Here's a statement of the obvious: The opinions expressed here are those of the participants, not those of the Mutual Fund Observer. We cannot vouch for the accuracy or appropriateness of any of it, though we do encourage civility and good humor.
We need a one pay system because our current health care model results in a a death spiral of continually increasing costs. You have the patient, the provider and the insurer in a three ring circus with no one caring about the costs going up. If it was a two-way business transaction, you would have natural checks and balances.
Until we remove the profit motive from health care, we'll have health care in this country that ranks down with emerging market countries . . . oh, unless you have great insurance and a lot of money - in which case it's pretty good.
And if someone wants to accuse me of expousing socialized medicine. Fine.
I have a very hard time accepting that unless you have good insurance or a lot of money, you can lose that leg, or that eye, or your teeth, or your life - because you can't afford the cure.
Some rights are fairly inexpensive. Free speech isn't entirely free if it encourages riots, the murder of minorities, etc., but it's fairly inexpensive. The right to bear arms costs several thousand lives a year, and the cost of guns varies.
Other "rights" will cost somewhat more. Medical care in the US is expensive because it is a "free market" enterprise, even with all the regulations trying to ensure quality care. Hospitals charge in many cases what they need to earn to survive. In St. Louis, several long-established hospitals have failed over the past 15 years, but there were other larger hospitals willing to accept their former patients. Other hospitals in small cities, such as one in Ft. Scott, AR, were sold to for profit enterprises willing to accept the $100M in debt it had accrued with its unreimbursed care and under-reimbursed care of Medicaid patients. The Hill-Burton "access hospitals" in small towns established to allow local hospital care often are in the red and require taxpayer subsidies. I'm only mentioning situations of which I have personal knowledge.
Hospitals like MD Anderson are selling a brand as well as expertise, as does the Mayo Clinic, the Cleveland Clinic, several of the Boston Hospitals, etc, much as Michelin three star restaurants and "luxury" automobile brands sell either an experience or a level of comfort or performance. They charge for this reputation, and some people benefit from it, while many others would have done just as well a few miles from home at a local hospital or many miles further away at their state medicals school(s) (which often have reduced rates available for in state residents - taxpayers and voters), as one would at a good local diner or with a Toyota Corolla or perhaps a Ford Fusion (maybe a risky choice, unless you avoid the "MyFord" system - but a friend says his Chevy Cruze is entirely worth the money). If your doctor says you need to go to MD Anderson instead of the state medical school, pack your bags (and your check book and credit cards - they are selective with their charity care). But, if you go to these medical Meccas as an out-of-state patient, you'd better have money or good insurance. If you feel you deserve this level of care, be prepared to pay for it.
As I understand it, the British medical system has 2 levels, one providing good basic care, which may require long waits for expensive services, such as hip replacements, and a "private" relatively parallel system for those who can afford it. There are also hospitals with particular expertise, to which one may be referred for unusual complaints. I think these are usually in London or major cities. I think the Canadian system is similar so far as the two tier level of care, but I could be wrong. The German system seems to rely more on an insurance based model, but it seems to work in a prosperous economy. I know there can be long waits in the Canadian system, since some wealthier patients get services in the US. The doctors in these countries must be happy with the system, since they don't emigrate to the US, where they presumably would make more money. The vast majority of immigrant physicians to the US come from areas where the health system is less advanced (and incomes are much lower), do their residencies, and visit their families back in the "old country" when they can. There is reputedly a medical school in Pakistan devoted to training physicians planning to emigrate.
While I think the vested interests (primarily insurance companies and hospitals) will successfully prevent a single payer system in the US until the situation becomes so bad that access to medical care becomes a primary political issue, I personally think the British two tier system would meet US needs - you get basic services and eventual access to expensive services and you pay to jump the queue. I don't expect to see this in my lifetime. I do admire Obama and Judge Roberts for starting the process. I'm sorry my Republican Party is so obstructive (couldn't vote for them this year, but they may see the light or become more irrelevant.)
While the majority of the MFO readership may be in the upper tier and so accept the British system (invest well, you may be buying that hip a few years earlier), we need to realize that most 75 y.o. US citizens have not really paid for the care they are getting. Neither political party is willing to accept the voter fallout of instituting controls on Medicare affecting the current generation, so they are reducing the benefits of the 50 year-olds and my children, who are much younger. Very few of us are willing to surrender our "rights", or to offer those struggling in the ghettos of the US a level of medical care equal to ours, especially if it costs us taxes or forces us to accept less medical care, so we will continue as we are.
More medical care is not necessarily better medical care, but it is more expensive medical care. If we insist on an MRI for our arthritic shoulder or low back pain, on antibiotics for our viral illnesses, or on a specialist referral when our primary care practitioner doesn't agree with our diagnosis, we should pay for the excess financial burden we put on our medical system. If you believe your doctor doesn't know what's best for you, get a different doctor. If you can't find another primary care physician, realize that the medical system in the US rewards specialists, and market forces dictate that there will be fewer primary care physicians. If you are fortunate enough to have a good FP or internist, bake him or her a cake or pie (unless they are overweight; then reward them some other way). If you believe that importing foreign trained physicians will lower health costs, remember that they came to the US to make money (strangely, the well-being of someone from a foreign land whom they've never met isn't their primary incentive, as compared to my peace Corp volunteer daughter), so they will be scheduling return visits or tests and procedures sometimes because you need them and sometimes because they need the income from them.
