WhiteCoat

My Interview With Mass

Mass left some questions in the comment section that I thought were insightful and added to the discussion about health care policy. So I’m treating them like an interview.

1) I’d like to know how Dr Whitecoat is an “Independent Voice for Emergency Physicians”? Does that mean that all or most independent ER docs are conservatives or Republicans or anti-HR 3200? It would seem so as there are plenty of references in his blog to the loaded phrase “socialized medicine” as well as (at times indirect) links to groups like CAHI (the health insurance lobby) or the NCPPR (a conservative lobby) or to other conservative blogs. Either admit you’re a proud conservative or give some left-leaning blogs and groups some links.

First, I’m not, nor have I ever asserted, the “Independent Voice for Emergency Physicians”. That phrase refers to the magazine Emergency Physicians’ Monthly, and you won’t find a better forum in emergency medicine for emergency physicians to express their views. You could even submit an article and have it published if it was germane to the practice of emergency medicine. Dis me, but don’t dis the mag.
I actually had to go look up conservative versus liberal qualities on a web site before I could respond to your challenge. I’d have to agree that if I had to choose between personal responsibility and government intervention, I’d pick the former. However, the news is replete with stories about how people and businesses, when left to their own dealings with the public, take advantage of others. Government intervention is necessary to establish and enforce rules by which everyone must abide.

2) How would WC doc define “socialized medicine”? Are patients in the VA system, or those who have Medicare or Medicaid part of such a system? Does it matter that Medicare patients have higher satisfaction than other insured patients? I would submit that if WhiteCoat Doc would term universal healthcare as “socialized medicine,” then I can call the present system, “Darwinian every-man-for-himself medicine.” Unwieldy, but accurate.

Socialized medicine = publicly funded health care. Period. I don’t think that anyone can draw a line between “socialized” medicine and “single payer” medicine (in which government pays, but does not participate in delivery of care). The “golden rule” always applies – he who has the gold makes the rules. Look at the Medicare system now. The government pays for care, but conditions payment on a plethora of byzantine rules. Fail to follow the rules – even if you provide the care – and you don’t get paid. Technically, even though the government is not “providing” the care, it is orchestrating the care – sometimes on an “ubermicromanagment” level.
Many people are content with Medicare because they get what they want at no current cost to them. Don’t forget that most people receiving Medicare have paid into the system through payroll deduction for all of their lives. I think that people in stories like this or this or this would disagree with your general assertion that Medicare patients have “higher satisfaction than other insured patients”. Being “insured” by Medicare doesn’t mean much if no providers accept it. Our Medicaid crisis right now is what Medicare will look like 10 years from now unless the system changes.

3) Is this blog written from the perspective of a professional concerned about his income, independence, status, the overall health of his patients, or some mix of these? While I too am a physician, I don’t believe that physicians’ and patients’ interests always go hand-in-hand. There is no shame in defending our incomes and status – let’s just not delude ourselves that our positions are always for the good of the patients.

This blog is written from the perspective of what a single speck in the universe of physicians happens to find interesting at the moment. I’m not going to go through a psychiatric profile to answer your question. If you like the blog, let me know. If you don’t agree with me, post a comment and challenge me. If you don’t like it, go read a blog that aligns more with your interests. I won’t be offended.
Physicians’ and patients’ interests can’t always go hand-in-hand. Physician interests should be aligned with patient interest, but at some point, paternalism must occur. We have to do what we believe is in the patient’s best interest even if the patients don’t realize it. Patients interested in multiple narcotic prescriptions from multiple physicians shouldn’t be allowed to receive them. Patients who think antibiotics cure colds shouldn’t just get antibiotics because they want them. Patients, and a lot of physicians, have to learn that sometimes doing nothing is better than doing everything.
Are there some specialists who go “scoping for dollars”? Absolutely. That practice must be stopped, but unfortunately, there is little disincentive to doing too much right now. In fact, our government has created monetary incentives for performing procedures. Guess what many physicians make their living doing.

4) If some believe that it is not our health care system’s fault — but other factors like income disparities, personal habits, etc — that we have much higher per capita healthcare costs but worse infant mortality and lower life expectancy than other countries, isn’t it incumbent on us as advocates for our patients’ health to see money directed AWAY from the medical system into areas of the economy that actually WILL improve those health statistics?

