Health care - administrative incompetence

[Rolfe]

Exactly. We have a substantial self-pay population. We're able to offer them services within our scope of practice at very affordable rates. These people aren't just immigrants; they are the working uninsured for the most part. We can't do cancer surgery, but we can do quite a bit.

I know where this is coming from, because it describes veterinary practice in the 1970s, when I was in general practice. You can do a lot of ordinary basic care and even simple surgery at prices most people can afford.

Isn't that nice, that xjx388 would like to see US healthcare at the level of 1970s veterinary practice.

You'd also be amazed at what our local physician-owned hospital provides in the way of heavily discounted (sometimes pro bono) services to these uninsured people.

And who would be paying for that, then? TANSTAAFL, and all that.

Either the physicians themselves are taking a cut in their film-star salaries, or someone is subsidising it. In fact the latter is inevitable, because even if the doctor takes no fee at all for his services, he is still utilising the hospital's overheads, which have to be paid for.

This went on in 1970s veterinary practice too. Probably still does to some extent. Vets hiked the prices a little on all the routine stuff so there was a bit of slack in the system for the deserving cases.

What was that about not wanting to contribute so someone else's healthcare? You're doing it, whether you want to or not, almost any way you slice it.

It can be done, people. It really can. If, I'm filtering your comments through my ideology then you are doing the same.

Oh yes, 1970s veterinary care level can be achieved and afforded quite easily. So long as you only ever need the simple stuff, there is a charity organisation there to take care of the poor, which is sufficiently well subscribed, and you have the option to put down any patient who's going to cost more than the system can bear.

Rolfe.

 

[Bob001]

I'm not sure where this discussion turned south. Does anyone really believe that there should be no medical insurance, and that anyone who contracts a severe illness should bear the costs himself, rely on charity or just die? Or are people arguing that the U.S. employer-based, profit-focused system of private insurance, which is great if you work for the federal government or a Fortune 500 corporation but leaves you and your family out in the cold if you lose your job and can't afford a private policy, is superior to national systems that guarantee all citizens basic care (and in which they can still buy extras if they choose to)? And who do you think ultimately pays for "pro bono" care? Maybe the people who do have insurance?

It makes no sense to compare the health care marketplace to food and shelter. The costs of food and shelter are predictable on a daily, monthly and yearly basis, and the government provides food stamps, rent subsidies, public housing and other help to people who need it. The cost of health care is NOT predictable for any particular person. You might get hit by a bus tonight, you might have a heart attack tomorrow, you might get diagnosed with lung cancer next week, your newborn might have a congenital condition that will require a lifetime of treatment. That's why it's essential to distribute those costs across the largest possible base. The current U.S. system has enormous administrative expenses and waste built into it, costs which would be greatly reduced in a single-payer system. And the potential costs of insuring the uninsured are rarely contrasted with the costs society pays for not treating illness promptly: Welfare costs for people who end up too sick to work, lost income taxes from people who would otherwise be working, unreimbursed emergency care for problems that could have been treated cheaply in early stages, etc. Numerous objective accounts indicate that universal care systems, whether they are government-run like the U.K.'s or based on private insurance like France's and Switzerland's, work well. But unlike the U.S. system, they don't allow insurance executives to get rich by denying care.

 

[varwoche]

You'd also be amazed at what our local physician-owned hospital provides in the way of heavily discounted (sometimes pro bono) services to these uninsured people.

It can be done, people. It really can.

Lacking the existence of Libertopia, we are left to imagine the glorious possibilities.

 

[kellyb]

Lacking the existence of Libertopia, we are left to imagine the glorious possibilities.

Or look at vet medicine, where rather a lot of the lifesaving technology is a "niche market", so a lot of patients get helped out of their misery in another way.

 

[jimbob]

Or look at vet medicine, where rather a lot of the lifesaving technology is a "niche market", so a lot of patients get helped out of their misery in another way.

Which is why Rolfe's experience is so pertinent as she has worked in this field, and has made this point several times.

