! ? ! ?

Who should provide it (public/private/both/other)? How should it be paid for? Exceptions/exclusions?

Edited by retropump on 12/14/2009 17:07:08 MST.

I don't think this discussion should go any further. It wouldn't end in a civilized manner.

"I don't think this discussion should go any further. It wouldn't end in a civilized manner."

Could it end worse than discussing guns/global warming/religion etc...?

I ask because I don't understand the differences between different countries and ideologies/methods of funding and allocation, plus when I Google it all I come up with is advertising from health care companies.

Aside from that, it has already come up in the general backpacking forum, and I had hoped to keep that forum clear of the chaff that could evolve from having the topic come up. It seemed tangential to the OP in that particular thread!

Edited by retropump on 12/14/2009 17:00:44 MST.

"I don't think this discussion should go any further. It wouldn't end in a civilized manner."

That's a shame. Have we really lost the ability to discuss, debate and disagree in a civilized manner? If so, we're truly adrift.

Anyway, I'll give my opinion as to the original question. It's a tough one, really. I'm a big believer in personal responsibility, not enough of it going around. But for health care, I certainly like the European model: socialized health care, for lack of a better term. I also like the Oregon model, which I believe is somewhat based on some European models: health care rationing. I believe everybody should receive taxpayer supported, no cost health care. I think that's the most economical system so far. But not for everything. If you want experimental treatments, or treatments that only work in a very few, then you pay for that yourself. I know that to many rationing is a dirty word, but you can't live forever, and I shouldn't have to pay for your lack of ability to accept your imminent death. We all die.

On a grander scale, I agree with Mario Cuomo's 1984 keynote speech (one of the greatest ever given, IMO): "We believe in a single fundamental idea that describes better than most textbooks and any speech that I could write what a proper government should be: the idea of family, mutuality, the sharing of benefits and burdens for the good of all, feeling one another's pain, sharing one another's blessings -- reasonably, honestly, fairly, without respect to race, or sex, or geography, or political affiliation. We believe we must be the family of America, recognizing that at the heart of the matter we are bound one to another, that the problems of a retired school teacher in Duluth are our problems; that the future of the child in Buffalo is our future; that the struggle of a disabled man in Boston to survive and live decently is our struggle; that the hunger of a woman in Little Rock is our hunger; that the failure anywhere to provide what reasonably we might, to avoid pain, is our failure."

Aaaargh! Health care is extremely frustrating. I had insurance for 10 years, but had to give it up. 15 years ago, premiums for me, my wife, and son, went from $165 per month to $350 per month over a 6 month period. In the 10 years we had it we never filed a claim. The last time we looked, premiums were over $500 per month. Over the 15 year period, we've saved approximately $72,000 in premiums. As long as we don't have a major illness, we're money ahead. Medical bills have been minimal. My son does qualify for basic medical care under a state program.

My major complaint on health care is that you pay different amounts for the same medical service depending on whether you have insurance. For example: we took my son to the doctor for a sinus problem. When we went to pay, the bill was $50 .... until my wife started to write the check. Because we didn't have insurance, they charged $75.

Another example: My grandmother recently had to have a hip replaced. She has medicare plus supplemental insurance, so the cost was fully covered. The total amount billed Medicare and the supplemental company for the procedure....$2,900. If she had no insurance, she would have been billed $40,000 for the exact same procedure. It is absolutely ridiculous to charge over 13 times as much for the same procedure. The doctor's rationale: "We made a deal with Medicare and that's all they will pay, so we have to make up the extra wherever we can." Imagine you went to a store and bought a can of soda. The guy in front of you buys the same soda and pays $1, they then charge you $13 for the same thing. Crazy.

Hey, thanks Douglas and PelePe That's the kind of insightful commentary I was hoping for. I think we all acknowledge there is no "perfect" system. And I don't think it is too controversial to say that Americans in particular seem to get stung with outrageous basic health care costs.

I personally see nothing wrong with rationing. Spend the most money where it will do the most good overall. I watched my father die after 3 months in hospital waiting for a heart transplant. Total cost $300,000 in 1992, and that's without getting any surgery! Even at the time, as much as I loved and wanted my father to live, I thought this was way too much to spend on one person's slim chance of surviving when there are so many folks who would benefit from just visiting their GP for some antibiotics.

