The Supreme Court decision on the Affordable Healthcare Act threw us a curve ball. Many people who predicted the outcome of the ruling swung and missed – including me.
The Court agreed with the government’s argument that the individual mandate contained in the Affordable Care Act was not a tax … for purposes of the Anti-Injunction Act (which would have prevented a lawsuit regarding assessment or collection of the mandate and forced those bringing suit to sue for a refund after paying it).
At the same time, the Court declared that the individual mandate contained in the Act was a tax … for purposes of validating and enforcing the mandate.
To me that’s a stretch. That’s like legal argument defending a dog bite lawsuit by simultaneously alleging that (1) I don’t have a dog, (2) you weren’t bitten, and (3) my dog didn’t bite you.
President Obama has declared the Supreme Court decision as a “victory” but this victory is largely Pyrrhic.
But many people will think that the tax … er, um … penalty is OK because our government is going to provide us with insurance. Millions of more patients will be INSURED! If you’ve read WhiteCoat’s Call Room on a regular basis, you know why this is such a false and empty promise. Insurance amounts to a series of promises. First there is a promise that, in exchange for a premium payment, someone else will pay for your medical care. Then there is a promise that someone else will provide your medical care. Finally, there is a promise that you will be provided with the medical care you need when you need it.
Now think about the effects of just these few fact patterns. When those employees lose coverage, what will happen? Perhaps the employees will be able to afford to purchase a private insurance plan. Even if they did, it is likely that the plan would be high-deductible so that the employees could save money on premiums. Perhaps the employees earn so little that they will be eligible for government “insurance” – if the states don’t cut the eligibility. That leaves a large group of people who earn too much to get Medicaid but who don’t earn enough to purchase decent “insurance.” What will happen to them? They will pay the tax … er, um … penalty and end up with no insurance. When employers drop the insurance benefits for their employees … and they will … their employees will receive less coverage because less coverage will probably be all that they can afford. Sure, the Affordable Care Act will provide “insurance” to an additional 30 million indigent patients, but the Affordable Care Act will also create more uninsured and underinsured patients from the group of people upon whom our country depends the most – our work force.
Medical insurance is only as good as the health care professionals who are willing to provide care under the terms of the insurance policy. accept the insurance as payment. Suppose you had a million dollars worth of Japanese yen in your pocket and you were in a rural Kansas coffee shop trying to buy lunch. You may be rich, but no one accepts your money. Similarly, if a doctor that you need to see using your new government mandated magical insurance plan doesn’t accept your insurance, then you either pay out of pocket for your medical care or you find someone else who accepts your insurance as payment. If few doctors take your insurance, you wait for an open appointment. It’s that whole fast care/free care/quality care triangle. Pick any two.
By now you should know that many doctors refuse to provide care to patients who are on government insurance. In Texas, one third of all the physicians don’t take Medicaid “insurance” due to low reimbursements and governmental red tape. Mayo Clinic in Arizona stopped accepting Medicare patients in 2010 after losing $840 million in 2009 due to low reimbursement rates. Patients with Medicare in the Raleigh, North Carolina area are finding that physicians who accept Medicare patients are “scarce.” All of these people have the magical medical insurance plan that so many more people will be receiving, yet many of the “insured” patients still cannot find medical care. Even though you will coerced by the IRS to buy into the concept that health insurance and health care are synonymous, they aren’t and they never will be.
The health care that you are able to obtain with your “insurance” may less than adequate, as well. Walter Reed Army Medical Center was just one of the government hospitals plagued by allegations of patient neglect and shoddy medical care. And you won’t find any government hospitals on the government’s own Hospital Compare web site. Ever wonder why?
Finally, keep in mind that medical insurance is also only as good as its covered benefits. Your medical problems just might not be a covered benefit on your insurance plan. Even though you have paid into the insurance plan for dozens of years, your covered benefits can change at any moment. Ask patients who have had to depend on their government “insurance” for care of their cancer or injuries, or asthma.
So our elected officials have foisted what amounts to a medical Ponzi scheme upon us and most of them will be long out of office before the medical insurance house of cards collapses. Tough luck, suckers.
Perhaps the thing that concerns me the most about the Supreme Court’s decision is the precedent that the ruling sets. Our highest court has now held that it is permissible for the federal government to impose a tax … er, um … penalty upon citizens in order to force citizens to purchase a private commercial product. In oral arguments, Justice Scalia joked about next creating a mandate that everyone purchase gym memberships to make sure that people stay healthy. Wasn’t funny. His point was spot on. Where do the new taxing … er, um … penalizing powers of our government end? I fear that we will only learn the answer to this question after the election.