Some of the largest costs in US health care are provision of end of life care and caring for critically ill patients. The same things that make our system so unique are also crushing our system under the weight of their expenses. We have to choose what we as a society want out of health care. Do we want to provide coverage for everyone at the cost of rationing or eliminating payment for many expensive treatments? That might mean limited or no cancer treatment, curbs on who is eligible for dialysis, limits on chronic ventilator care, and governmental “quality control” oversight on who is and is not resuscitated during a code.  We’re probably headed down this path anyway because the system is hemorrhaging so much money, but the government is now faced with the frog in the boiling water conundrum. Throw a frog in boiling water and it jumps out. Put a frog in a warm pot and turn up the heat until the pot boils and the frog doesn’t leave. I personally think that the government is floating a bunch of health care trial balloons to see just how fast it can turn up the heat without too many frogs jumping out.

5) Which Republican health care bill currently being proposed ought we to support as an alternative to the current “Obamacare” legislation?

I haven’t read them all and probably won’t. I posted some of my ideas on how to improve health care here, here, and here. Scalpel also had a great set of posts a couple of years ago. I just went over to his blog to link to them and he re-posted them two days ago for everyone. See here, here, here, and here. Incorporate some of these ideas into a bill and see what kind of traction it gets.

6) Given that the US spent 8.8% of GDP in 1980, up to 13.9% of GDP in 2001, and then most recently 16% of GDP for health care in 2007,
(http://www.kff.org/insurance/snapshot/chcm010307oth.cfm) — does anyone think this is sustainable and if not, what are our options? If “rationing” is out and no one (doctors, hospitals, health insurance) wants to get paid less and no one wants any restrictions of any kind on costs, should we all fly to other countries for health care?

Medical tourism is a free-market alternative for medical care. If cost is what is most important to people, then they will go to the centers that provide care at the lowest cost. However, if you fly to another country, do you know the qualifications of the doctor treating you? Do you care? If cost is all that is important to you, why not get Lucy VanPelt from the Peanuts to give you psychiatric counseling for five cents? Lower costs have to be weighed against quality. It will be difficult to legislate our way to higher quality medical care – if that is what we want. We’ll never have low cost, fast care, and quality care.
Two quick ways to drop costs and increase quality in the current system:
1. Divorce employment from health care coverage. Employers use health care benefits as a means to obtain and retain employees, but employers also try to find the least expensive ways to provide such coverage. Just let patients purchase their own insurance. Let the companies reimburse all or part of their premiums if that’s what you want. Then employees wouldn’t have to worry about COBRA coverage and insurance companies could extol their virtues to the consumers who actually seek their services – not to the employers whose bottom line is cost.
2. Create a government mandate (there’s my liberal side kicking in) that all prices for health care services must be clearly posted before a patient receives the services. Everything down to the last Kleenex box. If you don’t post a price for it, by law it is provided at no cost to the patient. Once people saw the wide disparity in pricing, they wouldn’t have to go to other countries for their care. They would just flood hospitals that provided the lowest prices in the US. Those hospitals would reap larger profits and expand. Other systems would either compete or fail. I guarantee that prices would drop significantly.

7) Since physicians seem strangely wedded to the idea of the private health insurance industry being the intermediary in our medical system, does it bother anyone that most areas of the US now have near-monopolies by private insurance companies in the markets for medical insurance? (http://www.marketwatch.com/story/study-confirms-health-monopoly-fears)
How does one reconcile the facts that “socialized medicine” in places like France, Germany and the UK are associated with frighteningly “high taxes” (used in menacing ways in posts) but that we spend at least 50% per capita more on health care than any other country? Is it possible that higher taxes are offset by…. something else lower?

Think about how the insurance industry monopolies affect care in those areas of the US.
Are you prepared for a country-wide monopoly and the restrictions that will go with it?

9) When the following post recommended by WhiteCoat doc (http://www.fundmasteryblog.com/2009/07/16/reform-healthcare-culture-and-politics-first/) explains how the free market indeed does work for the medical system, are there, um, more practical examples available than Lasik (a cash-on-the-barrel and completely elective procedure) and traveling abroad for health care? Does any ER doc discuss with a patient the pros and cons of all proposed tests (CMP vs BMP vs cardiac panel vs cardiac enzymes, etc) and radiological studies (MRI vs CT vs ultrasound) including full disclosure of the costs of these tests?