 

[FattyCatty]

It's not that the government can't manage healthcare reasonably well. It's that 1)The American people don't want the government managing it and 2)The private sector can manage it much better.
<snip>

Both statements #1 and #2 have been shown to be false. If you agree that the government can manage health care "reasonably well," which is a hell of a lot better than what we have now, let them. Use Medicare to cover everyone, just as a start. The mechanism is already in place (and is more efficient than the private sector), just expand eligibility to cover us all.

And the results of the last election show that the American people agree with them.

Not so. The election wasn't based on the health-care issue. Also, see Emet's and Gandalf's Beard's posts.

The private sector works to distribute the two fundamental human needs 1)Food and 2)Shelter. In healthcare markets that are completely private sector: 1)Vetrinary medicine, 2)Lasik, 3)Cosmetic surgery and 4)Self-pay primary care, it works just fine.

Lasik and cosmetic surgery are, in general, luxury items. I don't know if you can say veterinary medicine works well; many people can't afford care and either euthanize their animals, abandon them, or give them to a shelter (which usually euthanizes most of them because they can't find homes for them). Self-pay primary care? Do you mean people who pay for doctor visits but are **** out of luck is anything serious is wrong? Or do you mean rich people? Either way, it isn't something that is working well for the majority of the country, and certainly not for those with chronic and/or serious issues (see Harry Lime Juice, Ducky, Travis, Gandalf's Beard, and countless others).

Growing, harvesting, transporting and distributing food is very expensive.
Planning, obtaining materials, building and maintaining a home is very expensive.

People can't opt out of these markets; everyone needs both. Yet somehow, we are able to feed and shelter 99% of our 300,000,000+ people through the free market.

Your 99% number is a little high, as shown previously. Even so, our current health care system is nowhere close to taking care of that many of our citizens.

Give me specific reasons why healthcare is different and I can point to a way the free market might help.

The free market hasn't helped, it has hurt. The free market is a profit-making entity. It thrives on denying people coverage when something is wrong after taking their money when their health was ok. It has higher administrative costs than a government program (as shown before with Medicare). It has to put money into the pockets of its shareholders and its high-priced executives -- where do you think that money comes from? How can a free market help under those conditions?

I'm re-quoting these posts because you seem to have ignored them, xjx388.

CMAJ had an [editorial with citations] and in 2002 a peer-reviewed research [article] showing profit motive significantly deducts from quality of care in healthcare, rather than enhancing it.

Canada and the US had identical systems until the end of a transition over 1969-1972, and in the time since then, the US has fallen drastically behind in outcomes and is now more than double the cost. This value gap has grown especially fast since 2000.

IIRC, HMOs' costs outside actual care delivery - eg: accounting, marketing/advertising, lobbying, lawsuits, claim screening, collections - has inflated to about 30% of costs, compared to between 1 and 2% in Canada, depending on province.

The efficiency of US healthcare delivery is considered to be less than half of Canada's, even though Medicare is almost as efficient. This means that outside of Medicare (which has a 2% overhead) - so that means HMOs and private hospitals - is less than half as efficient. Maybe about 35% as efficient, based on my back-of-the-envelope estimate.

Statistics show that accessibility to primary care is actually worse in the US than in Canada or the UK. ie: longer waits in the US for GP.

There are complex factors that go into this that produce ranging estimates. One important factor is that it's hard to describe Americans who are not covered by anything and also do not have the money for a cash visit. Are they part of the 'cannot access GP' equation? Are they 'waiting' for the rest of their lives? Or do they get deducted from the wait survey?

Many people argue that if the question is about access, people who want access but are unable to obtain it should be considered a negative.


It's up to the doctor. My GP has what's called 'same-day-appointments' but some GPs prefer to book appointments in advance to balance their workload.

Yes, and this is a very studied hypothesis. There are competing models that have been tested, as you can imagine. Does a copay deter frivolous visits? Certainly. It also costs money to process and most importantly - deters legitimate visits. Consequently, copays appear to increase overall costs by reducing preventive opportunities while increasing avoidable emergency visits. It generates frictional cost shifting and deferral, without really reducing costs.

So, this is the problem. It's like a lot of things skeptics deal with: 'common sense' may be unreliable here. It would seem that copays should reduce costs. But the resarch shows that they inflate costs dramatically, which is why they're not sustained here in Canada very long.

