Negotiating Health Care Costs

Ezra Klein writes:

There is a simple explanation for why American health care costs so much more than health care in any other country: because we pay so much more for each unit of care. As [Kaiser Permanente CEO] Halvorson explained, and academics and consultancies have repeatedly confirmed, if you leave everything else the same -- the volume of procedures, the days we spend in the hospital, the number of surgeries we need -- but plug in the prices Canadians pay, our health-care spending falls by about 50 percent.

In other countries, governments set the rates that will be paid for different treatments and drugs, even when private insurers are doing the actual purchasing. In our country, the government doesn't set those rates for private insurers, which is why the prices paid by Medicare, as you'll see on some of these graphs, are much lower than those paid by private insurers. [. . .] The health-care reform debate has done a good job avoiding the subject of prices. The argument over the Medicare-attached public plan was, in a way that most people didn't understand, an argument about prices [. . .] "A health-care debate in this country that isn't aware of the price differential is not an informed debate," says Halvorson.

(Emphasis supplied.) What's fascinating to me is Ezra Klein has been one of the Village wonkers pooh poohing the central point of a public health insurance option - that the government does better negotiating health care prices than private insurance companies (for whatever reason you may want to attribute.) His focus on the exchanges and the "regulations" and his attempts to diminish the public option demonstrate that the one of the main wonkers not getting the whole "government does better at cost containment in health care" thing is - Ezra Klein. The irony of his post is rich.

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    That may be true.... in Canada (5.00 / 1) (#1)
    by jimakaPPJ on Mon Nov 02, 2009 at 10:12:25 AM EST
    and other countries.

    But the problem is that the vast majority of new drugs, equipment, new procedures, etc., come from the US health "system."

    Tinkering with it may have some very unexpected consequences.

    Klein seems surprised that Medicare payments are less than those paid by private insurance. He probably would be shocked, yes shocked, to learn that those with no insurance pay more than either.

    If Obama's planS are adopted and Medicare funding is cut, again, someone is going to have to pick up the difference or else services will be reduced. Palin's "Death Panels" resonate with us older folks because we have had a lifetime for common sense to be beat into us.

    Jim honey, this is just not true (5.00 / 1) (#4)
    by Militarytracy on Mon Nov 02, 2009 at 10:36:31 AM EST
    In fact the insurance companies have stalled many new developments for years and years because they refuse to pay for anything they can deem "experimental".  And they love to slap that label on anything and everything they can slap it on.

    experimental (5.00 / 1) (#5)
    by Fabian on Mon Nov 02, 2009 at 10:58:59 AM EST
    usually means "doesn't have a proven track record".

    If the procedure isn't done, then it can't get a track record - and many experimental procedures are expensive, so few people can afford to pay for it out of pocket.  So if the insurance companies aren't going to pay for new tech, who is?

    I can see the insurance company's POV sometimes.  If a doctor wants to do something risky and expensive with an unknown chance of success - should the insurance company pay for it?  Since we are talking medicine here - this isn't if it works, great, if it doesn't, no harm done.  A failed procedure can result in plenty of harm done.


    I can see the insurance POV sometimes too (5.00 / 1) (#6)
    by Militarytracy on Mon Nov 02, 2009 at 11:04:47 AM EST
    but then you have procedure like the titanium rib, where once it is out of study there are going to be thousands and thousands of life saving procedures done....and that is when they really start pulling sh*t.  In the West it was Colorado Medicaid that "broke out" the procedure, it gave other families weapons to fight with once other insurance had paid for the life saving successful procedure to be done.  The study sites think that the insurance industry also tied up the study though for four years longer than it had originally been scheduled for.  A six year study became a ten year study for absolutely no reason........the procedure was positively proven successful and life saving after six.  Something was tying up the FDA approval for four extra years but we never could find out what that was.

    And then there is my recent (none / 0) (#7)
    by Militarytracy on Mon Nov 02, 2009 at 11:12:41 AM EST
    discovery of the insurance industry killing the new Segway wheelchair.  It is a wheelchair that could climb stairs for some users, but think of how many new scripts would have been written for that life improving device?

    Insurance companies set up what (5.00 / 1) (#10)
    by MO Blue on Mon Nov 02, 2009 at 11:29:46 AM EST
    they consider "standards of care" treatments for various illnesses. These standards are rarely the most innovated. Many of them also prohibit participation in clinical trails even at leading treatment centers. The whole set up on how drugs are approved also inhibits adaptation of new forms of treatment such as chemotherapy drugs for various forms of cancer. Currently chemotherapy drugs must be approved for each different type of cancer.