I don’t think that any time-dependent service can be entirely free-market. If people are unconscious or having a heart attack, they can’t request transfer to a less expensive facility.
Regarding non-emergency care, few, if any, emergency DEPARTMENT physicians discuss cost, risk, benefits of any procedure. I bet that 99.9% of physicians don’t even know what the tests cost. Probably the biggest reason for nondisclosure is what you alluded to – everyone wants the best health care that someone else can pay for. Patients want the latest and greatest … as long as it is covered by insurance. If everyone had to pay out of pocket for everything, you better bet there would be a lot more discussion. Patients would demand it. I’ve had patients refuse helicopter transport to tertiary care centers because of cost. They would rather accept a larger risk of dying than be saddled with any portion of a $15,000 transport bill. The discussions would result in a better-educated patient and would be a good thing.
The malpractice climate encourages low-yield testing to “prove” that disease doesn’t exist. Right now the “defensive medicine” mindset is so deeply ingrained in many physicians’ minds that it will be difficult to change. The best way to mitigate that risk is to educate the patient and let the patient make a decision. But as the Happy Hospitalist says, FREE=MORE and until patients have some skin in the game, little disclosure will happen because there is no disincentive to not providing it.

43 Responses to “My Interview With Mass”

  1. Matt says:

    “2. Create a government mandate (there’s my liberal side kicking in) that all prices for health care services must be clearly posted before a patient receives the services. Everything down to the last Kleenex box. If you don’t post a price for it, by law it is provided at no cost to the patient. Once people saw the wide disparity in pricing, they wouldn’t have to go to other countries for their care. They would just flood hospitals that provided the lowest prices in the US. Those hospitals would reap larger profits and expand. Other systems would either compete or fail. I guarantee that prices would drop significantly.”

    Why do you need a government mandate to do that? If it would be that profitable, why wouldn’t hospitals do it now?

  2. Matt says:

    “But as the Happy Hospitalist says, FREE=MORE and until patients have some skin in the game, little disclosure will happen because there is no disincentive to not providing it.”

    Wouldn’t this be something that physicians should lead on? People go to this or that physician primarily because that’s who is in their network. Why are they in their network – because the physician signed up to be paid that way. As long as physicians continue to sign up for that system, how can you expect patients to go another direction? Particularly when you offer them no alternatives?

    You talk longingly about the free market, yet in a free market providers compete either on cost or quality. Physicians are not offering information on either to the public. Yours is the only profession where the practitioners pretty much all agree to be paid the same regardless of skill! And the public has really no way to rate you so even if you wanted to be paid more, why would they? As far as they can tell based on the info they have, this emergency physician is as skilled as that one. Sure, ED physicians are a little different in that you don’t really pick and choose quite as much as you would a family care doctor, but you get the point.

    If you and other physicians are so tired of this third party payment system, why do you keep agreeing to be paid in this manner?

    • BK says:

      “Physicians are not offering information on either to the public.”

      Not only that but WC and many (though by no means all) actively rail against measures and metrics that attempt to compare the quality of physicians and hospitals. there always be some degree of arbitrariness in the standards used. and as WC says he who pays gets to make the rules.

      • WhiteCoat says:

        Key phrase: “attempt to”
        The measures don’t define quality, but current measures are the only things that bureaucrats can tally, so the bureaucrats try to make everyone believe that those measures actually *do* define quality. What we’re left with is an attempt to measure distances using a pair of pliers.

      • BK says:

        Yes, attempt to. coming up with a perform metric to compare hospitals and doctors that is equally useful to all people is simply impossible. the factors that make a surgeon good differ from those that make a psychologist good and the qualities i want to see in a physician differ from those that the guy sitting next to me want in a physician. this can be easily seen in comparative rankings of schools and the variety of metrics that residencies use.

        the point that you are missing is that in a completely free market system the emphasis placed on these arbitrary rankings would be greatly increased. you can’t have it both ways.

    • WhiteCoat says:

      “As long as physicians continue to sign up for that system, how can you expect patients to go another direction?”
      “Yours is the only profession where the practitioners pretty much all agree to be paid the same regardless of skill!”
      “If you and other physicians are so tired of this third party payment system, why do you keep agreeing to be paid in this manner?”
      That is the power of a monopoly at work. Some physicians are able to get out from under the governmental thumb, but Medicare is such a monopoly that most physicians who treat elderly or disabled patients can’t afford not to participate. No hospital would let a physician work in its ED without signing up for Medicare.
      At some point the unwillingness of physicians to participate in the system will hit a critical mass. Then change will occur swiftly.
      There isn’t a good way to measure quality in medicine. Try to use outcomes and many providers will shun patients with a higher potential for a bad outcome. Try to use patient satisfaction and the paradigm shifts to do whatever it takes to make patients happy – even if it means practicing poor medicine. Try to use guideline adherence and patients who don’t fit the guidelines get the short end of the stick.
      Many times quality can’t be defined. It is better “quality” to let someone with a traumatic brain injury die after a few days (or weeks, or months) of no improvement or is it better “quality” to keep that person alive on a ventilator for years because he or she may some day wake up?