Oh yeah, and even back in 1992, I noticed they were charging something like $10 just to give my father two aspirin for his headache. What a racket!!!!!

Edited by retropump on 12/14/2009 17:52:20 MST.

As a former senior accountant for a non-profit health maintenance organization in the US, maybe I can offer a few insights into the US health care "system."

First, on the other thread, Lynn was wondering how the $100,000 bill for Sarah's baby would be subsidized. The answer is that her husband's employer contracts with one or more health insurance companies to cover health care cost for its employees. The rates negotiated will cover the cost of those larger bills (actually, $100K is not all that large these days), and the same premium rates apply to everyone covered by that employer. The portion paid by the employer is part of Sarah's husband's total compensation (wage and benefits) package. If a larger-than-average percentage of the firm's employees incur higher costs than would be expected for a group that size, then premium rates for the group will go up. The firm may decide it's worth the money to retain experienced employees, or it may make the employee pay a larger share of the premiums. Or it may select a health plan with less benefits (i.e., the employer is charged a higher deductible or copayment for each service).

Obviously under this system, larger employers have a far better bargaining position with the insurers than do small businesses. They also have a far larger pool of employees over which to spread the cost. That's one reason why very few small businesses furnish health insurance to their employees. And, of course, a person having to buy their own insurance (either because they work for a small business or are self-employed) has no bargaining position at all with the insurance company. Individuals also are faced with the much publicized problems of no coverage for pre-existing conditions and of having their premiums increase sharply as they grow older.

I'm not going to get into the current health care reform bills before Congress except for a couple of items. The part that puts individuals into a much larger health-care pool (in the Senate's bill, administered by the Federal Personnel Management agency) will greatly increase the bargaining effectiveness of the individual--who will now be part of a large group--in negotiating rates. The bad part is that with these individuals getting lower rates, the large groups will have to pay higher rates. We can't expect the insurance companies--including non-profit ones like the one I worked for--to operate at a loss. The large employers will probably pass this increased cost to their employees.

Left out of the "reform" packages is the large burden on hospital emergency rooms (my son-in-law is an ER physician, so I have "inside" info here, too). Many ER patients have no insurance at all, and a large proportion are undocumented immigrants who will still not have insurance under any of the proposed reform packages. By current Federal law, every ER has to treat these individuals, and already receives some subsidy (but not nearly enough to cover costs) for doing so. A lot of smaller hospitals are already closing their emergency rooms as a result. At least in some localities, this leaves the undocumented with no health care at all. The consequences to public health could be devastating.

The Oregon Health Plan (actually a variation on Medicaid, the program for those on welfare) was cited earlier as a model. Actually, it has fallen apart in recent years. Reimbursement rates are so low that most medical providers will no longer accept OHP patients. The same thing is happening with Medicare (the program for those of us over 65), where reimbursements also do not cover the cost. The Medicare Advantage program (in which the subscriber is enrolled in an HMO, and which pays said HMO a flat premium rather than fee-for-service) is the one exception (and that requires supplemental premium payments from the subscriber). That's the program all the proposed reform bills plan to cut drastically in order to pay for everyone else. That means that my HMO provider will be forced either to drop Medicare patients or to triple or quadruple our premiums.

Edited by hikinggranny on 12/15/2009 14:00:49 MST.

I'm still struggling with the claim of hospitals and doctors that lower medicaid and medicare payments do not cover costs when we pay so much more in the US than in other countries. e.g.






Data source International Federation of Health Plans, an association of insurance plans in different countries.

If were ever going to get control of health care costs in the US these numbers need to change.

Edited by nschmald on 12/15/2009 14:09:55 MST.

Nia,

Because EVERYTHING to do with healthcare in the US is more expensive- including the operating costs of the hospitals and doctors. For just one example, all those to-one-degree-or-another socialized countries on your charts don't have NEARLY the malpractice premiums we do in the US.

