Health care - administrative incompetence

[Uncayimmy]

@xjx388 - You're operating in/near McAllen, Texas, correct?

If so, this article points out that it's one of the most expensive cities in the country for medical care, mostly from overutilization.

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

This article is a great read. It was quote earlier in the thread, but everyone should read it.

 

[kellyb]

But the price of care won't come down until government get's out of the picture as an insurer.

US health care costs twice as much as the countries with socialized medicine because we have the government paying for our health care.

I see.

 

[Tatyana]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1614856/

Am J Public Health. 1995 March; 85(3): 341–344.

PMCID: PMC1614856
Copyright notice
Care denied: US residents who are unable to obtain needed medical services.

D U Himmelstein and S Woolhandler
Department of Medicine, Cambridge Hospital/Harvard Medical School, MA 02139.

Abstract
OBJECTIVES. This study analyzed data on US residents reporting that they were unable to obtain needed care. Inadequately immunized children and women inadequately screened for breast or cervical cancer were also examined.

METHODS. Data from the 1987 National Medical Expenditure Survey was analyzed



. RESULTS. A total of 6,375,000 (90% confidence interval [CI] = 6,039,000, 6,711,000) people could not get hospitalization, prescription medications, medical equipment/supplies, or emergency, pediatric, mental health, or home care. Although the uninsured were more likely to forego care unavailable, three quarters of those unable to obtain services were insured, and 46% (90% CI = 42.4%, 49.6%) had private coverage. Of those reporting the reason why they failed to obtain care, 65.1% (90% CI = 61.7%, 68.6%) listed high costs or lack of insurance, including 60.7% (90% CI = 57.1%, 64.3%) of the privately insured. More than a third of women had not had a breast examination in the previous 2 years, a fifth had not had a Pap smear within the previous 4 years, and half had never had a mammogram (ages 50-69 only). Of children 2 to 5 years old, 35.1% (90% CI = 31.5%, 35.7%) were inadequately immunized. Medicaid recipients had measures of access to care similar to those of the uninsured.

CONCLUSIONS. Many US residents--most of whom have insurance--are unable to obtain needed care, usually because of high costs.

http://www.healthcarefinancenews.co...-americans-denied-coverage-insurance-industry
New survey finds 12 million Americans denied coverage by insurance industry
August 11, 2009 | Diana Manos, Senior Editor

Health care crisis for pregnant women
http://www.amnestyusa.org/dignity/pdf/DeadlyDelivery.pdf

 

[Ampulla of Vater]

Did you know that:
Quote:
August 31, 2009
Would Tort Reform Lower Costs?

http://prescriptions.blogs.nytimes.c...th-care-costs/

One of her first statements is completely incorrect. Anne Underwood states:
As the cost of health care goes up, the medical liability component of it has stayed fairly constant.


For the years 2000 to 2008:
o Premiums rose 221 percent for OB-GYNS in Philadelphia, PA
o Premiums rose 149 percent for General Surgeons in New Jersey
o Premiums rose 348 percent for internists in Connecticut

http://www.hcla.org/PDF/HCLAHighCostFactSheet2009.pdf

 

[Uncayimmy]

One of her first statements is completely incorrect. Anne Underwood states:
As the cost of health care goes up, the medical liability component of it has stayed fairly constant.


For the years 2000 to 2008:
o Premiums rose 221 percent for OB-GYNS in Philadelphia, PA
o Premiums rose 149 percent for General Surgeons in New Jersey
o Premiums rose 348 percent for internists in Connecticut

http://www.hcla.org/PDF/HCLAHighCostFactSheet2009.pdf

Not to get too sidetracked here, but do you understand what the economy has gone through, particularly in terms of investments during that time? Insurance companies make a buttload of money off of investments. When rates of return go down, rates go up. If the investments lose money, they have to charge to bring it back up. Adjusted for today's dollars the Dow average close in April 1999 was $13,816 and in 1998 it was $8,468.

It's not nearly as simple as some people want to think.

 

[Emet]

One of her first statements is completely incorrect. Anne Underwood states:
As the cost of health care goes up, the medical liability component of it has stayed fairly constant.


For the years 2000 to 2008:
o Premiums rose 221 percent for OB-GYNS in Philadelphia, PA
o Premiums rose 149 percent for General Surgeons in New Jersey
o Premiums rose 348 percent for internists in Connecticut

http://www.hcla.org/PDF/HCLAHighCostFactSheet2009.pdf

Nice bit of selective data from the HCLA.