  3. Matt says:

    “The best way to mitigate that risk is to educate the patient and let the patient make a decision. ”

    Sorry, one more. You are absolutely right in this statement. However, it goes back to your payment model which you agree to that doesn’t compensate you for spending the time to educate the patient. Your payment model rewards quantity, not quality. You can blame the quantity of testing on malpractice if you want, but you must also acknowledge the large (really, much larger) role that your manner of payment plays.

    If you were paid based on the time you spent with your patient, that alone would likely reduce your malpractice risk as communication with the patient has been shown time and time again to be the most effective deterrent to lawsuits. And it’s a hell of a lot more equitable than just screwing over the worst injured with your arbitrary caps.

  4. Mass must be young and healthy. If he is old and sick, he is crazy and self-defeating. When another organ fails, he will be getting a visit from the hospice counselor. See one of those coming? Your time is over, my friend, under Obama Commie Care.

    Here is how to drop costs by 50%, insure those without insurance with top of the line policies, and to end medical error. It is quite simple. Get rid of the lawyer. Obama’s Commie Care is a crude attempt to take over health care and all the great things it does by the lawyer. As a patient, I feel personally, physically threatened by this mob takeover. There is good moral and intellectual justification to start to physically counterattack this criminal cult enterprise. The rowdy town hall meetings are the beginning of the resistance. It should become an armed resistance justified by self-defense against Commie lawyers that want old people dead. They are using physical intimidation by union goons to beat up old people. They want a Cuba style block spy reporting of dissent to the White House where a database of the enemies of the Revolution will be maintained. Castro learned that from Stalin era KGB officers. The Castro response? Placement in a Cuban gulag.

    http://supremacyclaus.blogspot.com/2009/06/lower-health-care-cost-by-50-by-getting.html

    • Santa Clause says:

      “Obama Commie Care,”
      “physically counterattack this criminal cult enterprise.”
      “The rowdy town hall meetings are the beginning of the resistance.”
      “It should become an armed resistance justified by self-defense against Commie lawyers that want old people dead”

      Ohhhh, Jeeeeeeeez.

      So, Sup, when did you decide to use “The Turner Diaries” as your very own personal life script?

      Do us all a favor and take that tin-foil hat off your head, crumple it up into a ball, and stuff it down your gullet – figuratively speaking, that is.

    • You must be young and healthy. If you are not, you are nuts and self-defeating, or worse, a low life lawyer.

      I am going to put a curse on you. When you get the visit from the hospice counselor, saying, it is time to give up, and no further treatment save for painkillers for you, you will remember the name of the Supremacy and nothing else. The same goes for all the lawyers and the low life, slimeball, left wing enemies of clinical care.

      A list should be made of the enemies of clinical care. All lawyers and left wing politicians get on it after they vote for Obama Commie Care. All service and product providers refuse them service.

  5. BK says:

    “I think that people in stories like this or this or this would disagree with your general assertion that Medicare patients have “higher satisfaction than other insured patients”.”

    anecdotes do not make data. “socialized” health care outperforms private healthcare on satisfaction metrics. i know conservatives often have to resort to anecdotes because of the dearth of data that supports their side, but it makes for a horribly unconvincing argument.

    http://www.nationaljournal.com/njonline/mp_20090629_2600.php

    http://www.commonwealthfund.org/Content/News/News-Releases/2002/Oct/Survey–Medicare-Beneficiaries-Report-Greater-Satisfaction-With-Insurance–Better-Access-To-Care-Tha.aspx

    • alex says:

      And “survey polls” also do not make “data”. Either you are disingenuous or dull if you can’t see the confounder in comparing satisfaction between two types of insurance when totally different groups of people have each type of insurance.

      I suspect the elderly are probably happier with their insurance than the young in most countries. They are by large less demanding and have less of a sense of entitlement than younger people with regards to medical care in general. Can’t remember the last time I saw an 80 year old who demanded a stress test or brain MRI.

      • BK says:

        how do you plan on measuring patient satisfaction then? is there some objective metric that one could use to measure satisfaction besides asking the people involved? what allows you to measure MY satisfaction better than I can? that’s pretty arrogant of you.

        “confounder in comparing satisfaction between two types of insurance when totally different groups of people have each type of insurance.”
        this problem is solved by looking at the satisfaction of people just before medicare age and just after. the problem with that is the people with medicare are still more satisfied.

        “Can’t remember the last time I saw an 80 year old who demanded a stress test or brain MRI.”
        i see it all the time. probably more often than i see young people demand anything. it takes a pretty dull person to not realize that the old guy who said “keep you government hands off of my medicare” has a pretty high sense of entitlement. or to realize that opposition from seniors largely extends from worries that their entitlements will decrease.