There are things Medicare doesn't totally suck at, and there are things it does absolutely horribly. One thing it does horribly is paying for almost any surgical procedure. If you bill only Medicare for any procedure, yes, you are taking a loss. A cardiothoracic surgeon makes less money for a quadruple bypass that takes him all day than a plastic surgeon gets for an augmentation mammoplasty that uses 1/8th of his OR time for the day- because it ain't Medicare paying for the mam aug! I would get reimbursed better for my patient's postop pain management than for his cholecystectomy. (Though I'm currently salaried, so I don't bill- my hospital does.) One learns to code stuff that arguably isn't relevent for one's postop patients- like including their hypertension in the list of things you treated while they were in the hospital, despite the fact that you merely kept them on their usual outpatient medications.

I mean- consider that Mediare's policy is to REDUCE its reimbursement rates for everything periodically. Not increase them, mind you, as if to account for inflation, etc. They reduce them regularly. Logically, eventually that policy must fail. Because, eventually, no doctor will accept Medicare. Unless the government makes it mandatory, at which point medical school enrollments will disappear. Heck, cardiothoracic and trauma fellowships can't fill all their slots NOW! Nobody wants to take that abuse and get paid crap for it.

And, yes, Medicare won't pay one more cent than their "official" reimbursement rates, and they are notoriously miserly and find every possible opportunity to short you, so why bother billing it? All that does is result in the patient getting the excess bill- which will then go into arrears and get sold to a collection agency, and pretty soon Katie Couric will be talking about the heartless hospitals, et., etc. But if you have reasonable insurance then, yes, the hospital will bill the full price- because they have a reasonable chance of actually getting reimbursed, unlike with Medicare. (The average reimbursement rate in the US is something like 33% at the moment. So there's no point in quoting these outrageous bills- they aren't getting paid, anyway. Which should tell you that if the system WORKED CORRECTLY the average bill would be about 1/4 of those outrageous ones.) And, yes, those losses from taking care of Medicare patients DO get passed on to everyone else. That should enrage you- and motivate you to lobby for fixing Medicare. But either way you're going to pay for it- either in your bills as now, or in higher taxes to fund Medicare. So what's the use in complaining? The solution is to fix the things making everything so expensive- not complaining about how reimbursements work. :o)

Personally, I also find the lobbying power of the pharmaceutical and insurance industries rather repugnant. I would like to see political contributions limited to $500 or some other reasonable arbitrary sum per person per candidate per annum. (Recall that corporations are legally people.) I would also specify that a majority-owned subsidiary does NOT get another $500 to give away. That way the rich and the corporations don't get much more say than I do.

Mary is 100% correct that ERs get used like primary care clinics by the uninsured, and that the insured underwrite it. So all of the conservative whining about how they don't want illegal immigrants covered in any public healthcare plan are idiotic. We will all pay for those uninsured illegals anyway. (But it looks good to their equally irrational constituents when they make a show of it. Yet accomplishes nothing.) Further, because of this ERs are simply overwhelmed right now- which leads to complaints about long wait times, etc. Bummer. Solution? Fix the insurance problem.

I also agree that there are large inefficiencies in the US system. But that's sort of what you have to accept with such a distributed system, with so much freedom of choice on the part of the patients. If you don't like it, vote in socialized medicine. I won't argue.

Predictably, I also back malpractice tort reform. The problem is, I will admit, that I have no better idea how to fix it than anyone else does. Patients do need to be able to seek redress through the courts when they've been hurt and have a valid case- but too many are frivolous, or are just a case of trying to blame someone when something bad happens even if no one is at fault. There was a study that showed that the only variable affecting malpractice awards in the US was how badly the plaintiff was hurt. NOT whether it was actually the healthcare provider's fault. I guess juries just think "that poor guy needs SOMETHING, and the only people he can get the money from is the doctor/hospital/etc."

Thus US healthcare providers unequivicollay DO practice defensive medicine, for fear of lawsuits. A good example- even if I am quite certain that I have diagnosed someone correctly, but there is a very low chance something else may be going on and I can rule that out with a CAT scan, I get the CAT scan. Because GOD HELP ME if that happens to be the one time the weird thing is going on. I'd loose everything. And the patient pays for that, as do you all when the patient can't pay the bill and the cost gets foisted off on you.