The low relative reimbursement of primary care physicians (difficult to do primary care if your medical school debt was $100K) means we will have more physician assistants, like my daughter, whom I would trust, because the GPA of her PA class exceeded that of the medical students at the same university, and nurse practitioners, who are diligent, dedicated, but often limited by the quality of their preceptors, who do much of their training. (It's also unlikely that their academic performance matched that of the PAs or primary care physicians.) The pressure of universal medical coverage will infuse a large number of previously untreated patients into an over-burdened system, encumbered by a requirement for electronic medical records, which slow patient flow by 20% with a good EMR and much more by a mediocre one, such as Allscripts or NextGen. Ask your doctor if s/he is using Amazing Charts, EPIC or Athena, apparently the best of the recent crop. It will mean that s/he will be happier with the new normal in medical care. (Interesting that one of the heads of Allscripts made $20M over the last 4 years for a system that never ranked even average in user evaluations compared to other competing systems.)
I agree, Rono, we need a single payer system. It's a fantasy. Move to Vancouver if you can afford the property values (or pick a less expensive and environmentally less appealing site - it's cold up there.) Otherwise, invest well or save your money - or exercise 30 minutes a day, follow the DASH diet (look it up), and pick your parents well - genes matter.
Peace
After this, I'll probably have to ask David for a new identity.
Some rights are fairly inexpensive. Free speech isn't entirely free if it encourages riots, the murder of minorities, etc., but it's fairly inexpensive. The right to bear arms costs several thousand lives a year, and the cost of guns varies.
Other "rights" will cost somewhat more. Medical care in the US is expensive because it is a "free market" enterprise, even with all the regulations trying to ensure quality care. Hospitals charge in many cases what they need to earn to survive. In St. Louis, several long-established hospitals have failed over the past 15 years, but there were other larger hospitals willing to accept their former patients. Other hospitals in small cities, such as one in Ft. Scott, AR, were sold to for profit enterprises willing to accept the $100M in debt it had accrued with its unreimbursed care and under-reimbursed care of Medicaid patients. The Hill-Burton "access hospitals" in small towns established to allow local hospital care often are in the red and require taxpayer subsidies. I'm only mentioning situations of which I have personal knowledge.
Hospitals like MD Anderson are selling a brand as well as expertise, as does the Mayo Clinic, the Cleveland Clinic, several of the Boston Hospitals, etc, much as Michelin three star restaurants and "luxury" automobile brands sell either an experience or a level of comfort or performance. They charge for this reputation, and some people benefit from it, while many others would have done just as well a few miles from home at a local hospital or many miles further away at their state medicals school(s) (which often have reduced rates available for in state residents - taxpayers and voters), as one would at a good local diner or with a Toyota Corolla or perhaps a Ford Fusion (maybe a risky choice, unless you avoid the "MyFord" system - but a friend says his Chevy Cruze is entirely worth the money). If your doctor says you need to go to MD Anderson instead of the state medical school, pack your bags (and your check book and credit cards - they are selective with their charity care). But, if you go to these medical Meccas as an out-of-state patient, you'd better have money or good insurance. If you feel you deserve this level of care, be prepared to pay for it.
As I understand it, the British medical system has 2 levels, one providing good basic care, which may require long waits for expensive services, such as hip replacements, and a "private" relatively parallel system for those who can afford it. There are also hospitals with particular expertise, to which one may be referred for unusual complaints. I think these are usually in London or major cities. I think the Canadian system is similar so far as the two tier level of care, but I could be wrong. The German system seems to rely more on an insurance based model, but it seems to work in a prosperous economy. I know there can be long waits in the Canadian system, since some wealthier patients get services in the US. The doctors in these countries must be happy with the system, since they don't emigrate to the US, where they presumably would make more money. The vast majority of immigrant physicians to the US come from areas where the health system is less advanced (and incomes are much lower), do their residencies, and visit their families back in the "old country" when they can. There is reputedly a medical school in Pakistan devoted to training physicians planning to emigrate.
While I think the vested interests (primarily insurance companies and hospitals) will successfully prevent a single payer system in the US until the situation becomes so bad that access to medical care becomes a primary political issue, I personally think the British two tier system would meet US needs - you get basic services and eventual access to expensive services and you pay to jump the queue. I don't expect to see this in my lifetime. I do admire Obama and Judge Roberts for starting the process. I'm sorry my Republican Party is so obstructive (couldn't vote for them this year, but they may see the light or become more irrelevant.)
While the majority of the MFO readership may be in the upper tier and so accept the British system (invest well, you may be buying that hip a few years earlier), we need to realize that most 75 y.o. US citizens have not really paid for the care they are getting. Neither political party is willing to accept the voter fallout of instituting controls on Medicare affecting the current generation, so they are reducing the benefits of the 50 year-olds and my children, who are much younger. Very few of us are willing to surrender our "rights", or to offer those struggling in the ghettos of the US a level of medical care equal to ours, especially if it costs us taxes or forces us to accept less medical care, so we will continue as we are.
More medical care is not necessarily better medical care, but it is more expensive medical care. If we insist on an MRI for our arthritic shoulder or low back pain, on antibiotics for our viral illnesses, or on a specialist referral when our primary care practitioner doesn't agree with our diagnosis, we should pay for the excess financial burden we put on our medical system. If you believe your doctor doesn't know what's best for you, get a different doctor. If you can't find another primary care physician, realize that the medical system in the US rewards specialists, and market forces dictate that there will be fewer primary care physicians. If you are fortunate enough to have a good FP or internist, bake him or her a cake or pie (unless they are overweight; then reward them some other way). If you believe that importing foreign trained physicians will lower health costs, remember that they came to the US to make money (strangely, the well-being of someone from a foreign land whom they've never met isn't their primary incentive, as compared to my peace Corp volunteer daughter), so they will be scheduling return visits or tests and procedures sometimes because you need them and sometimes because they need the income from them.