  6. scalpel says:

    Great post, and thanks for the link.

    Healthcare reform in brief:

    1) Disconnect health insurance from employment

    2) Government insures the chronically ill, elderly, poor, and otherwise uninsurable

    3) Balance billing is allowed for those willing and able to pay more for premium services – if Medicare stops paying for certain services over age XX and the pt and family want those services, then they can pay out of pocket. Medicare patients would then have access to physicians who would otherwise decline to treat them.

  7. DefendUSA says:

    If patients have to put out on their own, you can bet they will be more careful with how often they will use the ER as a GP.
    I have forever had great insurance, until we became unemployed. Though I never abused the access for stubbed toes or colds, I find that I wait a little longer to see if an illness is just a cold, or some viral bug before I put out the copay because should I get an RX, it’s expensive!
    I agree then, that more discussion will take place between the physician and patient.

    One thing that does get to me is the lack of a fee sheet in most offices or ER’s. I asked about the cost of an MRI so that I could save the money to pay for just one, just in case and nobody could tell me.

    I like that pricing for everything would go into a mandate. Can’t remember if I posted this here..but Baby 1 cost me a few out of pocket dollars, baby2, a little less. Baby 3 was a fight all the way to the insurer for services I was entitled to, but they would not pay for three years because of bureaucracy. I had to fight like crazy to get my 900 bucks. Baby 4 is when I made the OB call in an RX to bring to the hospital when I went into labor and I brought every other imaginable sundry, drug, food or Sanitary item with me. I got tired of being taken to the cleaners because knowing one pill’s cost that could have bought a bottle of 200!

    A great read.

    • alex says:

      One point that is consistently missed is that it’s actually government intervention that prevents effective price competition. You are forbidden from offering a lower price to someone than you offer to Medicare. So if you cut that guy half off on an MRI cause he can’t afford more, you need to do the same for the 40% of your practice that is Medicare paid.

      Obviously that’s not a recipe for anything but bankruptcy. So it is actually Medicare’s byzantine and arbitrary payment rules that do a good job of ensuring there’s no actual competition.

      • BK says:

        i thought the preferred line was that medicare pays pennies on the dollar? if medicare pays less than a service costs, why would someone want to price their services below what medicare pays?

        and doctors reduce fees all the time…all you have to do is ask. it also helps if you can pay upfront in cash. and hospitals give away free care all the time to those who can’t afford it…WC just posted on that a few days ago.

      • The government should cover catastrophes. The patient should be doing his own pre-authorizations with money from a health savings account, that is entirely his to keep, and for the estate after death.

  8. Doc99 says:

    “If you think healthcare is expensive now, wait ’til it’s free.” PJ O’Rourke

  9. Max Kennerly says:

    Quick quiz: in your local area, name good lawyers you’d feel comfortable going to in the fields of tax, real estate, business transactions, business establishment, personal injury defense litigation, personal injury plaintiff’s litigation, business defense litigation, business plaintiff’s litigation, trial, estates, and violent criminal defense, non-violent felony criminal defense, and white collar criminal defense.

    Now estimate their rates, and name two more lawyers: one with higher rates who is likely better at their job, and one with lower rates who is likely not as good.

    While you’re pondering that, consider this: Martha Stewart was represented in her SEC investigation by one of the most prestigious and expensive firms in NYC, which nonetheless lead her into being indicted for conduct that occurred entirely under their watch.

    Some markets are deeply inefficient. Medicare’s forced-discount is a problem. But it does no good to pretend the free market fairy is a panacea for all that ills health care.

    • Max: Medical procedures not covered by government are falling in prices rapidly, as fast as computer prices, in some areas. Martha Stewart’s lawyers should have been beaten with a stick. They failed to counterattack the DOJ cult criminal thugs, and to bring personal destruction to her enemies. The case was to get in the paper for worthless government hacks.

  10. Michelle says:

    I read this blog (which is far more than “a blog”) for the information and sanity it provides, thanks especially to people like White Coat and Supremacy Claus, though so many others write with amazing insight. But whatever you do, W.C., don’t let certain “types” get under your skin. Write what you know is true, and add wake up calls as needed. I for one count on you more than you realize.

  11. Nurse K says:

    Divorce insurance from employment?

    I chose nursing partially because I needed a job that had guaranteed insurance associated with it. My insurance kicks ass.