Is it worth it to spend $400 on abdominal CAT scans to find that 1/10000 thing that might hurt a patient? $4,000,000 to save one guy, and keep me from getting sued into poverty? (Or, keep my premiums down...)

It is to me.

Are their doctors and hospitals who order CAT scans because they own the scanner, and make money off of it? I am certain there are. But I imagine that there are also doctors who are practicing defensive medicine, and figured that if they were ordering all those scans that they may as well make a buck off of it, and bought their own scanner. Don't kid yourself- it is easy to attack doctors. In some ways we are easier targets than lawyers. But most of us DID get into medicine for altruistic reasons.

Anyway- these are the difficult decisions any healthcare plan must make. If you don't want to pay that $4 million, then protect me from the lawyers. Otherwise, stop whining. :o)

End rant.

Edited by acrosome on 12/15/2009 15:04:44 MST.

Thanks for a wonderful post Mary! Information is a wonderful thing.

I wasn't aware that the Oregon plan was suffering so much now. I still agree with the overall concept, that some kind of rationing is necessary. As Steven Wright once said,"You can't have everything. Where would you put it?"

I think as long as medical doctors are asked to swear an oath that includes something like:
"I will treat without exception all who seek my ministrations"
Then there needs to be a way to pay the doctors.

I also think that there should be a basic level of care provided for in the cheapest insurance plan but people should be able to get more/better care by buying a more expensive policy and/or paying the difference directly. I suppose that's "rationing".

Who should pay for it? Everyone who is covered.
How? Either directly, through their employment, or through taxes.

Edited by jimqpublic on 12/15/2009 14:58:30 MST.

Not to get off topic, but aren't CAT Scans recently in the news for causing cancer? How do you defend against that?

But I don't have to defend against it. It is a known risk, and I tell all those patients about that risk, and that the thing I'm trying to rule out is rare, and that it isn't unreasonable to forgo the scan, and if they refuse the CAT scan that is their right and then I'm still covered about the lawsuit. (Frankly this is what I'm usually hoping for, and is very common.)

The point of that paper- which all the media are leaving out- was that well people shouldn't be paying out of pocket for whole-body CAT scans, the way some are. That the risks outweigh the benefits. They were trying to make the point that the larger the area scanned, the greater the radiation dose. I mean, anyone who didn't already know that increasing radiation exposure increases cancer risk is a moron. Duh. This is just a study that the media have decided to sensationalize, in the interests of selling papers and ad time. (But an abdominal CAT scan nowadays gives you less radiation than a chest xray did fifty years ago.) I don't even know if it is a good study or not- it just came out in the last issue of Arch Int Med. If it is, then yes, that is good information to know. I'll wait for peer review before I panic.

I Suppose I'll have to go look it up, now...

But the CAT scan thing was just an example- getting superfluous lab tests is even more widespread. So is sending a patient to a specialist even when you already know what's going on, just to cover your butt. (As a specialist, I get to experience this daily.) Etc.

Heck, every quarter or so I have to get a CAT scan on a PREGNANT woman. You want to talk about radiation risks, try selling THAT one to a patient! But it's the right thing to do. Risks are small, for one study during pregnancy. Even ACOG says to get any one imaging study you want (except fluoroscopy) if you need to, even in first trimester- it's the difference in lifetime leukemia risks for the baby changing from 1/3000 to 1/2000. Significant? Heck, yes! But better than the abortion rate from a ruptured appendix (>30%).

Sometimes you just have to make a hard call, Brother.

Edited by acrosome on 12/15/2009 15:45:27 MST.

Dean don't get me wrong. I'm not attacking doctors. I believe in capitalism and charging what ever the market will bare. I also believe that most doctors, at least all the ones I have met, are sincerely trying to do the best they can for their patients.

I should have addressed malpractice in my first post because it was inevitably coming. From what I can tell the AMA places the cost of our malpractice system at about 10% of total cost. Lawyers predictably say it is much less, about 1%.

