita spending is around $4000 in the US. It would be just like term life insurance. Couple that with tax incentives for saving towards healthcare along with making purchase of these plans mandatory. What's wrong with a plan like that?

This hasn't answered my question. How should I have been budgeting for my situation? What personal irresponsibility is to blame for my getting multiple myeloma? What, exactly, do we do about people currently embroiled in out of control medical debt?

 

[Ducky]

Oh geez... This is why I dislike debates on discussion boards. Someone always has to make it personal or emotional. Why can't people just argue the facts and ideas dispassionately?

Your utopian vision of brotherly love and compassion and rosy cheeked common folk enjoying a show at the cinema is appealing, but we both know the world doesn't work that way.

You're simply going to have to accept the fact that this is a personal issue and it is emotional. This is real people having real medical problems with very real and massive debt associated with it.

So again: How should I have been budgeting for my situation? What personal irresponsibility is to blame for my getting multiple myeloma, having a chunk of spine replaced, learning to walk again and overall medical costs for 7 years of treatment and recovery at 1.2 million (ETA: Of which I personally owe quite a bit, but not all)? What, exactly, do we do about people currently embroiled in out of control medical debt?

Exactly what fiscal or personal irresponsibility is it I can look to in my past and say "yes, were it not for that choice I would not be facing more in medical debt than most people face in their mortgage."?

How is it we are to encourage startup businesses if those starting one cannot possibly hope to have their business survive an illness? This is a real problem facing industry innovation and market competition.

 

[Gandalfs Beard]

What a difference a thread can make.

The problem with the health care system in the US isn't "administrative incompetence," the problem is that it is a Profit Based system. Profiteers don't care about people's health, they only care about their profits.

Insurance Companies profit by denying care to those already on their "plans", not covering people with pre-existing conditions, price gouging the public, and convincing politicians to exempt them from Anti-trust laws. They are in fact a Parasitic and unnecessary "Middle Man."

Many of these same insurance companies also provide Malpractice Insurance to Medical Professionals at exorbitant rates forcing Practitioners to increase their rates to the Public.

The fact is that countries with a National Health Service (often tax based Single Payer insurance provided by the Government--public money spent on a public need), generally have much lower administrative costs, and EVERYONE is covered.

Sure, there are flaws in some of those systems too, but they are by far the most efficient, and cost effective.

The other Huge Profiteer in the Medical Industry? Big Pharma, who benefit by reaping Research Subsidies when they are not simply profiting from Research conducted by Public Institutions. They also Profit by charging extortionist rates, hoarding patents, fast-tracking potentially unsafe medications through the FDA process, not producing medications that only benefit small segments of the population, and actively opposing the creation of cheaper generics, and proselytizing against medicines that people can grow in their own back yards.

It should come as no surprise that Big Pharma and Big Insurance are joined at the hip. If the companies themselves are not necessarily part of the same conglomerate, it makes little difference as the Major Shareholders sit on Multiple Boards of Directors, creating what is essentially an Oligopoly.

So if your medical problems aren't being treated properly (in the US), Administrative Incompetence has almost NOTHING to do with it. Managers and Corporate Employees are PAID to ensure that PROFITS are maximized, not your health-care.

Health Care should NEVER be Profit-Based.

GB

 

[Fiona]

So if an individual is responsible for their routine care and that care is cheaper, there's still the prospect of major illness and bills that exceed their ability to pay. That's where a catastrophic plan comes in. Yes, it's an insurance plan, but it's not an HMO, PPO or anything like that. People could buy these plans to match the highest amount they are able budget for health care per year. Say they can only afford to spend $10,000 per year on medical care. They purchase the catastrophic plan to cover them in the event their bills exceed this amount. It would be very rare that someone has medical costs over this amount, given that per capita spending is around $4000 in the US. It would be just like term life insurance. Couple that with tax incentives for saving towards healthcare along with making purchase of these plans mandatory. What's wrong with a plan like that?

Well one of the things that is wrong with that plan might be this: Everybody has a "catastrophic" event sometime. Your approach to the statistics is flawed for that reason, I think.