    I’m not sick, but I have a chronic illness, and, hello, no chance anyone is going to insure me for anything reasonable. Now my son has a chronic illness too, and, so, we’d go from excellent insurance to really, really, really expensive crappy insurance. The only way to get around that is guaranteed issue insurance where the rates don’t vary based on PMH which will cripple the private insurance industry.

    For those who have employer-sponsored insurance, there isn’t anything wrong with it in most cases!! Leave it as it is!

    • WhiteCoat says:

      Employers could still sponsor insurance through reimbursing employees for the private premiums they pay. That way if you ever leave your job, you can take your insurance with you to your next job without having to worry about COBRA coverage or what kind of insurance plan your next job has.

      • Nurse K says:

        You’re not tracking properly on this issue, Whitecoat. Please explain why someone like me with excellent group insurance would want that taken away to be in a private policy that would exclude my pre-existing condition which costs hundreds/month to take care of? That’s crayzee. I’d at the very least have to sell my house and live in a small apartment to free up enough money to buy my supplies. Even if my policy is 100% reimbursed, it still won’t cover my ONLY medical problem! I need my healthy co-workers to help me out in the group policy!

        BTW, You’re really not insurable in the private market either, WC!

      • scalpel says:

        I don’t think chronic medications/supplies or routine office visits should routinely be covered by insurance either. When someone has a chronic disease requiring lifelong medical treatment, the treatment of that disease is no longer something to be insured against…it’s a given! The potential complications of the disease can still be insured against however.

        Health insurance needs to be more like other types of insurance in that regard – one insures against the unexpected big ticket items. The known expenses are what you budget for, not what you should hope your coworkers will help you out with. What’s next, grocery insurance for diet coke and cheetos? My fat neighbor would love that. Gasoline insurance? I drive a big gas guzzling muscle car, so my next fill up is on you.

  12. Samantha says:

    I’m young and disabled. I started reading some of these blogs out of curiosity, and I have learned to be more concious of the care I ask for and receive.

    When I was finally too sick to work, and had less than $200 in my bank account and no other assets, unless a 10 year old ford escort counts, I was ineligible for Medicaid, because, in my state, it isn’t just about the poor, it is about the disabled poor, and the state determined I wasn’t disabled.

    Fortunately, a few weeks later, under 6 months from the day I applied, I was awarded SSDI. Being determined disabled, doesn’t mean I’m eligible for Medicare, because of the 24 month waiting period, but it does require my state to recognize my disability and qualify me for Medicaid – Except,having had worked, my SSDI was higher than their $840 monthly earnings cut-off, so, I have to “spend-down” into the system, paying close to $350 a month to Medicaid to cover my $3-4k a month expenses, and subsisting on the remaining $840.

    This $350 to qualify me for Medicaid, however, does not however, qualify me for housing or any real amount of foodstamps. (law requires $22 a month in benefits for disabled people) So…after working and becoming disabled, being denied benefits for over 6 months, I now pay in $350 for Medicaid and attempt to live on $840. When I did receive Medicare, I ‘lost’ another $98 to go towards Part A and B, and dropped the Medicaid, which let me drop medicaid, despite my spend-down dropping to $270.

    And I’m grateful. I look at a friend of mine, in my state, with a severe illness, who lost insurance upon turning 24, and is considered pre-existing for a year on her new plan, and not particularly able to work, but not deemed disabled.

    How lucky I am! I have access to services, and some choice in the services i receive. It took, reading these blogs, however, to realize, that, I need to be more concientious when seeking care. It doesn’t always have to be visit to the specialist, sent to hospital for tests, go to hospital when sick or worried-well, follow up with specialists, and I have added in a PCP. It’s a clinic that has about a 4 hour wait, on average, and I get the usual vitals, a few questions, prompted from the computer screen, a script, and i’m on my way. I just wish I could fully trust a ‘medical professional’ who has me answer on a ‘yes/no’ basis while he pecks the response into the computer. Maybe I should go back to the ER for a second opinion? ;P

    Health plan, no health plan, same or change, system is messed up. Perception is key, but our problems are far more systemic than medical care. *shrugs*

  13. DefendUSA says:

    I chatted with many people last night about health care. I keep hearing that same phrase about people with pre-existing conditions and how they cannot get insured. Perhaps that is one aspect that needs to be revisited. It is discrimination at best and should never preclude covering a person willing to pay for it.

    The purpose of letting people choose their own health care and not Uncle is because only you can decide what’s best for you.

    This bill will allow for a law to be made where the gov’t takes money from your bank account if you have no private coverage and automatically put you in the system!! That also means they have access to every medical issue/record that should be between you and your physician.