The Supreme Court’s ruling and the implementation of this law are another example of how the Court and our legislature are hopelessly out of touch with the needs of the people and how to meet those needs. If President Obama’s actions and the Supreme Court’s decision don’t make our citizens realize that we need a profound change in the governance of our country, then woe to us all.
What a disappointment we will have been to our forefathers.
Yesterday, my 2 year old asked me, “Daddy, do clouds make rain by forming condensing nuclei of water vapor which act to form droplets which fall to the ground?” I said, “No, son. No. You’ve got it all wrong. Actually, those drops of rain are the tears of our founding fathers crying over the recent Supreme Court decision on Obamacare.”
Supreme Court upheld the Affordable Care Act (ACA). I was against “Obamacare” as it has come to be known, from the very beginning. I am still against it, for reasons too numerous to count. On the face of it however, the entire rationale for declaring Obamacare unconstitutional was absurd, and rather disingenuous. Amongst the 2000 pages of this behemoth of a law, the one portion that makes the most sense is the “individual mandate”, which is the single portion that actually attempts to require all Americans to take at least a sliver of responsibility for the cost of their own health care expenses. This is the one and only portion of it that is actually revolutionary and acts to reverse the central core of what is wrong with the health of our people, and our healthcare system itself: the complete lack of responsibility of so many individuals for their own health, and healthcare expenses.
Like many of you, I wished that the Supreme Court would overturn the law so that we could rebuild it in a way that makes sense both to patients and physicians, and less so to politicians. However, as much as it pains me, I have to admit that Chief Justice John Roberts’ opinion was courageous and brilliant. It tears my heart out to write it, but its true. As I interpret it, what he essentially told America and the opponents of Obamacare was, “Don’t ask me or the spirits of our Founding Fathers to overturn your law, written by your representatives, and approved by your President with some fabricated technicality to fix your ‘Oops!’ Man up, and live with it. Otherwise, if you don’t like it throw the fools out, elect a new government and start over, or fix it”.
Indulge me for a minute and allow me to play the “What Would Our Dead Relatives Have Thought, Game”: The Founding Fathers of this country lived under true tyranny. They were ruled by a tyrant King that would not hesitate to jail or execute someone for speaking an opinion infinitely less offensive that my own, and simply on a whim. Many of them lost their lives fighting for the right simply to have representation. (Remember your history class, “No taxation without representation!”?) I’m sure they would conclude that we have that luxury, and many other life easing luxuries they did without. (You know, real important stuff like electricity, running water, insulin for diabetics, iPhone 4s with integrated Siri personal assistant.) They didn’t have to worry about 40 million people being uninsured. Health insurance didn’t exist. It wasn’t a crisis for them, that only 80% of people could get an MRI. 0% of people got MRIs. MRIs didn’t exist. Neither did door-to-doctor times, ED wait-time billboards, sterile technique, antibiotics, cab vouchers or Sierra Mist with a meal tray.
If the “individual mandate” for all Americans to buy health insurance was severed from the ACA and we had to choose between it and the rest of the bill in its entirety, I would choose to keep the individual mandate, and strike down the other 2000 pages from this complex bill, the details of which no single person on Planet Earth has read let alone understands. Most unknown, are the costs and unintended consequences of this bill. As Nancy Pelosi has been repeatedly been quoted, so tragically and accurately, “We have to pass the bill so you can find out what is in it.” This is an irresponsible and dangerous attitude that would never meet the “standard of care” any of us physicians have to live under, yet we are now ruled by it.
For decades I have been required to pay Medicare tax to pay for your Grandma’s health insurance (Medicare). For decades I’ve been required to pay taxes to pay for your unemployed uncle Ed’s health insurance (Medicaid). How come these things are not “unconstitutional”, the “Joe’s Grandma Mandate” and the “Billy Bob’s Uncle Ed Mandate”? Now that the ever soradical concept comes along, of requiring me to pay for the health insurance not only for your Grandmother and your uncle Ed, but also for myself, all of a sudden it’s a cruel violation of my constitutional rights? Give me a break. The government can send 58,000 men to die in Vietnam, and that’s constitutional? The government can take your house, bulldoze it and build a road in its place “for the common good” and that’s “constitutional”? But to require Joe Six-Pack to chip in a few bucks for his ER course, ICU stay and redo CABG, half of the cost of which is eaten by insurance-buying Americans in inflated premiums, the other half of which is eaten by the doctors that took care of the patient in the first place, is unconstitutional? Give me a break.