I am not sure what the average you quote represents but I suspect it is an in year average? So what you envisage is that every one provides for themselves up to the amount they can afford in a year, and buys insurance for anything over that in any given year. Leaving aside that the amount they put to the insurance has to be deducted from the amount available to provide for themselves, look at it from the point of view of the insurance company. They want to make a profit. On your system for most individuals they are not going to have to pay out anything most years. But at some point they are going to have to pay out a very great deal of money. While some people die without needing a lot of medical care, most do not and most of the costs of health care are spent in the last few years of life, regardless of which system you use. In a universal system people pay (through tax or insurance) an amount which takes account of that fact. I do not know the numbers but to illustrate: on your system those who have a healthy year do not pay out anything except the catastrophic insurance premium: and those who get ill pay out a sum up to the limit of what they can afford: let us say somewhere between 0 and 10000 each year as an average. But hat is money which does not go to the insurance company; it goes somewhere else. So the insurers have to cover the "catastrophic" event directly from premiums. If it is inevitable that most people are going to have a big spend at some time, then effectively every individual is going to have to pay a very high premium because almost everyone is going to incur high costs and call on this policy at some point. It follows that the premium is going to have to equal that spend (plus profit): effectively that is not an insurance scheme at all: it is a savings plan. We already know that many people cannot save enough, and that is the reason for insurance in the first place. It is one of the things which always strikes me about this: folk don't seem to understand the nature of insurance. It depends on the fact that the risk is low and the hazard is high: for health the risk is not low at all; it is a very high percentage, if you tie to the individual. In this sense health insurance is not like fire insurance: because most people will go their whole lives without experiencing a big house fire. But if you apply the same logic to fire insurance or car insurance you get the same outcome. You don't notice because most people do not suffer the catastrophe at any time: and so we see "excess" which effectively does partially follow your model. I am not convinced that the "excess" keeps costs for insurance lower, however. Perhaps there is an actuary on the board who can say more about that?

 

[littleroundman]

How exactly would having more personal responsibility prevent multiple myeloma and a metric tonne of cost leading me to the brink of bankruptcy?

Quick,

hands up everyone who knows all about "multiple myeloma" what it costs, the treatments involved and the prognosis.

No Googling, now.

It simply amazes me that words like "multiple myeloma" or "chronic condition" and amounts such as "billions of dollars" and "costs upward of 1 million dollars" trip so lightly off the tongues of politicians and forum experts as if it was robots we are discussing and not human beings.

There but for the grace of God.............................................

 

[Fiona]

Oh geez... This is why I dislike debates on discussion boards. Someone always has to make it personal or emotional. Why can't people just argue the facts and ideas dispassionately?

Your utopian vision of brotherly love and compassion and rosy cheeked common folk enjoying a show at the cinema is appealing, but we both know the world doesn't work that way.

The tone of Rolfe's post does not affect the factual content in any way: the points she makes are valid whether you like the way the argument is expressed or not.

 

[Architect]

Oh geez... This is why I dislike debates on discussion boards. Someone always has to make it personal or emotional. Why can't people just argue the facts and ideas dispassionately?

Your utopian vision of brotherly love and compassion and rosy cheeked common folk enjoying a show at the cinema is appealing, but we both know the world doesn't work that way.

I think the problem is that you are indeed covering ground already raked over numerous times here, raising many of the same issues as have already been done to death.

A classic example, as I mentioned already, is clinical outcomes. BeAChooser has been trying to argue for over a year that these are higher in the States than the UK and Canada. He can show a number of areas where your system does seem to be more successful - breast cancer survival, for example - but on many other key indicators we outperform you. Thus the reason the rest of us have settled on the phrase "broadly comparable".

ETA: If you want an example of why caution is required with statistics then take a look at this: http://scienceblog.cancerresearchuk...careful-when-comparing-us-and-uk-cancer-care/ .
This is why, when you questioned what was meant by clinical outcomes a page or so ago, I asked whether you wanted to explore that further. If there is data you have which compelling shows a different picture then we'd all be interested to see it. But simply casting doubt on well-worn paths is only likely to get the kind of response you got from Rolfe.

I think there's a similar problem with your comments regarding personal responsibility as a means of reducing medical usage; specifically that the UHC systems in the likes of the UK have unrestricted access to GP facilities and ready access to acute treatment, yet there's no evidence that it has placed an unreasonable burden on the NHS or encouraged abuse.

The final one, and I'm afraid I'm going to pick you up on this again, is your hand-waving on the strep throat discussion. You have pointed to medical advice in the US which, as I understand, encourages treatment by antibiotics a priori. That the UK does not do so, you suggest, is probably a cost-saving measure. What we actually have, however, is a wide range of medical advice from different countries (the UK, France, Canada, and Australia) which all says that antibiotic treatment is usually un-neccessary.

Now if you want to analyse this strep throat issue any further the most appropriate way is to show, based on medical statistical data, that one system or the other has an adverse (or at least less beneficial) clinical outcome. In short, do the aforementioned countries suffer from the potentially deadly consequences you allude to earlier? Because if not then we have to conclude that the antibiotics don't make a significant difference.

The thing about JREF is that it's a sceptic site. People are, at one stage or another, asked to back up their arguments with hard data.