The low relative reimbursement of primary care physicians (difficult to do primary care if your medical school debt was $100K) means we will have more physician assistants, like my daughter, whom I would trust, because the GPA of her PA class exceeded that of the medical students at the same university, and nurse practitioners, who are diligent, dedicated, but often limited by the quality of their preceptors, who do much of their training. (It's also unlikely that their academic performance matched that of the PAs or primary care physicians.) The pressure of universal medical coverage will infuse a large number of previously untreated patients into an over-burdened system, encumbered by a requirement for electronic medical records, which slow patient flow by 20% with a good EMR and much more by a mediocre one, such as Allscripts or NextGen. Ask your doctor if s/he is using Amazing Charts, EPIC or Athena, apparently the best of the recent crop. It will mean that s/he will be happier with the new normal in medical care. (Interesting that one of the heads of Allscripts made $20M over the last 4 years for a system that never ranked even average in user evaluations compared to other competing systems.)
I agree, Rono, we need a single payer system. It's a fantasy. Move to Vancouver if you can afford the property values (or pick a less expensive and environmentally less appealing site - it's cold up there.) Otherwise, invest well or save your money - or exercise 30 minutes a day, follow the DASH diet (look it up), and pick your parents well - genes matter.
Peace
After this, I'll probably have to ask David for a new identity.
Reply to @STB65: Nope, no need to hide. Very well stated, thank you. It's always good to get an intimate, insiders view. Even if a two-tiered system wasn't part of an original plan I have no doubt that it would surface in short order.
It's always seemed senseless to me that we as a country can blow up the world a bajillion times over but we can't afford to feed, shelter and take care of those who need it.
Reply to @STB65: "If you believe your doctor doesn't know what's best for you, get a different doctor. If you can't find another primary care physician, realize that the medical system in the US rewards specialists, and market forces dictate that there will be fewer primary care physicians. If you are fortunate enough to have a good FP or internist, bake him or her a cake or pie"
STB65: I'm impressed by your apparent breadth of knowledge here. I recoiled earlier when you said most 75+ year olds don't really pay for their care. While not yet 75, I distinctly remember $$ being withdrawn on every payday from my check at work and labeled "Medicare-FICA Contribution". So I'd quibble a bit there. And, while medical care is much more expensive nowadays, I'd like to think my "contribution" was invested wisely over those many years so that the sum grew. (Yep, I know - He doth protest too much:-)
Overall you hit the mark based on my limited experiences. I copied your remarks above on compensation re: specialists and FPs - having noticed a stark contrast in quality (education, intellect, motivation, etc.) over the past dozen or more years. Not to degrade any in the profession, but it appears those who "can do" (the most) have migrated in mass into the specialist class. No doubt the different compensation levels has been a driver - among many other reasons of course. This has watered-down the available pool of FPs. (I've recently learned that Medicare employs a 2-tier payment system, allowing higher payments for the "specialist" tier provider.)
To an outsider like me the system looks like total chaos. Having recently had a few tests done and being fortunate to be insured by a PPO, I've received a constant stream of small bills for the same procedure over a 2-3 month span. These are for the (deductible) amounts not already paid by the PPO. Each generally amounts to only $10-$20. I pay them as they arrive - not bothering to investigate, as the amounts are so small. Have recently begun to wonder if some may be charges for affixing the stamp to the envelope upon mailing, or perhaps "opening fees" for when the checks arrive.
Back to FPs. A few months back I jokingly asked mine if half his time was spent filling out paperwork rather than treating patients. He responded that the paperwork load for insurers and Medicare was consuming about 80-90% of his time. Since a powerful sense of humor ain't one of this fella's finer attributes, I have to think he wasn't kidding. Thanks for your fine contribution. Hope I haven't muddied the discussion too much. Regards.
It's always seemed senseless to me that we as a country can blow up the world a bajillion times over but we can't afford to feed, shelter and take care of those who need it.
That pretty much says it all. The PROFIT needs to be removed from healthcare. Plain and simple. Either we are collectively afraid to do it, or the Big Money Medical Lobby is preventing it. I think it's a bit of both. The healthcare "system" is a bunch of holes connected by greed, crap, excuses, nonsense and damnable lies. The receiver of medical services is at the receiving end of it ALL.
We have Romneycare in MA where I live. Obamacare is modeled after it. The chaotic, nonsensical, crazy medical and medical insurance "system" is the exact opposite of what it was presented to be. It was PRESENTED as "universal" coverage. You have to turn the word inside-out and upside-down to get there....What we DO have is an INDIVIDUAL mandate. That's as far as you can get from truly universal coverage.
In MA, it goes like this now:Are you lucky enough to be covered at work? Fine. Oh, you're NOT working for a paycheck and you're not covered by your employer? Screw you, find insurance. It's a rule.
If you don't have much money coming in, you get coverage that is virtually free, including prescrips. for a very low, token co-pay. (I've been there.)
But now the wife and I are in a different plan. Get THIS: she works at a HOSPITAL, but she's not covered by their own plan. How do ya like THEM apples? So now we pay a monthly bill to remain covered, and monthly 'scripts will total over $120.00 for me. (My wife found a JOB, she didn't inherit a billion dollars!)
.....Come to find out, the State agency that runs the health-care availability system "runs" your SS # every month to see what's what with your household money situation. No one will TELL you what the thresholds are in order to be able to get plan One or Two or Three. You're just told, after giving them your quarterly income info. Providing that information is made possible by a host of new quasi-State employees who work in hospital and clinics, whose job it is to be the go-between--- between yourself and the lovely State agency who runs the "system."