Let's go back to the original source:

Medical Liability Monitor Publishes 2008 Annual Survey of Medical Liability Insurance Rates

Medical LiabilityMonitor's October 2008 Rate Survey shows physicians' malpractice insurance premiums remain stable or continue to decline in 2008

This year's study found 49.9 percent of rates did not change between 2007 and 2008; in fact, 20.8 percent of rates experienced a 0.1- to 9.9-percent rate decrease. This continues the stabilizing trend found in the 2007 Rate Survey, where 53.1 percent of rates had not increased and 21 percent had experience a 0.1- to 9.9-percent decrease from the year prior. In 2006, rates also experienced a similar stabilizing effect, perhaps their first in recent history.
"Rates are clearly following a stabilizing trend, and in a significant number of cases, continue to decline from their historic highs of 2004 and 2005," said Michael Matray, Medical Liability Monitor editor.
Since 1991 Medical LiabilityMonitor, an independent newsletter, has been surveying the leading providers of medical professional liability insurance for its annual rate report. This year's survey reports rates from 40 companies that represent as much as 75 percent of the physician's malpractice insurance market. It is the most comprehensive report on physicians' liability insurance rates available.

http://www.prweb.com/releases/2008/10/prweb1500114.htm

 

[Agatha]

No. What I'm saying is that the UK has a very different culture than the US. You pay tax money to support an outdated and irrelevant monarch and somehow justify this significant expenditure.

Yes, because we get more tourist money in to the country than we pay to the Royals, and believe me nobody is coming here for the climate. Our tourist industry is worth £115bn a year.

It has to do with the fact that you guys prioritize things differently. $62 million dollars could have easily paid for the drugs that helped Nikki Blunden and others like her.

By paying footballers more than doctors you are saying they are more valuable. The same is true in the US.

The surgeon does not operate in a free market. Tom Brady does. Let the doctor operate in a free market. Tom Brady's salary will have to go down because the people will stop spending so much on football. They will be forced to re-prioritize their spending to things that are actually important. Some people will choose not to save/plan for their healthcare and will still contribute to Tom Brady's salary. I wish them luck that they never get sick. But most will save/plan and contribute to the doctor's salary so they are covered in case they get sick. It's your choice, what do you value more? You can't have both. You may think you have both now, but Nikki Blunden might disagree with you.

As I keep on saying, our system isn't perfect, and sometimes things go wrong. When it does, as in the case of Nikki Blunden, it's headline news, and reviews are ordered, and things change. I see that Ms Blunden's specific case has been discussed by Tatyana above. When people die in the US through lack of care, or people go bankrupt because of medical costs in your system, is it so unusual that it gets to be headline news?

Interestingly, linked from that same Daily Fail news page is this story; the first baby mentioned, Finley Burton, is from one of the most deprived boroughs in the whole of England. Do you think his parents could ever afford the care that saved his life?

I do believe you. I think it could be much better. You can't possibly know that everyone who needs care gets it. Everyone YOU know does, but what of the people who are denied care everyday in the UK, because they are obese, because the NHS doesn't think their lives are worth extending, because they drink . . . a whole host of reasons?

This happens so rarely that when it does, it's headline news and reviews are ordered.. hold on, didn't I say this already?

I think a free market system could fix many of those inequities. I understand that you think a free market will leave people out in the cold. People are left out in the cold now. But a free market will let each individual decide how important healthcare is and provide the market forces to drive costs down.

A free market would exclude the complex, expensive cases because the recipients would never be able to afford them. A free market would exclude those people born into poverty who need care from birth (or before).

A free market would leave me out in the cold, even if I put every penny I ever earn over my whole life into healthcare. I could prioritise healthcare over everything else; no money ever for mortgage or rent, no money to feed or clothe myself, and still I could never earn enough to pay for the care I need.

And not just me, everyone born into poverty, everybody with a lifelong chronic illness (which, remember, severely limits their earning power), everyone who develops a rare cancer, and people like Stephen Hawking who need the treatment and support for ALS before they can possibly earn the money to pay for their care.

 

[Uncayimmy]

@xjx388 - You're operating in/near McAllen, Texas, correct?

If so, this article points out that it's one of the most expensive cities in the country for medical care, mostly from overutilization.



This article is a great read. It was quote earlier in the thread, but everyone should read it.

From this article:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=5

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income.

Damned socialists!

Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.

In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”

“How much?” I asked.

“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.

So, who is really responsible for the higher costs? Doctors or patients?

 

[Rolfe]

I guess I've been consuming too much of the Christmas spirit, because this is what this argument sounds like to me.

The rest of the world: A large number of people in the USA either cannot obtain health insurance, or are denied care by their insurance company when they need to make a claim. Many more are bankrupted by the copays and the deductibles.

xjx388: That's OK, if they haven't taken responsibility for themselves then that's what happens.