    Do you really want that because you are afraid of the free market? Not me. I am a healthy person at the moment and I pay for individual health insurance. It’s disconcerting that there is a lifetime limit, but I still have control over what *I* want or need, not what Uncle thinks is best in regard to rationing and containment of care.
    Sometimes it takes a leap of faith or a real fight… I’ve got faith and I’m fighting it all the way to DC on 9/12. 9000 people have signed up to protest this. It is NOT about your health care, really. It is a power play to control every aspect of your lives. Your best interests aren’t even on the table.

    The way I see it is that those who support this bill somehow believe they will be untouched by the controls that government will actually have in their lives. It’s as if they want to keep wearing the RCG’s (Rose-colored glasses) and as long as they do, there will be no oppression, taxation, and everything will be equal. (Cue Kumbaya)
    Just think Animal Farm…some pigs more equal than others.

    • Max Kennerly says:

      You have “control” through private insurance?

      If you develop a serious condition requiring substantial medical expenses on your behalf, your odds of policy “rescission” are 50/50.

      Worse than Russian Roulette.

      See http://bit.ly/UO4Va
      See also http://bit.ly/S0cx7

      You don’t have “control.” The insurance companies do.

      • Doc99 says:

        Don’t forget the issue of portability either.

      • DefendUSA says:

        At the moment, I do not have the same choices as I might with a big employer. I am not employed.

        So, while I could be playing roulette, that is a personal choice. I DO have the ability to ask my physician to charge me and not the insurance for whatever procedures I consider a necessity vs them, especially if I know it isn’t covered.
        If I should be dropped it will hopefully be upon maxing my limit. There is no panacea, what is it that people don’t get? No system is infallible and some are more fallible than others. (UK Britain, HI, even Sweden is screwing people over for all the taxes they pay)

        That is the beauty of my current care vs. government control.

        Nothing is perfect and I have portability as well on this policy.

  14. WC: Pick up the pace on the Trial of WC. That is all I am interested in. The level of discussion on this other subject is pretty low, and it is getting boring. You do not have any intelligent left wing commenters to argue facts and real numbers. They just make personal remarks out of debate frustration. Commie Care is not acceptable to freedom and life loving people like Americans. They do want to die without an attempt at treatment, on a waiting list that never comes around. Commie Care is cheap care. It has strengths in cheap care. So, physical exams, vaccinations, minor injuries in the ER, routine chronic conditions, like hypertension. Euro saps do great with those, perhaps better than we do. They also lie by omission. For example, premature babies are called miscarriages, and allowed to expire with zero medical support. Our count toward infant mortality unfairly because we try to treat them.

    Any care with 4 numbers in its cost, they just prepare for death. The best example is Princess Diana. Speaking for 30 minutes. No EMS. No trauma experienced supervisor. No jaws of life. No telemetry. No helicopter to the academic medical center, 4 miles away. No trauma team waiting for her in an OR. No board certified chest surgeon in the OR. It took 45 minutes to extract her. Then the 4 mile ride took one and half hours. Why? They stopped to do street resuscitation. Compress the chest of a trauma victim, you accelerate the exsanguination. They spent the first Golden Two Hours in the street by lack of equipment, trained personnel and no trauma infrastructure. Then they arrested the reporters to cover up the inadequacy of their health system. That was a princess. What chance does the ordinary person have in an accident there?