As much as it pains me that Obamacare stands, since I’ll be paying higher taxes, certainly get paid less from Medicare, Medicaid and private insurance all of whom will cut payments to doctors to cover the newly insured, and likely be overwhelmed by the masses of newly insured patients with government insurance that pays pennies on the dollar…. I still think John Roberts did the right thing. We as Americans, and we as physicians allowed this to happen. We let them walk right in, take over our house, repaint it, decorate it, rob it and remake it in their own image with nary a fight. We are amazing healers, but the most hapless complainers and the feeblest of pushovers. Let this be a lesson to us all. We have allowed them to raise the stakes to a much greater height and will face a much more epic battle to save God’s profession.
Probably one of the largest pending changes in health care is payment reform.
Right now, payment for medical services is essentially a fee for service model. Patients (or their insurers) are generally charged for the services utilized. If a patient goes to hospital for chest pain, and a physician evaluates the patient, either the patient or the patient’s insurer pays the physician for those services. If the physician orders an EKG and lab tests, either the patient or the patient’s insurer pays the hospital for the EKG and lab tests. If the patient is admitted to the hospital, the hospital gets paid a given fee for the admission. It goes on and on.
The feds want to reduce costs by changing the payment model for medical care to a “bundled” approach. I don’t think it’s going to work. Bundling won’t change the behaviors necessary to save money. This will be a two part post on why. This part will discuss incentives and how they drive utilization of health care. Next part will apply those concepts to bundled health care.
Why is our current system going bankrupt? It is all about incentives. There are three main concepts driving health care costs: profit, demand for services, and fear. Before we can see the effects of a policy change on health care costs, we need to understand how these concepts drive the actions of the major players in the health care market.
For Providers, the incentive is currently to provide more services.
Demand for services is created by illness. When ill, patients often demand as many medical services as the providers are willing to provide. Patients may seek alternative providers if their demands are not met. There is little incentive to provide less care with increased demand.
Profit is created by providing services. In a fee for service environment, the more services that are provided, the more that the providers are paid. If patients want the testing or services, more often than not, they get the testing or services. Unhappy patients tend not to come back. No patients = no income.
The most pervasive fear for providers is fear of liability – either legal or professional. This fear is often mitigated by providing more services. Increased testing decreases the fear of liability because if there is a bad patient outcome, the provider can point to all the testing and argue that they should not be liable because “we did everything we could.” It is uncommon for a provider to suffer adverse consequences for performing too much testing. Fear of liability may lead to extremely expensive and questionably beneficial medical care.
Hospitals also fear regulatory sanctions. It is comical to watch hospital administrators scurry about when there is a JCAHO survey. Poor performance on a JCAHO survey threatens a hospital’s Medicare reimbursement.
For Insurers, there is an incentive to increase customers who pay into the system, but who do not take money out of the system.
Demand for services is still created by illness, but as demand for services goes up, insurer profits go down (or, in the case of government insurance, debts increase).
Insurers profit by having healthy and wealthy subscribers. Healthy subscribers pay into the system, but don’t take as much out of the system. Insurers can increase profits by raising insurance premiums, but must be careful when setting prices. If premiums are raised too high, healthy insurers may drop their coverage because they perceive too much of a disconnect between the premiums that they are paying and the services that they are utilizing. In that case, the profits from increased premiums may be diminished because the insurer has fewer subscribers and proportionately more “unhealthy” insureds who utilize more services that the insurer must pay for. Insurers increase their subscribers by contracting with employers to provide services to employees. If an employer chooses a specific insurance company, it would be a huge financial burden for an employee to try to go with another company not offered by the employer. There are even tax disincentives from purchasing your own insurance instead of using your employer’s insurance.