The rest of the world: It doesn't happen in countries with universal healthcare.

xjx388: I can't believe a universal healthcare system can possibly cover everyone for everything they need.

The rest of the world: Pretty much, actually.

xjx388: No, I don't believe you. You get denied care if you're fat or you smoke or the government doesn't think your life is worth saving.

The rest of the world: Er no, there would be a bloody revolution if that actually happened.

xjx388: Hey look, I found a couple of tabloid newspaper articles claiming people were denied particular expensive drugs.

The rest of the world: We raise you about a squillion articles about miracle heart transplants and pioneering treatment, many cases involving people with few resources, and all absolutely free.

xjx388: That doesn't count, I found an article about a woman who didn't get treatment.

The rest of the world: No system is completely perfect, but when someone is let down by a universal healthcare system there are enquiries and revised guidelines and procedures to try to prevent it happening again.

xjx388: That doesn't count. I've proved universal healthcare doesn't cover absolutely everyone for absolutely everything. Which means it's evil backward socialism, and the USA is far better off with a system where many people can't get insurance at all, many more are denied treatment by their insurer when they need it and many more are bankrupted by the copays and the deductibles. That's obviously so much more preferable to a system where I can find a couple of tabloid articles about isolated examples of people who didn't get what they should have got from a universal healthcare system.

You see it's like this. I'm quite content that people who haven't saved every penny they have left after basic necessities don't get healthcare when they need it, in the US system. I'm also quite content that people who have done that, but whose healthcare requirements are still greater than their resources, don't get treatment. That's the free market for you. I'm all right, Jack! But if I can find a single person who didn't get treatment under a universal healthcare system, then of course that shows it's evil commie wickedness, and the US should never contemplate such an arrangement.

The rest of the world: Well, we'd rather have it our way, thanks.

xjx388: You lot are just weird. The Royal family, and footballers' salaries, and that proves my case.

The rest of the world:

Rolfe.

 

[Rolfe]

I find xjx388's repeated calls for doctors to be paid more then footballers and pop stars quite interesting. On one hand, he wants the cost of medical treatment to decrease so that people like Ducky can afford the sort of surgery we can all see in his avatar. And on the other hand he wants doctors to be paid like David Beckham. I'm not quite sure how he squares this circle.

He's suggesting that everyone needs to re-prioritise, and value their healthcare more than they value sport, or music. So instead of watching football, or listening to music, they put that money into savings so that when they need medical care they'll be able to pay the sort of fees that will see the doctors on multi-million dollar incomes.

Ordinary people in low-wage jobs should save every spare penny they have, and go without all luxuries and all entertainment, so that doctors can live like Michael Jackson.

Bear in mind that xjx388's wife is a doctor and his own income comes from working in her medical practice.

Rolfe.

 

[xjx388]

You have a very limited understanding of accounting. I really don't know how to respond without covering a few semesters of basic business education. Insurance companies right now pay your overhead - it's built into your pricing.

No Caca, Sherlocka. It's built into every businesses pricing. This is a ridiculous argument. I charge to cover my overhead and get a profit. It wouldn't matter if an insurance company was paying me (except that I have very little say in how much I get paid from them) or collecting directly from the patient.

Maryland malpractice rates:
Internal Medicine - $19K
General Surgery - $74K
OB-GYN - $144K

I can't speak for Maryland. They should implement reform and lower their rates, like we have in Texas.

According to this discussion board, dentists pay $2K to $5K per year for $3M in liability insurance.

Dentists don't have nearly as much malpractice risk. And you shouldn't believe what you read on discussion boards; as your posts illustrate perfectly, sometimes people talk out of their butts.

As for the ballpark numbers I used:

Good enough for you?

Nope. You don't understand how malpractice works. What kind of policy was that?

Except for all the places where that has actually worked. Can you cite some free market examples as evidence of the resulting price drop?

Cosmetic surgery. Lasik.

 

[Uncayimmy]

No Caca, Sherlocka. It's built into every businesses pricing. This is a ridiculous argument. I charge to cover my overhead and get a profit. It wouldn't matter if an insurance company was paying me (except that I have very little say in how much I get paid from them) or collecting directly from the patient.

I have no idea what you're yammering about at this point. Here's how it went:

Me: Tort reform is an issue that needs addressing, but what's your issue with taxing to cover malpractice? It's a cost of doing business. We pay for it now. Why would you not think we'd pay for it under UHC?

You: Let's tax to cover my overhead too, then. How many taxes do you propose we add?