The AMAs cost estimate includes defensive medicine. While I agree that many/most doctors practice socialized medicine I think this has more to do with patient desires/demands than worries about getting sued. The recent outcry concerning mammograms for women under 50 is a perfect example. A panel of doctors examining the data suggested that women might be more likely to suffer harm from a false positive than benefit from early detection. The response has resulted in mammograms on demand being added as a right to the health care bills.

But back to malpractice costs, either end of the range only explains a small fraction of the cost difference between us and the "commies".

I don't understand your comments about medicare. The charts I linked show that medicare while paying less than the rest of us still pays significantly more than the other countries sited for every procedure. You mention bypass surgery, where medicare pays 2x vs the others and the rest of us pay 10x more.

Your's and Mary's comments about emergency rooms are well taken. We require doctors both legally and morally to save peoples lives even if they won't be payed for it. I think virtually every doctor agrees with this moral responsibility. That IS socialized medicine. Providing the social safety net in emergency rooms is the most expensive socialized medicine in the world. Seems like we should be doing it smarter and cheaper.

It's good to have input from those in the firing line, but still no one seems to have any solid actionable ideas of how to fix things.

"First, on the other thread, Lynn was wondering how the $100,000 bill for Sarah's baby would be subsidized."

I wasn't really wondering...I know. But to me, the private employment insurance system works just like a social system, it's just applied to a smaller group than a whole nation. The employer pays. Either way, Sarah's healthcare is subsidised by other's labour and money. I don't feel she had the right to lambast someone who uses a free clinic because they don't have private insurance. OTOH, if she bragged that her pregnancy was gonna cost $100K, and she was paying entirely out of her own savings, then perhaps she would be entitled to take the moral high ground.

It is surprising to those of us outside the US that America is the last of the developed countries to adopt a semi-socialised medical care system. Everyone should be entitled to basic preventative and treatment based health care. Like here: you need a new hip? OK, you will be triaged and those that need a new hip the most will go to the top of the list. If you are far down the waiting list but don't want to wait, well you can pay out of your own pocket or buy private insurance to cover it.

And mal-practice litigation is just that...mal-practice. It's a bad practice and doesn't distinguish between doctors who are negligent or criminal versus good doctors who make a plain old human mistake or over sight (or don't order every test on earth to cover their buts). In NZ, these types of human error are called "accidents", and so are covered under our no-blame national accident compensation scheme. Yup, the taxpayer pays, not the doctor. It sure does hack the lawyers off, but helps keep health care costs down. Most docs are good people. They don't deserve to be sued!!

" I think virtually every doctor agrees with this moral responsibility."

While the following is an outlier, and I'm certainly not attacking doctors or hospitals or mom or apple pie (but maybe hugging, sorry Dean), I do remember some expose not too long ago where a hospital (California if memory serves) that was putting indigents into cars and dropping them off on the street instead of treating them. Horrendous.

I think, though, that that points more to the severe financial crunch many hospitals are in these days. Still, horrendous. And I doubt it's an isolated incident. So while we may 'require' emergency rooms to treat, that doesn't mean it's always happening.

Another thing that jacks up the cost of US health care is insurance billing. Find out how many people your medical or dental group hires just to keep track of the different benefits from different companies and to bill the companies. There are two of them in my dentist's office which is a two-dentist practice--in other words, one insurance billing clerk per dentist! This is where a single-payer system would be far more efficient, but don't hold your breath waiting for that to happen!

Another thing, as I understand it (someone please correct me if I'm wrong) that adds to our (American's) cost of healthcare is that in other countries, the educational cost of becoming a doctor is partially underwritten, while here a new doc can graduate with up to $100,000 in college debt. They've got to pay that huge sum off somehow.

Does anyone on the inside know, what percentage of a drug's costs go to cover specifying the shape, coating, color, and packaging of a drug ?

I'm curious.

"Does anyone on the inside know, what percentage of a drug's costs go to cover specifying the shape, coating, color, and packaging of a drug ?"

Don't know, but I'm sure it's a tiny fraction of the costs of discovery, patenting, development, testing, marketing and profit margin.