Insurer profits also increase when insurers deny care. Insurers have an incentive to deny claims to subscribers or to create roadblocks to providing care (also known as “pre-authorization”) in order to discourage people from taking money out of the system. A patient’s MRI doesn’t meet medical necessity — the insurer refuses to pay for it. Expensive cancer treatment is “experimental” — the insurer refuses to pay for it. Patients need an expensive medication? The physician has to call and pre-authorize the medication — which is uncompensated time spent away from caring for patients. However, too many inappropriate refusals may cause the insurance company to get a bad reputation with its insureds and may cause further attrition – or may cause a corporation to drop its affiliation with the insurer. Underwriters make a determination whether the risks of denying care are worth the potential financial benefit
Finally, insurers increase profits by paying less to providers. Providers need patients in order to make money. If insurers have control over a large proportion of a market’s patient population, then providers may be financially forced to contract with the insurer on the insurer’s terms so that the provider has access to the insurer’s patient base. Sometimes the providers have unconscionable contract terms to which providers will not agree. For example, Medicaid pays such little money that many providers will not accept patients who have Medicaid. The government gets around this conundrum by creating laws that force certain providers to provide care to Medicaid patients and by giving states funding to provide care to Medicaid patients.
Some private insurers also create unconscionable terms in their contracts in order to increase profits. In our area several companies have a reputation for low reimbursements and long reimbursement delays. Therefore, many providers simply refuse to contract with those companies. Think about it. Would you work for an employer who paid less than minimum wage and who didn’t give you your paycheck for 120 days? But insurers that cut corners then market lower cost products to employers who purchase their product to save money. Then the employees get “insurance,” but that “insurance” has less options and less physicians than other insurance plans.
For the most part, providers can still care for patients under private insurance plans, but patients must pay proportionately more for “out-of-network” physician services. In other words, if an insurer is only willing to pay a physician $20 for an office visit costing $150, the patient may being billed for the $130 balance. This is so-called “balance billing.” When patients pay a substantial amount of money in insurance premiums, they become upset by having to pay more than a small co-pay for provider services. Private insurers then blame “greedy” providers for charging too much and have successfully lobbied many state legislatures into making balance billing illegal and forcing some providers to accept whatever amount of money the insurance company chooses to pay. In other words, states such as California make it so that if an insurance company wants to compensate a physician 10 cents for providing medical care to a patient, the physician has to take the 10 cents and cannot bill the patients for the difference.
Medicare has also outlawed balance billing. Providers either agree to what Medicare pays for services or they don’t accept Medicare patients. Because of Medicare’s large patient base, it has considerable influence over medical providers. All patients over age 65 are eligible for Medicare. Because these patients typically are high utilizers of medical care, a hospital’s refusal to accept Medicare could threaten the hospital’s financial viability. Medicare knows this and it creates arcane rules that enable it to refuse payment or diminish payment to providers if the rules are not followed. For example, failing to note that a patient is a smoker may cause a provider’s payment to be diminished by up to 40% per patient. Hospitals have “chart police” who are hired solely to make sure that providers properly document everything that Medicare wants us to document.
Insurers fear financial risk. If a patient has a history of a potentially costly medical problem, an insurer will not contract with that unhealthy patients. Try getting a private insurance policy if you have a history of diabetes or cancer. Fear therefore diminishes the availability of care to patients who need it most.
Insurers also fear legal liability. In many cases an insurer can be successfully sued for refusing to pay for medically necessary services. To mitigate this risk, a law called ERISA was created that minimizes insurer liability for refusing payment for services when those payments are for an employee-sponsored health plan. ERISA doesn’t apply to private insurance plans, so insurers have less fear of employed patients than they do of private patients.
For Patients, there are mixed incentives, depending on their insurance status and ability to pay for care.
Well-insured patients or patients on government insurance have an incentive to demand comprehensive medical care. If they are paying large insurance premiums, if they can afford to pay out of pocket, or if someone else is paying for the cost, why shouldn’t everyone have the latest and greatest testing, medications, and treatments?
In addition, patients with government insurance have no disincentive to seek medical care for trivial complaints or for secondary gain (such as narcotic prescriptions or work notes). With no financial risk involved in seeking medical care, the only disincentive for those with government insurance is time spent obtaining the medical care. The only time a monetary disincentive comes into play is when government insured patients seek care from a provider who does not take their insurance or when a government insured patient is prescribed a medication that is not on the government’s formulary.
Monetary issues aren’t a much of a concern for well-insured patients. If there is no out of pocket cost, very few patients even question how useful a test is or how much the test costs.