Everyone's covered, yes. And Medicare is a different animal, yes. But the talk is all about requiring you to be covered by insurance, and how much you have to pay. Not a word about the absurdly ridiculous costs. ....And further, I have to wonder why we are required to report income, when Big Brother is finding and taking the info. "He" needs, with regard to eligibility and Plan-Types provided to you.
Most recently, I was offered a choice between my current carrier, but going forward, I'd have to pay X premium every month. I was offered the chance to go with a different outfit. The savings? Meh, about $10.00 per month.
That's not to mention the aggravation: a phone loop which loops you around and around without ever getting to a human on the other end; then, talking to a human--- after deliberately dialing one of the "wrong" options in my case; then there are assurances made, but please call the proper number next time. I went through 5 different people before there was even any conversation about what I needed. Then they sent the wrong stuff by mail to the house.
We're living the "1984" Orwell novel. Truth is stranger than fiction. You would not believe the crap. Change doctors? You're permitted to do that thrice per year. If the "System" contains the wrong doctor's name for you, you gotta move heaven and earth to convince them to fix it. Once, the underqualified person on the other end of the line asked me if I wanted to switch to Dr. Z. Yes, OK. Do that..... Only afterwards, I find out that Dr. Z is...GONE.
I've filled out a stupid form to allow my local State House Rep's office the authority to make calls on my behalf, to get these morons to call me back, and other stuff. Doesn't do much good. ...And needless to say, even if the error is not your own, you sure better be prepared to give all the stupid identity info. to them again and again and again and again and again and again--- until you end-up finally talking to someone who knows what they're doing.
Coverage is good. Being a SLAVE to the very tool that's supposed to be serving PEOPLE is outrageous and crazy.
hello. I don't want to defend MD Anderson. Worked there many yrs ago as a clerk. I think they are the 'NIEMAN'S OF HOSPITAL. Their expertise extraordinary. They care much for patients. Most rich folks go there [when I was there a prince from Saudi Arabia got cancer and went here, senators, retired sport icons, Bush family, etc...] I think they do the best jobs all around. Most patients go here because it's the last thing they can do [if they afford it] before they go six feet under
...I show up to the doctor for a visit. I get past the Waiting Room, escorted by a nurse. Before I am led to an examining room, I am asked for my birthday. Once, I asked the guy: "You need to know that right now? What's going on, you looking for a date? You'll only consider people of a certain age?") The response is always: we are required to ask. That does NOT answer the question, "why." It's a side-step. It's a non-reply. ...My brother says they're preventing fraud....Good, when they find fraud, let them go after the scumbags. That doesn't mean the rest of us have to treated with suspicion, as if we ALL are criminals. And jump through the same crap-ola hoops at every turn, even when the turns we're making are the result of a System error, not my own. Sucks mightily. No one can truthfully say that the Insurance Lobby isn't in the driver's seat when it comes to getting medical care. And my doctor told me that she "shares my feelings about this state of affairs." And she talks to me like a human being, not rushing through to get to the next person who's also been waiting for too long a time... I'm going to keep her.
STB65: I enjoyed reading your post and appreciate it when people offer thoughtful opinions on important subjects such as this one. Being more of a lurker I don't normally post, however, there are a couple of statements in your post I wanted to comment on.
More medical care is not necessarily better medical care, but it is more expensive medical care. If we insist on an MRI for our arthritic shoulder or low back pain, on antibiotics for our viral illnesses, or on a specialist referral when our primary care practitioner doesn't agree with our diagnosis, we should pay for the excess financial burden we put on our medical system.
I agree with this statement wholeheartedly. However, the article stresses extra tests ordered by doctors, not patients. It is speculated that by ordering the extra tests, or substituting more comprehensive (expensive) versions of those tests, doctors are either padding the bill or protecting themselves against malpractice claims. Perhaps both.
If your doctor says you need to go to MD Anderson instead of the state medical school, pack your bags (and your check book and credit cards - they are selective with their charity care). But, if you go to these medical Meccas as an out-of-state patient, you'd better have money or good insurance. If you feel you deserve this level of care, be prepared to pay for it.
I have to take exception to this statement. If my doctor says I need to go to MD Anderson then it would be because they provide a level of expertise that I can not get elsewhere. In this case I would consider that a level of care that I require, not one that I "deserve".
I see this thread is as far away as you can get from mutual funds. Still, I am not sure why you are angry. It looks like your interactions with medical insurance providers is at the same level as your interactions with the mutual fund/brokerage companies. Do you think there is pattern somewhere?
Your insurance might not be as cheap as you wish it to be (what is new?) but did you investigate what fees you need to pay without insurance? I am not saying the current solutions solve all the issues but it helps, it is the beginning. Previously, if you needed certain medication, you were not even written an insurance policy or insurance policy cost was so much more prohibitive than the numbers you are complaining.
People should pay for small medical charges. When they do, they will be aware of the costs involved in providing the services and potentially shop more and start questioning if/why the provider is padding the numbers. Such attitude drives the costs down, system becomes more competitive over time. There are now minute-clinics that accept walk in patients and services are cheaper than a regular doctors office. Generics, instead of branded medication do provide savings. If you do not pay a portion, then system automatically lead you to highest profit margin solution whether or not you need it.
People should use more of the high deductible plans that basically allows you discounted (negotiated) health care prices up to deductible and high deductible ensures that when there is something big that happens to you will not be bankrupt and get treatment for serious issues.