(Every once in awhile a politician thinks he's the genius who just thought about copays and that it will reduce costs to introduce a flat charge of, say, $10 for a visit. Then costs increase and he has to be educated about this. Again and again and again, over and over and over. Such is the life of skeptics.)

Point is: some of this delivery model's benefits are counterintuitive, like may aspects of economics.

This is why it's easy to 'sell' to the public. It 'makes sense' even though it's not empirically true. Instinctively, we assume there is no free lunch. But management can be considered a technology, and single payer is the newer tech that the US is not upgrading to for various reasons (ideology, protection of profits, &c).

I know this soujds heartless but I don't really blame the insurance companies that much. Most are private businesses that by law have to protect shareholder intersts i.e make lots of money- in the insurance game there are only two real ways of doing that - charge higher premiums and become uncompetative or not pay out. Because of the frequency of denials it doesn't make the news so no damage to reputaton happens.

Quite why anyone would want to trust their life under such circumstances puzzles me like.

 

[Gandalfs Beard]

I feel sick...sick enough to throw up actually.

Here is how Medicaid works in Practice, not in theory. Every year you have to re-up, fill in forms and go through the humiliating process of proving that you are poor enough to receive it. Medicaid covers the premiums due for Medicare (that's right, you still have to pay premiums for Medicare even after you qualify through disability, or social security pensions).

The premiums are directly taken from your SS Disability or Pension checks.

On Oct 7th, a Medicaid Benefits agent claimed after a phone interview with my mother that as long as the forms were returned by Oct 31st, my mothers Medicaid benefits would continue without any break in coverage.

That agent lied. The forms were returned before Oct 31st with all the same information that my mother had given during the phone interview. The agent then claimed (after I phoned several weeks later to confirm that coverage was continuing as it should) that not all the information was received, AND THAT SHE HAD NOT EVEN GOT AROUND TO REVIEWING THE FORMS YET.

She threatened to send my mother's benefits claim to the fraud dept. The agent never even informed me that all she had to do was send an affidavit to be signed.

Several more weeks go by. Another phone call to the benefits department (this time with the help of a seniors aid group) and it was finally revealed that all my mother needed was to have an affidavit form signed. The form was mailed out, signed and returned.

Several weeks later, still nothing. Another call from Senior Network Services got through, and after a lengthy run-around with another agent, the Medicaid agency finally got around to approving the re-up. Benefits would be retroactive to the date of Oct 31st, the date of continuance.

I have just received a letter from the Social Security Administration, that my mother's Medicare premiums would be retroactively charged back to Nov 1st, and that her Social Security retirement check for January would have the deductions for two months worth of premiums from her already miniscule retirement check. And starting in February her retirement check will have the regular monthly premium for Medicare taken out.

I am outraged . After two months of argy bargying over a clerical snafu, the Medicaid benefits agent has ****** everything up. Now I will have to contact Social Security (because the local Medicaid agency will likely not bother to deal with it for weeks) and explain that my mother's Medicaid coverage should be retroactively applied and her checks not be debited.

I doubt I will be able to do this until after the New Year, because both the Social Security Department and the Medicaid Department have lovely holidays during which time no business will be conducted.

So that's how it works in America folks. If you're poor, and some bitchy agent ***** up your paperwork, you're ******.

So xjx388 explain again the wonders of America's ****** up health care packages for the needy. What's that? Charity you say. Bollocks.

GB

 

[Agatha]

I am appalled, actually, at the idea that people like me should have to rely on charity to get the basic healthcare we need, never mind the extras to give us a decent quality of life.

In America I'd have to give up my tiny part-time job in order to get nothing but the most basic of care, and for that you want me to rely on Mr and Mrs Bountiful, giving the crumbs from the rich man's table? It appears that along my job and my self-respect, I also have to give up my pride under your broken system.

Over here, I can keep my job, and I can have the satisfaction of knowing I'm contributing something (not much at the moment, admittedly) to the system for the good of everyone, not just me. I'm not caught in a poverty trap, I get good quality 2010 healthcare with top doctors, in modern hospitals with short wait times. I get to be as well as my condition permits, physically and mentally, and I get to keep my pride and self respect.