Patient fears drive increased utilization. Perhaps a relative just had a stroke or died from cancer. If an insurance company is picking up the tab, fear may cause the patient to demand that those same diseases be ruled out or that low-yield testing be performed, or that a family member be inappropriately admitted to the hospital. Patients who pay out of pocket or who have high insurance deductibles have an incentive to obtain the minimum necessary care. Medical care is extremely costly and medical costs are behind a large proportion of bankruptcies in this country. Those who pay face value for their medical services avoid any services that aren’t essential – sometimes to the point of letting a treatable disease become worse or even become untreatable. To illustrate, consider a patient with good private insurance who has a $3000 deductible. Before the deductible is met, testing is kept to a minimum. Providers may have some difficulty obtaining co-pays or other payments. Toward the end of the year, when deductibles are met, there is a rush to have testing and procedures performed before the end of the year and the onset of a new deductible. Another example might be a patient who requests a questionably necessary service or test. If a patient or family member is given an Advance Beneficiary Notice to sign, acknowledging that they may personally be responsible for payment if the government does not pay, a large proportion of patients decide to forego the service or test.
Monetary concerns are a large disincentive to patients who pay out of pocket. Medication prescriptions may not be filled if they are too expensive. If pre-authorization for testing is needed, patients often forego the testing if pre-authorization cannot be obtained. Often patients become angry at physicians because they are not able to obtain pre-authorization so that the patient does not have to pay for the test.
Fears of monetary outlay serve as a disincentive to care for patients who pay out of pocket.
That’s it. I think that these are the main market forces at work in determining the cost of medical care. The examples certainly aren’t exhaustive. I’m interested in seeing comments on what other forces people think may contribute to medical costs.
The second part of this post will use the above concepts to show how the current proposed payment reforms will have little effect on controlling costs.
While scanning the news this morning, I laughed out loud at Pennsylvania’s newest proposal to cut Medicaid costs.
According to this Kaiser Health News report, Pennsylvania plans to pay Medicaid recipients up to $200 to visit “higher quality and lower cost hospitals and doctors.”
Gary D. Alexander, the Pennsylvania secretary of public welfare, compared the idea to a shared cost savings. “If the state saves $1,000 on a medical procedure we may give the beneficiary $100 or $200 as a reward.”
Does anyone see a problem with this approach?
Let me lay it out for Mr. Alexander, just in case someone who reads my column has his e-mail address.
In some of the inner-city emergency departments where I have worked, there used to be a policy that patients would be given subway tokens … or bus fare … or cab vouchers at the conclusion of their ED visit. The theory was that hospitals didn’t want patients loitering in the emergency department waiting rooms after their visits trying to find a ride home. The policy was also viewed as creating good public opinion since the hospitals were making sure that patients had a way home if they came by ambulance and had no other means of transport. Ambulance transport to the hospital is provided at no cost to the patients. Ambulance transport home must be paid with credit card.
Once the general public got wind of the cab voucher policy, guess what happened. Patient volumes increased. Ambulance transports increased. Wait times went up. People waited hours for free medical care so that they could then get their free subway token … or bus fare … or cab vouchers at the end of their visit. The policies were quickly discontinued.
If Pennsylvania begins paying people to go to “better” hospitals, the cab voucher fiasco will occur in Pennsylvania, only on a much grander scale. Once Pennsylvania Medicaid recipients learn that they will be paid to go to a certain hospital for medical care, those hospitals will be deluged with patients. To those receiving public medical assistance, the medical care is free, the medical testing is free, and the medical procedures are free. Now, with a monetary incentive to have a procedure done at a given facility, what do you expect will happen? Patients get $200 if they get a cardiac catheterization at one hospital versus another? Twelve year olds will go to those emergency departments complaining of crushing chest pain. Patients get $50 if they go to one emergency department that provides “higher quality”? There will be lines out the door.
Medicaid will end up footing the bill for an increase in medical care because it has incentivized the patient population to seek out that care.
Brilliant. Just brilliant.
Mr. Alexander even went to a meeting of “300 health insurance executives” in Washington and pitched his plan. I’m sure he got a little round of golf claps for his innovative approach to reducing health care costs.
This is what happens when people who make policies have no practical experience in the industry in which they are making the policies. Mr. Alexander was a political science major in college and has a law degree.
You want to decrease utilization? Pay Medicaid patients that same $200 at the end of a year only if their medical resource utilization (ED visits/prescriptions/whatever other variable you want to control) is below the average utilization for other Medicaid recipients for that year. Kids get $50 per year. Send out letters to those who didn’t get the money telling them why they didn’t get their “incentive payment”.