    Even if you are able and willing to pay for a better treatment, one that actually works, the insurance company will refuse to pay for other areas of treatment that they would normally cover, once you deviate from their "standard of care" treatment in any way.  


    You assume (none / 0) (#12)
    by jimakaPPJ on Mon Nov 02, 2009 at 11:34:01 AM EST
    the doctor can't explain what and/or why they want to do what they want to do.

    I don't assume anything (5.00 / 2) (#15)
    by MO Blue on Mon Nov 02, 2009 at 11:40:56 AM EST
    I am stating actual cases where people are denied the ability to participate in clinical trials or the care that their doctor wants them to have by their insurance companies.

    The insurance companies do not care what the doctors recommend. They are in the business of making money and they use whatever is available to deny care or force people to use less expensive treatments even if they are not the best treatment for the individual.


    The government does not pay for clinical trials (5.00 / 1) (#33)
    by vicndabx on Mon Nov 02, 2009 at 12:34:42 PM EST
    either.  You would expect this to change under a public option?

    Indications and Limitations of Coverage

    Effective for items and services furnished on or after July 9, 2007, Medicare covers the routine costs of qualifying clinical trials, as such costs are defined below, as well as reasonable and necessary items and services used to diagnose and treat complications arising from participation in all clinical trials. All other Medicare rules apply.

    Routine costs of a clinical trial include all items and services that are otherwise generally available to Medicare beneficiaries (i.e., there exists a benefit category, it is not statutorily excluded, and there is not a national non-coverage decision) that are provided in either the experimental or the control arms of a clinical trial except:

        * The investigational item or service, itself unless otherwise covered outside of the clinical trial;
        * Items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient (e.g., monthly CT scans for a condition usually requiring only a single scan); and
        * Items and services customarily provided by the research sponsors free of charge for any enrollee in the trial.

    Routine costs in clinical trials include:

        * Items or services that are typically provided absent a clinical trial (e.g., conventional care);
        * Items or services required solely for the provision of the investigational item or service (e.g., administration of a noncovered chemotherapeutic agent), the clinically appropriate monitoring of the effects of the item or service, or the prevention of complications; and
        * Items or services needed for reasonable and necessary care arising from the provision of an investigational item or service--in particular, for the diagnosis or treatment of complications.

    In short, Medicare covers the stuff that would normally be covered as part of a hospital stay, or normal course of treatment tied to a particular diagnosis.  Not the new, unapproved treatment.


    Insurance companies often deny people (5.00 / 3) (#39)
    by MO Blue on Mon Nov 02, 2009 at 01:03:52 PM EST
    the ability to participate in clinical trials by refusing to pay for the stuff that would normally be covered as part of a hospital stay, or normal course of treatment tied to a particular diagnosis (standard of care portion) even when the trial will pay for the new, unapproved treatment.

    Of course they are in the business to make (none / 0) (#18)
    by jimakaPPJ on Mon Nov 02, 2009 at 11:47:46 AM EST
    money.... Does that bother you?

    I have never been denied by an insurance company. Nor has my family or anyone I know. I have been asked for additional information.

    I have been denied by a government run agency, aka Medicare, until my Doctor called an received approval per Medicare guidelines.


    I have (5.00 / 1) (#23)
    by Militarytracy on Mon Nov 02, 2009 at 11:58:15 AM EST
    It was on the verge of paralyzing my son too.  It would have eventually killed him as well.  They still denied us.  My son has cost around a million dollars though now.  I've had to fight for every dollar too.  Rather than go through all of this fighting as well, one doctor thought that the best thing to do would be to allow him to "slip away".  What sort of country have we become where this a backroom discussion with the mother of a three year old child who had not suffered any major illness thusfar in his life.  He is still extremely healthy outside of his bone structure too.  He has never been hospitalized for a cold or flu or even had a single instance of pneumonia.  He probably would have though soon with how compressed his lungs had become due to his scoliosis.

    You didn't ask me, but (5.00 / 2) (#65)
    by Spamlet on Mon Nov 02, 2009 at 02:18:01 PM EST
    Of course they are in the business to make money.... Does that bother you?

    yes, that does bother me. Call me crazy, but I think health care should be a tax-funded service, not a for-profit private enterprise.

    And I'm very happy to hear that you have never been denied care by an insurance company. Many others have, including my late best friend, whose treatment for lymphoma was delayed while she battled with her insurance company over the details of a so-called experimental treatment that was completely standard for her type of cancer.