Charity? How blooming dare you.

 

[Bob001]

Quite why anyone would want to trust their life under such circumstances puzzles me like.

Actually, the U.S. system works pretty well IF you get your insurance as an employee of a large corporation or a federal or state government. Those groups are so valuable to insurance companies that the companies have a strong financial incentive to provide good service, and corporations and governments have human resources departments that go to bat for their employees when problems arise. The feds closely supervise the insurance companies that are allowed to compete for federal business. But if you get your insurance through a small group or have to buy it for yourself, the insurer has big financial incentives to deny your claims or throw you out or keep you out in the first place. That's where the problems lie.

One proposal during the health care debates was quite simple: It would have allowed any person to enroll in the federal employee programs on the same terms as federal employees themselves. This would have been purely voluntary, simply one choice that would be available to people who weren't happy with their other alternatives. John Kerry proposed something similar during his presidential campaign. The idea didn't get very far, largely as a result of vociferous opposition by the insurance companies. But I'm not sure why it would be considered "radical" or "revolutionary" or "socialist" to provide the same benefit to every American that government employees give themselves.

Sen. McCain, an outspoken opponent of health care reform, is a particularly perplexing case. As a federal official, and previously as a career naval officer, and previously as the child of a naval officer, he has received his health care through federal programs HIS ENTIRE LIFE (except for that visit to Hanoi). In fact, if his mom got her prenatal care at Navy clinics, he was getting federal care BEFORE he was born. But he doesn't want other Americans to have what we are buying for him. Can anybody spell "hypocrisy?"

 

[Delscottio]

Actually, the U.S. system works pretty well IF you get your insurance as an employee of a large corporation or a federal or state government. Those groups are so valuable to insurance companies that the companies have a strong financial incentive to provide good service, and corporations and governments have human resources departments that go to bat for their employees when problems arise. The feds closely supervise the insurance companies that are allowed to compete for federal business. But if you get your insurance through a small group or have to buy it for yourself, the insurer has big financial incentives to deny your claims or throw you out or keep you out in the first place. That's where the problems lie.

One proposal during the health care debates was quite simple: It would have allowed any person to enroll in the federal employee programs on the same terms as federal employees themselves. This would have been purely voluntary, simply one choice that would be available to people who weren't happy with their other alternatives. John Kerry proposed something similar during his presidential campaign. The idea didn't get very far, largely as a result of vociferous opposition by the insurance companies. But I'm not sure why it would be considered "radical" or "revolutionary" or "socialist" to provide the same benefit to every American that government employees give themselves.

Sen. McCain, an outspoken opponent of health care reform, is a particularly perplexing case. As a federal official, and previously as a career naval officer, and previously as the child of a naval officer, he has received his health care through federal programs HIS ENTIRE LIFE (except for that visit to Hanoi). In fact, if his mom got her prenatal care at Navy clinics, he was getting federal care BEFORE he was born. But he doesn't want other Americans to have what we are buying for him. Can anybody spell "hypocrisy?"

I am in no doubt some people recieve excellent care in the US its the IF bit that i find odd. I presume the 'others' fall in to the majority? Seems a bit russian roulette to me.

 

[joobie]

Actually, the U.S. system works pretty well IF you get your insurance as an employee of a large corporation or a federal or state government.

i posted this upthread but it bears repeating: i have excellent health insurance, and i still cannot afford the co-payments on care i need. and so i will remain disabled until something changes.

 

[xjx388]

First of all, show me one post where I used the word "charity."

Secondly,

I know where this is coming from, because it describes veterinary practice in the 1970s, when I was in general practice. You can do a lot of ordinary basic care and even simple surgery at prices most people can afford.

Isn't that nice, that xjx388 would like to see US healthcare at the level of 1970s veterinary practice.

I never said any of that. What I said was that there is a free market in Primary Care medicine and it works very well for what it can do, which is actually quite a bit. If this were extended into other specialties, costs would have to come down.