  15. Painless says:

    I wish I could say the insurance at the hospital where I worked “Kicks ass”. I remember the day when – because I worked in health care – I had few if any deductibles from physicians, and I was treated the way I would treat others – with dignity and respect. Now, (thanks to Medicare – even though I’m too young to need or qualify for Medicare at this time), I’m just another patient in the 80 – 100 they need to see that day to keep their doors open. Since they do have to accept Medicare patients, they no longer are able to see me without charging a co pay – even physicians I work with on a daily basis. It’s the law! Unless they pass on that same no co pay to Medicare patients. Also, due to the litigious society we live in, they can no longer see me as a “favor” nor can they just write me a script for the antibiotic or whatever. Yes, occasionally they will still see you as a courtesy, yes they will examine and yes they will write that prescription for the antibiotic or inhaler or whatever – but they now have to keep such extensive medical record of this so if something should happen it’s all documented appropriately that it’s become something you rarely see any more. Even though it was a personal favor!! It’s become such a hassle, that most physicians won’t do it at all any longer. Yes, I do remember the day when I could go to the ER as a paramedic and be looked at as a professional courtesy by the ER physician and get a prescription for antibiotics for the sore throat I had at that time. It was one of the perks of the job. Now? Forget it! Won’t happen. Wouldn’t even think of it.
    Every year, my deductible rises, the co pay for medications rises, and the amount I pay for my portion of insurance rises. And when I do seek care – I often get another bill from the physician for overage that the insurance didn’t cover. Because Medicare only pay’s whatever, the insurance company will only be required to pay the same amount.
    IMHO, we do need to cut back on defensive medicine. Granted, there are those times when we will miss something, but at some point you have to realize that while it’s getting a lot better, medicine is not an EXACT science. Things change. The body is in a dynamic state, not a static state. What’s going on today may be totally different several days from now.
    Another thing we need to recognize, is insurance companies nowadays are not the vestige of spreading risk among a large population in order to mitigate cost at making a small but reasonable profit, but rather they are in the business of making money… and lot’s of it. They have stock holders and they have bonuses, expense accounts, etc. They have a vested interest in not covering something if they can possibly get away with not covering it. Why? It saves them money – money they can use for bonuses and higher salaries. It doesn’t matter who you are or who insures you (at least privately), this rule applies. The sky is blue, the ocean is salt water and insurance companies will do whatever they can to save a dollar. Their interest is not in your care, but rather what can make that care cheaper.
    And THAT is what causes dissatisfaction with our health care.
    Every year, I get paperwork from the health insurance company that I have to fill out – saying where my wife works, saying whether she has insurance or not that covers anyone, or if I have any other insurance that might cover us. I have had several claims DENIED initially, while they investigated whether there was any other insurance in force out there or not that the claim could be billed to.
    Nowadays, with nearly every mid and large sized company’s offering insurance – it’s not so much of a reason to stay at a job.. maybe not as much as it was several years ago when it was an actual perk. What’s the answer? I don’t know – but I do suggest that we ask whether testing and care were done based on evidence based medicine or whether defensive medicine was used, also that we separate insurance companies from profitability and make them what they were originally supposed to be – a way to spread the risk among a large enough group of patients to keep costs low while providing the best health care at a reasonable price.

  16. Doc99 says:

    Question for Matt and Max – How do you think Trial Lawyers would respond to the question of a repeal of ERISA?

    • Matt says:

      As a whole I’ve never thought about it. I wouldn’t mind making their subrogation rights subject to the made whole doctrine though.

      • But medical care is being made whole, unless you are claiming a market value for missing body parts, pain, etc. So subrogation should apply to all medical expenses settlements.

    • Max Kennerly says:

      Poorly, not least because I don’t see how a repeal of ERISA would help anything. What do you think employers need to be able to do that ERISA (and/or HIPAA) prevents them from doing?

      • Doc99 says:

        Matt and Max … I’m wondering if removing the deductibility of these benefits might actually benefit small business employers ultimately. I’m quite certain that removing the ERISA shield protecting the healthcare insurers would benefit trial lawyers as well. I’m asking because not being a lawyer, I’m quite naive on these matters and looking for answers.

      • Matt says:

        I don’t know that it helps lawyers, but it definitely helps the plaintiff.

        How are you thinking it would benefit small business employers? Most ERISA plans are from larger businesses, in my experience.

  17. Mass says:

    I commend WC on taking the time to respond at some length to my earlier set of questions. He dodged a few of my pointed questions but still I appreciate his effort. I think most people (including me) are quite wedded to their viewpoints and will selectively use data and/or anecdotes to support their arguments. I’ll give a last summary of my basic thoughts and let it go at that:

    Health care is different from any other service provided. The costs involved are often so astronomical, the lack of transparency in costs are so great and the inefficiency of a medically-ignorant/sick/disoriented/dying patient as a “consumer” are such that the free market works poorly if at all. Other industrialized countries have realized this and offer similar overall care compared with us (in most parameters) at about 50-67% of our cost. Those in the medical field, especially us doctors, want to be left alone by the “bureaucrats” (only government workers are bureaucrats, apparently, not those pencil-pushers in the private sector). But since we are the gateways for almost all costs – we decide what labs are ordered, what prescriptions are written, what patients are admitted and for how long, how often they are seen in clinic, what kind of studies they require — then there is something seriously wrong with our vaunted independent judgment if health care spending has gone from 8% of GDP in 1980 to 16% last year for minimal improvements in the most important health statistics.

    And that is why the government is stepping in. The US resisted several attempts at national health care — under Truman, Johnson, Clinton. But we have finally showed that we need some supervision before we bankrupt the country. And finally – WC never answered the questions of how other countries with “socialized medicine” have such steep taxes and yet WE spend much more on health care than they do. Where does that money come from? More importantly, how much longer do we keep paying more and more for negligible improvements in care? In a few decades time, “socialized medicine” will be seen as unremarkable here as Medicare and Social Security are today.

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