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February 16, 2006

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» Price check in exam room two from Schussman.com
The problem with insurance is that it’s too expensive as it is, and HSAs will do very little for people who can’t already afford insurance. There are two significant pieces of the puzzle. The first are the problems of getting and paying for care. [Read More]

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I was standing at the reception desk at the eye doctor's office just this afternoon...next to a young woman who teared up when they told her that the basic visit was 87. cash, since she had no insurance they did offer to phonre around for her to find a dotor that accepts our state medical fund for low income people. By the way, i'm blind and a three-eyed drunk tonnnight. i phone up my eye doc because I was seeing spots and I do have health insurance . I really wasn't expecting to discover a serious probelm. In fact I wasmostly there to get a persriptioon renewed. But the eye doc saw a torn retina! Half hour later I was at the reinologist getting lasered. I wonder how the shopping around is supposed to work when the treatment is urgent?
Thank god for good medical insurance. No kidding, I am so grateful that when I need it, I have it. And there is a place in hell for government officals who pursue polidies that threaten people's health insurance,

Blind AS a drunk. I'm not intoxicated at all, wish I was. Cheers!

I wonder how the shopping around is supposed to work when the treatment is urgent?

Your personal assistant can handle that, can't she?

Dynamite post.

it is but one manifestation of your president's general awesomeness, that he can make your current, fairly ludicrous, non-"socialised" system of healthcare actually sound really goddamn appealing, in precisely the speech in which he proposes to unravel it. observe:

"You show up, you got a traditional plan, you got your down payment, you pay a little co-pay, but you have no idea what the cost is. Somebody else pays it for you. And so there's no reason at all to kind of worry about price. If somebody else is paying the bill, you just kind of -- hey, it seems like a pretty good deal."

the man is clearly a genius.

Yes, Mr. President, I'm sure I can do a far better job of negotiating medical expenses than my health insurer. After all, I might have to pay a whole $5,000, while they're only on the hook for a few hundred million a year. And obviously I have a much bigger incentive to make cost minimization my main goal, since it's only my own health on the line instead of a bunch of strangers'. Not only that, but every economist knows that individuals are far better at getting the best prices than large companies. Yes, I'm sure this is going to work spectacularly well.

And yet somehow I think that if my employer offered HSAs, I might still like to be able to cover my out-of-pocket costs at the rates my insurer has negotiated instead of paying the rates the providers are charging to cash patients. I'm kind of stupid that way.

Health care is privately owned enterprises, but it is not I repeat NOT that's *NOT* a market enterprise.

This is because it has evolved from the system doctor's put into place. Little protected niches with no price advertising debveloping into a business where there are all kinds of restrictions on sales of various products and not only no list of prices, but resistance to ratings. You can't find out how well a doctor performs.

I have a chronic illness (cf). I'm one of those who burden the public heavily. I also am part of what is arguably the most advanced and developed nedicine in America. Yet I work with a cf team that must be continually redeeducated to my history, which forgets it even when they participated it, which has no short record (one or two pages) of my specific conditions or what distinguishes me. One of the later being that I have resisted the intense treatment (eg.. 2 week hospitalization every quarter) and reduced costs, I am not a hypochonidraic.

Yet when I was last in the hospital I warned that based on various symptoms I might still be harboring an infection (as we get older our infections (mostly harmless to the normal) develop antibiotic resistance) but because I was engaing in 6 hours of lung clearance (hand percusssion, a thing called the vest, walking and other things to shake the gunk out of my lungs) I was improving. Thus no problem to the doctors. The new one (I saw 6 in 15 days, a bit unusual) diagbosed me with diabetes because cf patients my age all have it because he hadn;t looked at the past including the blood sugar tests taken the night before.

Tens and tens of tests are made and forgotten, patterns not recorded. Doctors work in hurried rushes with no time to evaluate or think. They throw treatments out almost randomly and the system is arranged to their convenience.

And these are good doctors in caring systems. They also do not admit mistakes on the part of themselves or their colleagues despite the fact that this leads to juries filled with memories of similar treatments for themselves and relatives. Solid evidence that admitting mistakes and addressing them leads tyo far more settlements, but less moneyy going out while allowing reforms doesn't matter because the public pays the huge costs that protect the doctors egoes.

The vast system we have were insurance companies and hospitals never thought of standardizing forms is the direct development of medicine that doctors controlled. Now they whine because bureaucrats take power but in most industries you have standardization and a bit of clarity on quality and prices. This has happened in medicine because it has developed in the form of little protected businesses where competition was discouraged.

The frustration of dealing with it makes people resentful and thinking they deserve every bell and whistle. I recently found that a simple inhaled saline solution (a concept developed in Australia when they foiund cf surfers were not develpoing infections) works better for me than an expensive ($1600/month) drug and will discontinue the later, but it's against doctors advice.

So much could be saved if they would take time to analyze and deduce. With poor people thee is even less time. They get a really, really overworked set of professionals in a bureacracy no one could navigate and we have decided that rather than spend $10,000 to educate them and follow up on something like diabetes we prefer $100,000 in emergency rooms and surgery.

The waste is horrendous and it will not be solved by "letting doctors practice medicine." The strengths in our system are nurses (who include sime very very highly skilled administrators and who actually run the complex systems that doctors treat as black boxes that automatically produce the results they order) respitory therapists and others in the non com class.

A number have the legal right for limited practice (nurse practioners, doctors assistants) and many of the others do truly practice medicine, spending time with the patient and educating.

In many areas we have a surplus of doctors, when that happens you don't get a reduction in prices, you get an increase in expensive procedures. It's a non market economy.