 

[Agatha]

Oh geez... This is why I dislike debates on discussion boards. Someone always has to make it personal or emotional. Why can't people just argue the facts and ideas dispassionately?

Your utopian vision of brotherly love and compassion and rosy cheeked common folk enjoying a show at the cinema is appealing, but we both know the world doesn't work that way.

What in Rolfe's post is inaccurate?

like being the sort of moral degenerate whose taxes paid for Mr. Yaffle's cancer care (would that he could have had more of it) and Architect's busted knee and all the rest. I see all my friends, neighbours, relations, worst enemies, and people I don't know from Adam living securely in the knowledge that whatever their healthcare needs happen to be, they will be taken care of. It's natural and normal and nobody appears to be the worse for it. Just where this great gain is in "personal responsibility" escapes me completely.

This isn't a utopian vision, this is the actual situation in the UK. We spend half as much for broadly similar outcomes, and nobody ever goes bankrupt due to medical costs. Nobody ever has to choose between healthcare and paying their mortgage, or between healthcare and living the lifestyle they want. Here the NHS is seen, by 99.9999% of the people as a national treasure. The papers will report on any shortcomings (and we're all realistic, it's not perfect), there will be handwringing and then there will be change for the better. No politician would ever get elected here on a platform of scrapping the NHS.

Of course it's going to be emotional - this is people's lives we're talking about. And not just abstract people but people we know, people on the furum and even posting in this thread.

 

[Architect]

What in Rolfe's post is inaccurate? This isn't a utopian vision, this is the actual situation in the UK. We spend half as much for broadly similar outcomes, and nobody ever goes bankrupt due to medical costs. Nobody ever has to choose between healthcare and paying their mortgage, or between healthcare and living the lifestyle they want. Here the NHS is seen, by 99.9999% of the people as a national treasure. The papers will report on any shortcomings (and we're all realistic, it's not perfect), there will be handwringing and then there will be change for the better. No politician would ever get elected here on a platform of scrapping the NHS.

Let's take my busted knee, as Rolfe has raised it.

Pigmented Villonodular Synovitis, a very rare condition in that joint. If you google it, a paper by Mr. Stother at Glasgow Royal Infirmary comes up and I'm one of the anonymous patients referred to in the study. Once diagnosed - which took several months and an MRI scan back in 1995 - it was treated by an athroscopic synovectomy. The operation will be required around every 10 years, as the PVNS recurrs, and the cost in the UK private sector is about £5k. This is, of course, perfectly affordable if in work.

Now personal responsibility isn't going to stop my PVNS recurring or magically avoid the synovectomy. Use of Voltarol slows the rate of regrowth and permits sports, but otherwise it's unavoidable.

Now let's take my friend Stuart, who has chronic recurring Crohn's Disease. He is hospitalised about every 4-5 years, usually for up to a month at a time, and has been warned on the wider impacts that the disease will have on his health as he gets older. There's a history of cancer and liver disease in his family as well. The NHS covers all of this without missing a step, however in the US system Stuart would be damned near uninsurable. Likewise there's hee-haw way he could ever afford to meet the treatment costs himself.

Am I happy that a proportion of my taxes are used to pay for a health service that Stuart and I can access equally, even though - thus far - I've been fairly lucky health-wise and hence am "subsidising" those with more sever complaints? Too right I am. Everyone resident in the UK, taxpayer or not, is entitled to exactly the same high standards of medical treatment regardless of personal means.

In the UK no-one need spend the night coughing up blood because they are worried about treatment costs (Travis), no one will be made bankrupt or blow their life savings because of ill fate and a severe medical position. If I lose my job, I'm still covered. If I get a severe, long-term illness such as Crohns or Lupus then I'll be treated right up until I turn up my toes, with no limits on treatment costs over my lifetime.

And we do this for something like half the cost of the US system. France and Germany, which have even better clinical outcomes, do it for 2/3 of the cost of the US system. If that's not an argument about the role of waste and profit in the US medical regime then I don't know what is.

 

[Agatha]

I also have Crohn's, which was diagnosed when I was 17. Could I even have got insurance in the US, and if so at what cost? One of the things about chronic illness is that it tends to make it difficult to work full time (or at all), and leads to regular absences from work, so one's income is lower. At the moment I am managing 24 hours a week but some weeks that is too much. Recently, I developed Rheumatoid arthritis and now I can't walk more than a few steps so I use a wheelchair some of the time.

What element of personal responsibility is going to stop my immune system attacking my body?

 

[Rolfe]

Architect, my good and dear friend, did you read all of my post?

Hint, hint....

Rolfe.

 

[Architect]

It's not forgotten, trust me.