Medical services today is one field (only one?) that you do not ask for prices before getting the service. When you are not involved before, there is potential for abuse. That has to change. Medical inflation has been several times over other components of inflation in the last 15 years. On the other hand, public medical services, insurance companies have been rewarding the share holder and executives handsomely. There is too much profit in the system due to black box inefficiencies of the system. But I do not see anyone complaining about the returns they get from their health-sciences mutual fund. When you own a fund like that you are sharing some of that excess profits.
I see the changes are not perfect but a step in the right direction in getting control on medical expenses.
Medical insurance turned out to be the domain of companies as a result of historical consequences because when companies could not increase pay, they provided compensation to their employees via fringe benefits and medical insurance ended up in company provided service.
There are many things wrong with it. First, if you lose your job, you lose the insurance. So, it is not portable. Secondly, it is an extra cost for corporations not directly related to main activity. It is a disincentive for employment and growth.
Ultimately, I expect more and more companies will drop insurance completely and provide a small fine (tax) and people will be directed to insurance exchanges. Some people are to blame it to ObamaCare. But this was inevitable as medical costs became more and more unaffordable. Employers would dump their insurance plans eventually even without insurance exchanges.
Reply to @MaxBialystock: My wife has had occasion to visit the hospital a few times in the past year or so. We have also been subjected to the question "what is your birthday?" Each successive hospital representative asked the same question. It was explained to us the reason for the question was to make sure that whoever was escorting my wife knew who they were with. I suppose you could look at it as fraud prevention. You could also look at it as protecting themselves from a malpractice claim due to improper treatment because they thought she was someone else.
Thanks for the response. You're obviously in the field and sharing some great insights.
Obamacare was a start but alas, the pressure from the insurance companies and hospitals and drug companies gutted it quite badly.
I concur that we'll probably never see a single pay system - unless it gets pretty nasty - at least we know we're we need to head.
I would envision that with any single pay universal system, there would be various and sundry private options. Between elective surgery and/or avoiding the line, it would be easy to establish a market for those services.
And indeed, of the current system we can all tell tales long into the night.
Reply to @MaxBialystock: The reason for health- care givers asking your age is to protect them "and you" from mistakes. Have you ever heard the stories in the past of nurses giving the wrong medication to patients, some times at catastrophic results. Have you ever heard the stories of someone having a leg amputated when they were in there to get an appendix removed. Asking your age or name continuously is for your safety, not because they don't trust you!!!!!!!!! Trying to identify you at every step is to help you from medical mistakes and themselves from law suites.
It seems you already are familiar with this. I read this book when it came out and thought it was a pretty thorough comparison of medical systems throughout the world. It was an entertaining and informative book. There is is synopsis of the book here.
on a different slant the rising cost of health care is also due in part to the issues discussed in this book (link to interview). An interesting, informative read also.
Reply to @rono: I agree with you completely and it is what O'Bama wanted the health care system to be, but i think the Supreme Court ended that possibility. I just read the Time article on healthcare and something must change, and the American people will have to demand it I guess, given the current congress. seven77
Comments
Hope you're doing well. Nice article.
We need a one pay system because our current health care model results in a a death spiral of continually increasing costs. You have the patient, the provider and the insurer in a three ring circus with no one caring about the costs going up. If it was a two-way business transaction, you would have natural checks and balances.
Until we remove the profit motive from health care, we'll have health care in this country that ranks down with emerging market countries . . . oh, unless you have great insurance and a lot of money - in which case it's pretty good.
And if someone wants to accuse me of expousing socialized medicine. Fine.
I have a very hard time accepting that unless you have good insurance or a lot of money, you can lose that leg, or that eye, or your teeth, or your life - because you can't afford the cure.
That's absolutely unconscionable.
peace,
rono
Other "rights" will cost somewhat more. Medical care in the US is expensive because it is a "free market" enterprise, even with all the regulations trying to ensure quality care. Hospitals charge in many cases what they need to earn to survive. In St. Louis, several long-established hospitals have failed over the past 15 years, but there were other larger hospitals willing to accept their former patients. Other hospitals in small cities, such as one in Ft. Scott, AR, were sold to for profit enterprises willing to accept the $100M in debt it had accrued with its unreimbursed care and under-reimbursed care of Medicaid patients. The Hill-Burton "access hospitals" in small towns established to allow local hospital care often are in the red and require taxpayer subsidies. I'm only mentioning situations of which I have personal knowledge.
Hospitals like MD Anderson are selling a brand as well as expertise, as does the Mayo Clinic, the Cleveland Clinic, several of the Boston Hospitals, etc, much as Michelin three star restaurants and "luxury" automobile brands sell either an experience or a level of comfort or performance. They charge for this reputation, and some people benefit from it, while many others would have done just as well a few miles from home at a local hospital or many miles further away at their state medicals school(s) (which often have reduced rates available for in state residents - taxpayers and voters), as one would at a good local diner or with a Toyota Corolla or perhaps a Ford Fusion (maybe a risky choice, unless you avoid the "MyFord" system - but a friend says his Chevy Cruze is entirely worth the money). If your doctor says you need to go to MD Anderson instead of the state medical school, pack your bags (and your check book and credit cards - they are selective with their charity care). But, if you go to these medical Meccas as an out-of-state patient, you'd better have money or good insurance. If you feel you deserve this level of care, be prepared to pay for it.