That policy will pay for itself within the first two years.
But what do I know? I’m just a dumb ER doc without a political science degree.
I read an article in the New York Times that underscores my argument that health care insurance does not and never will equal health care access.
Our federal and state governments are being crushed by debt. There are many reasons for that debt, and addressing the reasons for the debt are a necessary aspect of decreasing the debt. For example, if a family household had overdrawn its checking account by several thousand dollars and their credit cards were maxed out, most people would consider it foolish for the family to purchase expensive cars, to donate large sums of money to charity, to go out to eat at expensive restaurants, or to continue purchasing large amounts of weapons to stockpile in its basement. When in debt, there are two options – earn more money or reduce spending. Using the example of the family in debt, perhaps they sell their assets and move into a smaller house. Perhaps they eat macaroni and cheese for dinner. You get the picture.
But if we assume that the family has cut all of its non-essential spending (and many would argue that this part of the analogy fails when applied to state and federal governments), yet is still in debt, then how can the family further reign in costs?
That is the problem with which most governmental entities are now faced.
Patients such as a father of six (pictured at the right), a plumber, and a basketball coach all need various types of transplants, but are no longer eligible to receive them. The state estimates it will save $4.5 million per year by not providing these services to roughly 100 Arizona citizens. The state also warns that “there will have to be more difficult cuts looking forward.” Read that as Arizona being poised to cut funding for other types of expensive care.
Going back to the analogy about the family – is it morally appropriate to just let family members die because you don’t want to pay for the cost of caring for them?
This fairy tale about providing “insurance for all” is the biggest problem with the health care overhaul. We can strive to provide “insurance” for everyone, but “insurance” is only as good as what it insures you for.
If you are on Medicare and need expensive care or if you live in Arizona and need a transplant, you still have insurance, but that insurance just doesn’t pay for your medical care. Even though patients pay into the system all of their lives, they get nothing out of it when they actually need the care. Ponzi medicine?
If governments were serious about providing medical care for patients, they would create a system similar to the VA Hospital system that is available to every citizen in this country. You walk in the door, you get medical care. Perhaps the care wouldn’t be as good or as fast as care available at private facilities, but care would at least be available.
As the implementation of health care reform takes place, it begins to appear that our new health care system may provide the most benefits to the people that use it the least.
When companies are required to pony up money for the new health care reform law that is going to give everyone in the country insurance, guess what happens. The companies balk.
Multiple companies have applied for and received waivers so they don’t have to change the “insurance” they provide to their employees. By threatening to raise health care premiums by 200 percent or threatening to drop coverage altogether, the companies got the Department of Health and Human Services to cave. Now the companies have our government’s blessing to continue offering “insurance” to their employees that is capped at a few thousand dollars per year instead of the $750,000 required in the health care law.
Workers compensation in Idaho wasn’t paying enough, so these orthopedists allegedly colluded to refuse to treat any workers compensation patients until the state raised the rates that were being paid. In addition, several of the physicians allegedly threatened to stop seeing Blue Cross Blue Shield patients because Blue Cross payments were insufficient. Orthopedists across Idaho even published articles in the newspapers regarding the Blue Cross dispute. Now, as a result of the settlement, the orthopedists won’t be able do this same thing in the future.
The assistant attorney general stated that “The orthopedists who participated in these group boycotts denied medical care to Idaho workers and caused higher prices for orthopedic services.” No word on when this brainiac is going to file suit against all the state and government hospitals that deny care and cause higher medical prices. Oh. Forgot. States and insurance companies are exempt from antitrust actions, so no one can sue them for colluding to deny care.
I think I’ve discovered how patients will be guaranteed care under the new health care proposal. If too many doctors stop seeing Medicare and/or Medicaid patients because the reimbursement is too low, the Justice Department will just step up its antitrust enforcements.
Watch what happens to speed and quality of care then …
If you read this blog regularly, you know that I am an advocate of free market medicine. Force medical providers to advertise their prices like all the other businesses, let insurance cover catastrophic costs instead of everyday costs, and let market forces go to work.
In order for the free market concept to work, though, we have to get rid of the third party obfuscation, though. Right now, not many people care about the cost of a product because they aren’t paying for it. Third party “middlemen” are paying for the product.