Me: Insurance companies right now pay your overhead - it's built into your pricing.

You: The above?

It's almost like I'm dealing with two different people switching off responding because I can't make heads or tails of the exchange at this point.

I can't speak for Maryland. They should implement reform and lower their rates, like we have in Texas.

Dentists don't have nearly as much malpractice risk. And you shouldn't believe what you read on discussion boards; as your posts illustrate perfectly, sometimes people talk out of their butts.

Nope. You don't understand how malpractice works. What kind of policy was that?

Once again, I have no idea what you're trying to say. I pointed out that malpractice insurance suffers from the same issues as health insurance but to a worse degree.

Cosmetic surgery. Lasik.

How are either evidence of free market success? The reality is that both are ridiculously expensive, and the surgeons make ungodly amounts of money. The average surgeon's fee for breast implants is $4,000. They spend less than an hour on the consultation. The surgery itself takes one to three hours, so call it a max of four hours to include prep time. A follow-up visit is brief. Let's call it five hours total.

That's $800/hour for the surgeon to perform a procedure that quite frankly just isn't that difficult as far as surgeries go. Is this what you're holding up as an example of free market medical practices?

 

[Ducky]

Someone mention boobs?

/me perks up.

 

[Ducky]

I find xjx388's repeated calls for doctors to be paid more then footballers and pop stars quite interesting. On one hand, he wants the cost of medical treatment to decrease so that people like Ducky can afford the sort of surgery we can all see in his avatar. And on the other hand he wants doctors to be paid like David Beckham. I'm not quite sure how he squares this circle.

He's suggesting that everyone needs to re-prioritise, and value their healthcare more than they value sport, or music. So instead of watching football, or listening to music, they put that money into savings so that when they need medical care they'll be able to pay the sort of fees that will see the doctors on multi-million dollar incomes.

Ordinary people in low-wage jobs should save every spare penny they have, and go without all luxuries and all entertainment, so that doctors can live like Michael Jackson.

Bear in mind that xjx388's wife is a doctor and his own income comes from working in her medical practice.

Rolfe.

Isn't calling for the redistribution of wealth something those dirty socialists do?

 

[Emet]

Cosmetic surgery. Lasik.

Okay. If true, these represent two elective and cosmetic procedures that are not medically necessary.

Not really relevant to the health care issue, eh?

 

[Agatha]

As Emet says, elective procedures are not going to advance your argument much. Market forces rely on the supply and demand forces being elastic and where people can choose cheaper procedures or not at all. Healthcare tends to be driven by need, not choice. Preventative campaigns and programmes skew demand away from healthcare, which would push prices up rather than down.

Last night when pain stopped me sleeping, I was considering the footballer salary argument again, and this is why I think it fails: Tom Brady commands $8m dollars because of market forces, there are so very few top flight footballers and many teams want him to play for them, and the fans and sponsors are willing to pay almost anything he asks. This works because of the scarcity of top footballers, and the amount of audience (consumers) that they can entertain. I don't know what the TV audience is for a football game, but I'm willing to bet it's more people than an individual doctor could see in several lifetimes.

If an entire country's healthcare system could be run by say just twenty or so absolutely brilliant doctors/surgeons/midwives/nurses etc, and each one could treat millions of people every week, they'd certainly command those multimillion dollar salaries. And that would be fine, because the amount of money each patient would have to pay towards those mega-salaries would individually be very small and affordable (a bit like our 62pence per day for the Royals). But with the best will in the world, to treat a population of 300,000,000, you need many more healthcare workers than you do footballers. It's not that individual footballers are valued more than any individual health care worker, it's that you need so many more healthcare workers for an effective system. The total size of the domestic market in footballers should be compared with the total size of the domestic market in healthcare to make a proper comparison of which is valued more by a society.

Our tax-funded NHS works pretty much like a giant insurance backed system, except that there's no profit disappearing out of the system, so all the funding goes to the actual health care, and there's only one payer. The risks are pooled so that everyone can access care and there is no need for exclusions. Preventative campaigns and programmes are welcomed in this system, because the success of these frees up more resources for people who need them.

I was considering drug prescribing (more insomnia). I am aware that because of the purchasing and negotiating power of the NHS (that's those market forces in action), we pay less for medication than you do in the US, and I was wondering what the mix is between branded and generics there. My suspicion would be, perhaps because of the direct advertising of branded POM to the public, that you would prescribe more branded drugs than generics. Is that a fair assessment?