As I understand it, the British medical system has 2 levels, one providing good basic care, which may require long waits for expensive services, such as hip replacements, and a "private" relatively parallel system for those who can afford it. There are also hospitals with particular expertise, to which one may be referred for unusual complaints. I think these are usually in London or major cities. I think the Canadian system is similar so far as the two tier level of care, but I could be wrong. The German system seems to rely more on an insurance based model, but it seems to work in a prosperous economy. I know there can be long waits in the Canadian system, since some wealthier patients get services in the US. The doctors in these countries must be happy with the system, since they don't emigrate to the US, where they presumably would make more money. The vast majority of immigrant physicians to the US come from areas where the health system is less advanced (and incomes are much lower), do their residencies, and visit their families back in the "old country" when they can. There is reputedly a medical school in Pakistan devoted to training physicians planning to emigrate.
While I think the vested interests (primarily insurance companies and hospitals) will successfully prevent a single payer system in the US until the situation becomes so bad that access to medical care becomes a primary political issue, I personally think the British two tier system would meet US needs - you get basic services and eventual access to expensive services and you pay to jump the queue. I don't expect to see this in my lifetime. I do admire Obama and Judge Roberts for starting the process. I'm sorry my Republican Party is so obstructive (couldn't vote for them this year, but they may see the light or become more irrelevant.)
While the majority of the MFO readership may be in the upper tier and so accept the British system (invest well, you may be buying that hip a few years earlier), we need to realize that most 75 y.o. US citizens have not really paid for the care they are getting. Neither political party is willing to accept the voter fallout of instituting controls on Medicare affecting the current generation, so they are reducing the benefits of the 50 year-olds and my children, who are much younger. Very few of us are willing to surrender our "rights", or to offer those struggling in the ghettos of the US a level of medical care equal to ours, especially if it costs us taxes or forces us to accept less medical care, so we will continue as we are.
More medical care is not necessarily better medical care, but it is more expensive medical care. If we insist on an MRI for our arthritic shoulder or low back pain, on antibiotics for our viral illnesses, or on a specialist referral when our primary care practitioner doesn't agree with our diagnosis, we should pay for the excess financial burden we put on our medical system. If you believe your doctor doesn't know what's best for you, get a different doctor. If you can't find another primary care physician, realize that the medical system in the US rewards specialists, and market forces dictate that there will be fewer primary care physicians. If you are fortunate enough to have a good FP or internist, bake him or her a cake or pie (unless they are overweight; then reward them some other way). If you believe that importing foreign trained physicians will lower health costs, remember that they came to the US to make money (strangely, the well-being of someone from a foreign land whom they've never met isn't their primary incentive, as compared to my peace Corp volunteer daughter), so they will be scheduling return visits or tests and procedures sometimes because you need them and sometimes because they need the income from them.
The low relative reimbursement of primary care physicians (difficult to do primary care if your medical school debt was $100K) means we will have more physician assistants, like my daughter, whom I would trust, because the GPA of her PA class exceeded that of the medical students at the same university, and nurse practitioners, who are diligent, dedicated, but often limited by the quality of their preceptors, who do much of their training. (It's also unlikely that their academic performance matched that of the PAs or primary care physicians.) The pressure of universal medical coverage will infuse a large number of previously untreated patients into an over-burdened system, encumbered by a requirement for electronic medical records, which slow patient flow by 20% with a good EMR and much more by a mediocre one, such as Allscripts or NextGen. Ask your doctor if s/he is using Amazing Charts, EPIC or Athena, apparently the best of the recent crop. It will mean that s/he will be happier with the new normal in medical care. (Interesting that one of the heads of Allscripts made $20M over the last 4 years for a system that never ranked even average in user evaluations compared to other competing systems.)
I agree, Rono, we need a single payer system. It's a fantasy. Move to Vancouver if you can afford the property values (or pick a less expensive and environmentally less appealing site - it's cold up there.) Otherwise, invest well or save your money - or exercise 30 minutes a day, follow the DASH diet (look it up), and pick your parents well - genes matter.
Peace
After this, I'll probably have to ask David for a new identity.
Other "rights" will cost somewhat more. Medical care in the US is expensive because it is a "free market" enterprise, even with all the regulations trying to ensure quality care. Hospitals charge in many cases what they need to earn to survive. In St. Louis, several long-established hospitals have failed over the past 15 years, but there were other larger hospitals willing to accept their former patients. Other hospitals in small cities, such as one in Ft. Scott, AR, were sold to for profit enterprises willing to accept the $100M in debt it had accrued with its unreimbursed care and under-reimbursed care of Medicaid patients. The Hill-Burton "access hospitals" in small towns established to allow local hospital care often are in the red and require taxpayer subsidies. I'm only mentioning situations of which I have personal knowledge.
Hospitals like MD Anderson are selling a brand as well as expertise, as does the Mayo Clinic, the Cleveland Clinic, several of the Boston Hospitals, etc, much as Michelin three star restaurants and "luxury" automobile brands sell either an experience or a level of comfort or performance. They charge for this reputation, and some people benefit from it, while many others would have done just as well a few miles from home at a local hospital or many miles further away at their state medicals school(s) (which often have reduced rates available for in state residents - taxpayers and voters), as one would at a good local diner or with a Toyota Corolla or perhaps a Ford Fusion (maybe a risky choice, unless you avoid the "MyFord" system - but a friend says his Chevy Cruze is entirely worth the money). If your doctor says you need to go to MD Anderson instead of the state medical school, pack your bags (and your check book and credit cards - they are selective with their charity care). But, if you go to these medical Meccas as an out-of-state patient, you'd better have money or good insurance. If you feel you deserve this level of care, be prepared to pay for it.
(More to come)
While I think the vested interests (primarily insurance companies and hospitals) will successfully prevent a single payer system in the US until the situation becomes so bad that access to medical care becomes a primary political issue, I personally think the British two tier system would meet US needs - you get basic services and eventual access to expensive services and you pay to jump the queue. I don't expect to see this in my lifetime. I do admire Obama and Judge Roberts for starting the process. I'm sorry my Republican Party is so obstructive (couldn't vote for them this year, but they may see the light or become more irrelevant.)