Either the physicians themselves are taking a cut in their film-star salaries

I never said this either. I said that any society that thinks healthcare is a right for all people cannot justify expenditures on luxuries until all of the healthcare needs of the people are met. Therefore, how can the British people justify the sums they pay their footballers, pop-stars, movie-stars, etc. while people are denied healthcare they need. I gave examples of people who have been denied in the UK (and if you think they are the only ones who have ever been denied anything, you are very, very naïve). I also said that people should be paid based on the value they provide to society. Teachers, doctors, etc. should be high on that list and footballers, etc. should be lower.

Just two examples of how my arguments have been twisted based on your ideologies and not on what I'm actually saying.

 

[xjx388]

i posted this upthread but it bears repeating: i have excellent health insurance, and i still cannot afford the co-payments on care i need. and so i will remain disabled until something changes.

Can you elaborate on this a little more? How do you have excellent insurance if you can't even afford copays for said insurance.

 

[Bob001]

I am in no doubt some people recieve excellent care in the US its the IF bit that i find odd. I presume the 'others' fall in to the majority? Seems a bit russian roulette to me.

Our insurance system is employer-based, and a majority of Americans -- particularly the ones in decision-making positions -- do get their coverage that way. But if you don't, your alternatives are expensive and limited. And even if you do, you are dependent on your employer's choices of company and coverage. And some major employers play games that limit who can buy coverage: One major retailer for a long time offered benefits only to "full-time" employees, then routinely scheduled much of its work force to work 39 hours a week ("full-time" is usually 40 hours). The health-care reforms just enacted will help people get coverage and will limit the worst abuses, but the system still relies on private insurers motivated to maximize profits. And if you contract a severe illness without insurance, your odds might not be as good as in Russian roulette.

 

[joobie]

Can you elaborate on this a little more? How do you have excellent insurance if you can't even afford copays for said insurance.

my insurance is paid for by my employer, and i cannot afford the copays because i don't have a spare $105/wk.

 

[kellyb]

I never said any of that. What I said was that there is a free market in Primary Care medicine and it works very well for what it can do, which is actually quite a bit. If this were extended into other specialties, costs would have to come down.

Sure, the costs for things like Ducky's surgery/treatment would come down.

Not to a level most people could afford, though.

 

[Ivor the Engineer]

<snip>

I never said any of that. What I said was that there is a free market in Primary Care medicine and it works very well for what it can do, which is actually quite a bit. If this were extended into other specialties, costs would have to come down.

<snip>

Stop using terms you don't understand the meaning of.

 

[banquetbear]

I said that any society that thinks healthcare is a right for all people cannot justify expenditures on luxuries until all of the healthcare needs of the people are met.

...why not?

 

[Delscottio]

First of all, show me one post where I used the word "charity."

Secondly,


I never said any of that. What I said was that there is a free market in Primary Care medicine and it works very well for what it can do, which is actually quite a bit. If this were extended into other specialties, costs would have to come down.

I never said this either. I said that any society that thinks healthcare is a right for all people cannot justify expenditures on luxuries until all of the healthcare needs of the people are met. Therefore, how can the British people justify the sums they pay their footballers, pop-stars, movie-stars, etc. while people are denied healthcare they need. I gave examples of people who have been denied in the UK (and if you think they are the only ones who have ever been denied anything, you are very, very naïve). I also said that people should be paid based on the value they provide to society. Teachers, doctors, etc. should be high on that list and footballers, etc. should be lower.

Just two examples of how my arguments have been twisted based on your ideologies and not on what I'm actually saying.

Every example that you've put forward has been refuted by actual evidence based research. Unless I missed some . Just because you think someone should get something doesn't mean its the correct course of action. Tatyana has linked a load of studies which are worth reading.

What footballers has got to do with I still don't know.

 

[Uncayimmy]

What footballers has got to do with I still don't know.

Oh, that's easy. Professional athletes make more money than doctors and teachers, so that means we value them more than we do doctors. Therefore, we value luxuries more than we do necessities, so I'll be damned if I'm gonna support people who value luxuries more than necessities.

Never mind that I am an avid Redskins fan, but they have not received a single dime from me in 20 years. I just watch the games on TV and read free articles on the web.