I was flicking through a copy of the British National Formulary from Sep 09 (no. 58, the latest issue is 60 but I don't have that here) and note that one of the drugs I am prescribed, gabapentin, costs the NHS £7.39 for 100 300mg capsules. If I were to be prescribed the branded drug, Neurontin, this would cost the NHS £42.40 for the same strength/amount. Looking through my latest carrier bag of drugs, everything I have is generic. Not all have the same cost differential as the gabapentin (in fact the generic fluoxetine costs more by a couple of pence per pack than Prozac), but I would suspect that this would be another reason why our system costs around half of yours for broadly similar outcomes.

 

[Rolfe]

That's exactly what I was thinking. The very few top footballers and pop stars can sell the same piece of work to huge numbers of people. The creator of a hugely popular piece of entertainment, which can be consumed by millions or even billions, with no additional effort on the part of the creator, can amass an enormous fortune by way of the tiny contributions from these billions of fans.

A doctor or surgeon has to repeat the effort again and again for every single patient. Having done one perfect quadruple bypass, he has to start all over again and do another, and another. Even if he's paid pretty well for each job, he can't possibly rack up the sort of fortune someone like J. K. Rowling can amass, just by sitting at home while more people buy more copies of the books she wrote.

That's market forces. For xjx388 to bleat that his wife is doing a more vital job than Joanne Rowling or David Beckham or the latest pop goddess and so should receive millions in reward demonstrates a lack of appreciation of market forces which is simply staggering in someone coming from his position. He seems to be advocating that each person's contribution to society should be assessed and their income fixed according to that assessment, rather than letting the market decide.

Sounds positively communist to me.

Rolfe.

 

[Blue Mountain]

Isn't calling for the redistribution of wealth something those dirty socialists do?

Only if the distribution is from those who have more wealth than they know what to do with to those who don't have enough to live on. When it flows the other way, rich Americans called it "capitalism" declare it to be Good.

 

[Emet]

I was considering drug prescribing (more insomnia). I am aware that because of the purchasing and negotiating power of the NHS (that's those market forces in action), we pay less for medication than you do in the US, and I was wondering what the mix is between branded and generics there. My suspicion would be, perhaps because of the direct advertising of branded POM to the public, that you would prescribe more branded drugs than generics. Is that a fair assessment?

There are several factors in play here. I believe I stated a while ago that some MDs in the US will choose to Rx the latest, greatest drug that is on patent. MDs are marketed directly: Drug reps come to their practices to pitch their products, and advertise in some journals.

Prescription drug prices in the US are the highest in the world. Wiki link.

As to the patients and direct marketing, it will often come down to their health insurance plan. More about that after your second quoted paragraph.

I was flicking through a copy of the British National Formulary from Sep 09 (no. 58, the latest issue is 60 but I don't have that here) and note that one of the drugs I am prescribed, gabapentin, costs the NHS £7.39 for 100 300mg capsules. If I were to be prescribed the branded drug, Neurontin, this would cost the NHS £42.40 for the same strength/amount. Looking through my latest carrier bag of drugs, everything I have is generic. Not all have the same cost differential as the gabapentin (in fact the generic fluoxetine costs more by a couple of pence per pack than Prozac), but I would suspect that this would be another reason why our system costs around half of yours for broadly similar outcomes.

I believe most insurers use a formulary now; but they may vary as to what they allow/don't allow.

Here's 2 anecdotal examples:

My plan offers a PPO and a fee for service (I have the latter), but a separate company manages drugs like most PPOs do. They will pay a differing amount according to the formulary: 60%, 70%, or 80% (until I reach my out-of-pocket), depending whether it's a recommended drug, a generic, or a brand name. (I don't remember exactly which is which). Some drugs will simply not be covered. Since I'm not in the PPO, my MD can Rx drugs as often as s/he determines is needed.

My friend's PPO: he pays a fairly standard co-pay for most drugs--say $10-20. But his PPO keeps a tighter reign on the MDs ability to prescribe drugs willy nilly. He was on Accutane (for Acne); his PPO balked when his MD wanted to prescribe a second course, so the MD prescribed doxycycline. My friend may have been able to obtain the second course (I'm not sure), but he would have paid significantly more. My insurer would have simply paid for a second Rx.

 

[Rolfe]

Only if the distribution is from those who have more wealth than they know what to do with to those who don't have enough to live on. When it flows the other way, rich Americans called it "capitalism" declare it to be Good.

I'm particularly struck by the husband of a doctor insisting that his wife should be paid a superstar salary, while at the same time denouncing as "irresponsible" any spending on small luxuries by people on limited incomes, rather believing they should save it all to contribute to his wife's megabucks lifestyle.

The more I read from xjx388, the less I like him, I'm afraid.

Rolfe.