While the majority of the MFO readership may be in the upper tier and so accept the British system (invest well, you may be buying that hip a few years earlier), we need to realize that most 75 y.o. US citizens have not really paid for the care they are getting. Neither political party is willing to accept the voter fallout of instituting controls on Medicare affecting the current generation, so they are reducing the benefits of the 50 year-olds and my children, who are much younger. Very few of us are willing to surrender our "rights", or to offer those struggling in the ghettos of the US a level of medical care equal to ours, especially if it costs us taxes or forces us to accept less medical care, so we will continue as we are.
More medical care is not necessarily better medical care, but it is more expensive medical care. If we insist on an MRI for our arthritic shoulder or low back pain, on antibiotics for our viral illnesses, or on a specialist referral when our primary care practitioner doesn't agree with our diagnosis, we should pay for the excess financial burden we put on our medical system. If you believe your doctor doesn't know what's best for you, get a different doctor. If you can't find another primary care physician, realize that the medical system in the US rewards specialists, and market forces dictate that there will be fewer primary care physicians. If you are fortunate enough to have a good FP or internist, bake him or her a cake or pie (unless they are overweight; then reward them some other way). If you believe that importing foreign trained physicians will lower health costs, remember that they came to the US to make money (strangely, the well-being of someone from a foreign land whom they've never met isn't their primary incentive, as compared to my peace Corp volunteer daughter), so they will be scheduling return visits or tests and procedures sometimes because you need them and sometimes because they need the income from them.
I agree, Rono, we need a single payer system. It's a fantasy. Move to Vancouver if you can afford the property values (or pick a less expensive and environmentally less appealing site - it's cold up there.) Otherwise, invest well or save your money - or exercise 30 minutes a day, follow the DASH diet (look it up), and pick your parents well - genes matter.
Peace
After this, I'll probably have to ask David for a new identity.
It's always seemed senseless to me that we as a country can blow up the world a bajillion times over but we can't afford to feed, shelter and take care of those who need it.
STB65: I'm impressed by your apparent breadth of knowledge here. I recoiled earlier when you said most 75+ year olds don't really pay for their care. While not yet 75, I distinctly remember $$ being withdrawn on every payday from my check at work and labeled "Medicare-FICA Contribution". So I'd quibble a bit there. And, while medical care is much more expensive nowadays, I'd like to think my "contribution" was invested wisely over those many years so that the sum grew. (Yep, I know - He doth protest too much:-)
Overall you hit the mark based on my limited experiences. I copied your remarks above on compensation re: specialists and FPs - having noticed a stark contrast in quality (education, intellect, motivation, etc.) over the past dozen or more years. Not to degrade any in the profession, but it appears those who "can do" (the most) have migrated in mass into the specialist class. No doubt the different compensation levels has been a driver - among many other reasons of course. This has watered-down the available pool of FPs. (I've recently learned that Medicare employs a 2-tier payment system, allowing higher payments for the "specialist" tier provider.)
To an outsider like me the system looks like total chaos. Having recently had a few tests done and being fortunate to be insured by a PPO, I've received a constant stream of small bills for the same procedure over a 2-3 month span. These are for the (deductible) amounts not already paid by the PPO. Each generally amounts to only $10-$20. I pay them as they arrive - not bothering to investigate, as the amounts are so small. Have recently begun to wonder if some may be charges for affixing the stamp to the envelope upon mailing, or perhaps "opening fees" for when the checks arrive.
Back to FPs. A few months back I jokingly asked mine if half his time was spent filling out paperwork rather than treating patients. He responded that the paperwork load for insurers and Medicare was consuming about 80-90% of his time. Since a powerful sense of humor ain't one of this fella's finer attributes, I have to think he wasn't kidding. Thanks for your fine contribution. Hope I haven't muddied the discussion too much. Regards.
In MA, it goes like this now:Are you lucky enough to be covered at work? Fine. Oh, you're NOT working for a paycheck and you're not covered by your employer? Screw you, find insurance. It's a rule.
If you don't have much money coming in, you get coverage that is virtually free, including prescrips. for a very low, token co-pay. (I've been there.)
But now the wife and I are in a different plan. Get THIS: she works at a HOSPITAL, but she's not covered by their own plan. How do ya like THEM apples? So now we pay a monthly bill to remain covered, and monthly 'scripts will total over $120.00 for me. (My wife found a JOB, she didn't inherit a billion dollars!)
.....Come to find out, the State agency that runs the health-care availability system "runs" your SS # every month to see what's what with your household money situation. No one will TELL you what the thresholds are in order to be able to get plan One or Two or Three. You're just told, after giving them your quarterly income info. Providing that information is made possible by a host of new quasi-State employees who work in hospital and clinics, whose job it is to be the go-between--- between yourself and the lovely State agency who runs the "system."
Everyone's covered, yes. And Medicare is a different animal, yes. But the talk is all about requiring you to be covered by insurance, and how much you have to pay. Not a word about the absurdly ridiculous costs. ....And further, I have to wonder why we are required to report income, when Big Brother is finding and taking the info. "He" needs, with regard to eligibility and Plan-Types provided to you.
Most recently, I was offered a choice between my current carrier, but going forward, I'd have to pay X premium every month. I was offered the chance to go with a different outfit. The savings? Meh, about $10.00 per month.