Our stats are not so good. We spend over 18% of gnp on health as opposed to 12% in the rest of the industrial world. We have the lowest life xpectancy and highest infant mortality in this group. We spend over 30% on "administration" as opposed to under 18% in the rest of the insustrial world. This difference is around a quarter trillion.

The dominant "privatizers" such as Bush do not want efficency. They wish to create more protected niches. Note the new Medicare bill which has actually cut off many essential drugs for the poor while creating a lucrative quagmire for insurance companies.

This gives a lot of strength to those who wish for a centralized system. It could work, but we must watch out for the "equalizers." For example these people resent the fact that some people pay $1,000 + per year to get more attention from their doctors. Yet on balance time to discuss and explore wil mean less spent throwing expensive tests and treatments. This individual "luxury" will benefit the whole.

I favor some sort of market system, but one thing to note: a large number of those who are healthy will move to catastrophic insurance and other plans where they don't bear the burden for people like me. This burden will more clearly fall on soxciety as a whole (alredy Medicare and 2/3rds of Medicaid go to the disabled and elderly) but I think a rational isolation and the building of specialized programs for various types of disease can be useful.

Despite my critiques of the cf system it has been there and it can be applied to various cancers and other chronic diseases.

In my opinion it is an "organizational" and "information" revolution. It is complex because at one level such as the specific response to a situation (eg. trauma) you have among the most efficient and amazing organizatons, but at a larger scale you have all kinds of holes and lacks. And waste. Huge amounts of information are gathered. But most are in black holes. Even where computers host the records their search capacities are primitive.

I support hospitals moving to the open source program the VA has made availible (it is a complete program for hospitals.) Not because it is perfect or the best, but it is ok, it provides a standard and like the net open source means it can be constantly improved and the improvements made public.

But if the Republicans ever find out the VA is doing such a thing they will shut it down.

it gets better!

not only do you get to shop around for doctors, you get to shop around for the secondary services like lab work and radiology!

imagine the joy of shopping for a doctor, then shopping for lab work, then a place to do your x-rays, then telling your doctor he has to use the lab and radiologist you've selected !

now imagine doing all this while being pulled from your car with the Jaws Of Life ! "Hold on! Don't start the ambulance yet, I'm trying to find cheaper radiologist !"

And the patient (ahem, I mean customer) is not the only person in this little free-market tableaux who will be taking on a huge new burden; doctors will also need to spend time learning their market, and will need to invest in research, marketing, etc.; soon they will be competing with lawyers for space on the spines of phone books. Nothing could be further from "just letting doctors practice medicine" than requiring them to negotiate with every patient and undercut the endocrinologist down the hall.

Also, not to nitpick a great post by david, above, but this statement:

But if the Republicans ever find out the VA is doing such a thing they will shut it down.

is not entirely fair; I have a friend who has been with the VA for about 8 years, and who works on the program you are talking about. It started in '96, but according to him, it has gotten full support and has expanded during the 6 years the VA has been run by Republicans. So, credit where due, I suppose. They didn't start it, but they haven't f**ked it up.

it gets better!

I'm baffled who no one has put proctology and the invisible hand in the same sentence.

"I'm baffled who no one has put proctology and the invisible hand in the same sentence."

An enterprising proctologist might advertise his services as "The power of glove." He might even offer a special deal, with the slogan "Glove me two times."

I'll get back to work now.

and who among us can forget KISS's early-80's disco hit: I Was Made For Gloving You ! or the J Geils Band's "Glove Stinks!

whew. i could run with that for days.

david,

Do you think doctors WANT to be harried and overworked to the point that they can't follow patients properly? Ask any of them and they'd tell you that our system punishes them for taking the time to do the right thing.

Egos are rampant in medicine but so is beauracracy. Physicians do not have the reins anymore, hospital administrators and insurance companies dictate who gets what and when. The AMA protects physician's compensation like any lobbying group but the insurance lobby has much more pull in DC. The system is screwed up b/c THEY make huge profits off of it.

The invisible hand is fisting all of us, and without a proper introduction, too.

Heet:

They built this system. It evolves directly from their business models. Now they are victims of it but they don't use their power (which they wield so effectively elsewhere) to change it. Believe me the public would be supportive of proposals.

But they don't make them, just as public school teachers bitch about the system but don't push for alternatives besides smaller classes and no pay.

I have being involved in analysis of complex systems and simple useful summaries do save time in the long run. Doctors woyld be less pressed if they weren't constantly rediscovering information. Even obvious things like complete lists of prescriptions are lacking from records.

So yes pragmatically they want it. They are not pushing for obvious changes. In many cases they benefit from the complexity of billing information, they benefit from consumers ignorance of success rates and resist any attempt to document failings.

Yes they get to bitch about various things. But a VA hospitals and others have tried systems were patients are informed of mistakes. The number of claims goes up, currently 90% of the victims of medical error get nothing except the right to pay the extra bills, but total costs would go down.

Such a system also encourages reform rather than hiding problems. So wy do doctors oppose it? Because it would require that they and their colleagues admit mistakes. Better let the consumer pay through higher insurance and taxes.

I am going to argue for HSA's.

First, patient-paid care (LASIK, plastic surgery, etc) has not risen in cost to nearly the same extent that insurance-paid care has. Thus, there is at least some evidence that directly paying for care would help control costs.

Second, direct-paid care would reduce administrative costs. My sister works in an urgent-care facility; they have as many office staff as nurses. With HSA's, the need to bill insurance companies, follow up on randomly rejected claims, etc is much lower--this would reduce costs.

Third, HSA's enable people to afford insurance who otherwise couldn't, since HSA plans are very much cheaper.

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Whatnot


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