Take all of those who are suffering from low back pain. You want to know if something might be wrong. Do you need an MRI? That depends. Is the pain acute or chronic? Are you having any “red flag” symptoms? Will you be willing to undergo surgery if something is wrong? You may need to see a primary care physician to see whether an MRI is warranted.
That’s another thing I would change with the system, by the way. Do away with the concept of requiring a physician’s order to obtain testing. You want an x-ray? Go to the radiology department, plop down your credit card, and get your x-ray. We can buy pregnancy tests, HIV tests, and glucose testing supplies over the counter, why can’t be buy urinalysis test strips or tests for strep throat? Why do we need a doctor’s order to have blood testing done? Don’t give me the song and dance about the dangers of x-rays, either. We allow tobacco companies sell lung rockets to any patient with a nicotine addiction as long as the packets have a label stating that the surgeon general has determined that cigarette smoking is bad for your health. Everybody is hereby warned that the surgeon general has determined that excess radiation is bad for your health. Done.
It would make the practice of medicine a lot easier and a lot less expensive if we didn’t erect so many barriers for patients to get testing done. Sorry about the tangent. Off the soapbox and back on topic.
Let’s say you get the prescription for an MRI of your low back. You lost your job and lost your COBRA coverage. You have to pay for everything out of pocket and you know how expensive MRIs can be. Where do you go to have your back MRI done? According to LesliesList.org, you can have your MRI done at Northwestern Memorial Hospital in Chicago for$3800 plus the cost for the radiologist to interpret the films.
Or, if you want to have the exact same test done at the Lincoln Imaging Center in Chicago, according to LesliesList.org the test and reading fee together would cost you $325. That’s more than a twelvefold difference in price … in the same city … for the same exam.
Now maybe you want the university radiologists to read your scan and you’re willing to pay extra. Or maybe the Lincoln Imaging Center sees that the prices it is charging are too low and increases them to reflect the market pricing. The whole point is that prices will take care of themselves once customers begin voting with their feet and their wallets.
Hopefully LesliesList.org will be one of many resources that patients can use to decrease the costs of medical care.
While many legislators praise this vote as an historic event, it is a pyrrhic victory.
I went looking for the final text of the health care bill and performed several internet searches. Came up with lots of results. Noted that the number of hits to this blog increased substantially looking for health care bill highlights. During my searches, one result that came up persistently was here.
I don’t think that this is the final version of the bill, but I’m not sure. One thing that I did notice was that since HR3200 was introduced in the House, there have been more than 1000 changes to the bill. More than two thirds of the bill has changed and the word count from the bill has more than doubled. Only 22% of people voting on the site stated that they supported the bill. Is there any wonder why most Americans don’t like the bill? No one can figure out what it contains. I’d venture a guess that most members of Congress don’t know what it contains. There were deals being brokered and changes being made shortly before the bill was passed, and less than an hour after it was passed, it was amended again.
I think that the final wording in the bill is here, but I’m not sure. One summary of the contents of the bill (posted at 6:30 PM on the evening of the vote) can be found here.
The more commentary I read about the contents of the bill , the more worried I become.
No insurance companies can “deny coverage” for people for pre-existing conditions – effective 2014. Why the wait? What happens when, instead of “denying coverage” for people with pre-existing conditions, the insurance companies just hike the insurance premiums for those patients? Then those with pre-existing conditions end up with no coverage because they can’t afford the premiums. It is already happening.
When 16 million people are added to Medicaid ranks when the Medicaid system is already imploding due to lack of funding throughout the country, should we consider it a victory that those people now have “insurance” but little access to health care? When patients in Massachusetts received insurance but couldn’t find physicians to take care of them, the amount of emergency department usage increased. You know – that cheap inexpensive care.
Illegal immigrants are no longer eligible for Medicaid. Denying illegal immigrants health care insurance won’t keep them from becoming sick. Where will they go for health care? You guessed it – to the emergency department. Now instead of receiving a pittance for providing care, the hospitals will likely receive nothing for providing that care. Who will end up paying for care to the uninsured?
What happens when all the projected “savings” aren’t realized in the future and the feds start cutting benefits and cutting payments to providers even more? Your payments into the system won’t go down, but what you get out of it sure will. The only way to make up for the gargantuan health care deficits is for the government to pay out less than it takes in. How does that happen? Either increase taxes or decrease benefits. The bill already cuts Medicare spending by $500 billion and increases taxes on investments. Look for even more taxes and less benefits in the future.
Remember: Health care insurance does not equal health care access. Never has. Never will.