That's not to mention the aggravation: a phone loop which loops you around and around without ever getting to a human on the other end; then, talking to a human--- after deliberately dialing one of the "wrong" options in my case; then there are assurances made, but please call the proper number next time. I went through 5 different people before there was even any conversation about what I needed. Then they sent the wrong stuff by mail to the house.
We're living the "1984" Orwell novel. Truth is stranger than fiction. You would not believe the crap. Change doctors? You're permitted to do that thrice per year. If the "System" contains the wrong doctor's name for you, you gotta move heaven and earth to convince them to fix it. Once, the underqualified person on the other end of the line asked me if I wanted to switch to Dr. Z. Yes, OK. Do that..... Only afterwards, I find out that Dr. Z is...GONE.
I've filled out a stupid form to allow my local State House Rep's office the authority to make calls on my behalf, to get these morons to call me back, and other stuff. Doesn't do much good. ...And needless to say, even if the error is not your own, you sure better be prepared to give all the stupid identity info. to them again and again and again and again and again and again--- until you end-up finally talking to someone who knows what they're doing.
Coverage is good. Being a SLAVE to the very tool that's supposed to be serving PEOPLE is outrageous and crazy.
I think they do the best jobs all around. Most patients go here because it's the last thing they can do [if they afford it] before they go six feet under
More medical care is not necessarily better medical care, but it is more expensive medical care. If we insist on an MRI for our arthritic shoulder or low back pain, on antibiotics for our viral illnesses, or on a specialist referral when our primary care practitioner doesn't agree with our diagnosis, we should pay for the excess financial burden we put on our medical system.
I agree with this statement wholeheartedly. However, the article stresses extra tests ordered by doctors, not patients. It is speculated that by ordering the extra tests, or substituting more comprehensive (expensive) versions of those tests, doctors are either padding the bill or protecting themselves against malpractice claims. Perhaps both.
If your doctor says you need to go to MD Anderson instead of the state medical school, pack your bags (and your check book and credit cards - they are selective with their charity care). But, if you go to these medical Meccas as an out-of-state patient, you'd better have money or good insurance. If you feel you deserve this level of care, be prepared to pay for it.
I have to take exception to this statement. If my doctor says I need to go to MD Anderson then it would be because they provide a level of expertise that I can not get elsewhere. In this case I would consider that a level of care that I require, not one that I "deserve".
I see this thread is as far away as you can get from mutual funds. Still, I am not sure why you are angry. It looks like your interactions with medical insurance providers is at the same level as your interactions with the mutual fund/brokerage companies. Do you think there is pattern somewhere?
Your insurance might not be as cheap as you wish it to be (what is new?) but did you investigate what fees you need to pay without insurance? I am not saying the current solutions solve all the issues but it helps, it is the beginning. Previously, if you needed certain medication, you were not even written an insurance policy or insurance policy cost was so much more prohibitive than the numbers you are complaining.
People should pay for small medical charges. When they do, they will be aware of the costs involved in providing the services and potentially shop more and start questioning if/why the provider is padding the numbers. Such attitude drives the costs down, system becomes more competitive over time. There are now minute-clinics that accept walk in patients and services are cheaper than a regular doctors office. Generics, instead of branded medication do provide savings. If you do not pay a portion, then system automatically lead you to highest profit margin solution whether or not you need it.
People should use more of the high deductible plans that basically allows you discounted (negotiated) health care prices up to deductible and high deductible ensures that when there is something big that happens to you will not be bankrupt and get treatment for serious issues.
Medical services today is one field (only one?) that you do not ask for prices before getting the service. When you are not involved before, there is potential for abuse. That has to change. Medical inflation has been several times over other components of inflation in the last 15 years. On the other hand, public medical services, insurance companies have been rewarding the share holder and executives handsomely. There is too much profit in the system due to black box inefficiencies of the system. But I do not see anyone complaining about the returns they get from their health-sciences mutual fund. When you own a fund like that you are sharing some of that excess profits.
I see the changes are not perfect but a step in the right direction in getting control on medical expenses.
http://www.marketwatch.com/story/why-your-boss-is-dumping-your-wife-2013-02-22?link=SM_hp_ls4e
Medical insurance turned out to be the domain of companies as a result of historical consequences because when companies could not increase pay, they provided compensation to their employees via fringe benefits and medical insurance ended up in company provided service.
There are many things wrong with it. First, if you lose your job, you lose the insurance. So, it is not portable. Secondly, it is an extra cost for corporations not directly related to main activity. It is a disincentive for employment and growth.
Ultimately, I expect more and more companies will drop insurance completely and provide a small fine (tax) and people will be directed to insurance exchanges. Some people are to blame it to ObamaCare. But this was inevitable as medical costs became more and more unaffordable. Employers would dump their insurance plans eventually even without insurance exchanges.
Thanks for the response. You're obviously in the field and sharing some great insights.
Obamacare was a start but alas, the pressure from the insurance companies and hospitals and drug companies gutted it quite badly.
I concur that we'll probably never see a single pay system - unless it gets pretty nasty - at least we know we're we need to head.
I would envision that with any single pay universal system, there would be various and sundry private options. Between elective surgery and/or avoiding the line, it would be easy to establish a market for those services.
And indeed, of the current system we can all tell tales long into the night.
thanks,
peace,
rono
It seems you already are familiar with this. I read this book when it came out and thought it was a pretty thorough comparison of medical systems throughout the world. It was an entertaining and informative book. There is is synopsis of the book here.
http://en.wikipedia.org/wiki/The_Healing_of_America
on a different slant the rising cost of health care is also due in part to the issues discussed in this book (link to interview). An interesting, informative read also.
http://www.npr.org/2011/10/24/141429392/deadly-monopolies-patenting-the-human-body
seven77