    Joshua's doctors always say and explain why (5.00 / 0) (#22)
    by Militarytracy on Mon Nov 02, 2009 at 11:51:12 AM EST
    and they get told NO by a nurse who is employed by the insurance company Jim.

    Uh Tracy baby... (5.00 / 1) (#9)
    by jimakaPPJ on Mon Nov 02, 2009 at 11:27:11 AM EST
    I didn't say the insurance companies had anything to do with developing new drugs, equipment or procedures. And no, they haven't stalled anything. If it is FDA approved and the Doctor wants to use it the insurance companies will approve it, although they may require justification or explanations.

    You said that the European system (5.00 / 1) (#25)
    by Militarytracy on Mon Nov 02, 2009 at 12:00:28 PM EST
    discourages innovations and new medical tech without one single actual reference to such a situation.  I gave you actual instances of our system discouraging and actually killing innovation and new medical tech.

    If it is experimental it is not (2.00 / 0) (#40)
    by jimakaPPJ on Mon Nov 02, 2009 at 01:10:10 PM EST
    approved. It is approved as experimental/trials.

    Big difference.

    And I didn't say it discouraged... I just noted that the vast majority of new things come out of our system. My larger point is, was and will be that anything we do will have unintended consequences.

    Remember, I am for a single payer system modeled on Medicare. I just don't believe you can pay for it by reducing the standard of living of the people involved in providing the care and the new "technologies" for like of a better word to combine drugs, procedures, admin, etc.

    Remember, you can buy most drugs cheaper in Canada than here. Some are generic, some not. There is a reason they can do that. By and large they aren't paying the up front costs. Our system is.

    How do we fix that? I confess that I don't know. But I do know that Obama's planS will just make things worse.


    Please give evidence that (5.00 / 1) (#51)
    by Militarytracy on Mon Nov 02, 2009 at 01:49:30 PM EST
    "Obama's plans" will just make things worse?  Which plans are you talking about because we don't even have a defined Obama plan?

    Did you note (none / 0) (#76)
    by jimakaPPJ on Mon Nov 02, 2009 at 05:45:11 PM EST
    that I wrote "Obama's planS?" See the plural??? No no knows for sure what's in the planS. And it is my experience that when dealing with any organization if you don't know what is in the planS then they will always make things worse.

    In this case taking $500 billion out of Medicare will certainly make things worse for us seasoned citizens.


    And the first page and first glance of a google (5.00 / 1) (#61)
    by Militarytracy on Mon Nov 02, 2009 at 02:07:35 PM EST
    produced this actual evidence outside of my own personal experiences of Insurance companies eager to classify something experimental in their book and uncovered that is FDA approved.  And the denial actually ended up costing insurance companies more money in the process of working so hard to find ways to deny coverage.  But growing a culture of denying coverage overall benefits them so I'm certain they don't overly worry about the occassional cutting off of their own noses.

    Anthem Blue Cross is one of several insurance companies that considers the procedure "investigational and not medically necessary." In a statement they also ad that: "While the FDA has approved the procedure... Authorizing broader use requires a five-year review. Blue Cross looks forward to such medical research being completed in the next few years."
    But Dr. Light believes there are more than enough patients like Parish who would benefit from the increased mobility, and faster recovery times, to justify the coverage.
    "She had the operation, she was in the hospital for only one day, went home the next day and was cured. And why Blue Cross, Blue Shield, the insurance industry won't embrace this technology is really a difficult thing for me to understand," says Dr. Light.
    Dr. Light believes the policy is coming between patients making decisions based on their doctor's recommendations. When it comes to cost, Dr. Light points out disc replacement runs about half as much as spinal fusion.
    "It is in my opinion the single greatest advancement in spinal surgery in the last 50 years," says Dr. Light.
    There are several competing models of disc replacements now on the market. There are also new micro-bracing technologies emerging as well.

    Your link doesn't work (none / 0) (#78)
    by jimakaPPJ on Mon Nov 02, 2009 at 05:47:26 PM EST
    Sorry, I'll do that again (none / 0) (#107)
    by Militarytracy on Tue Nov 03, 2009 at 07:21:14 AM EST
    So Dr Light "believes." (none / 0) (#92)
    by jimakaPPJ on Mon Nov 02, 2009 at 08:22:57 PM EST
    And the insurance companies (5.00 / 1) (#26)
    by Militarytracy on Mon Nov 02, 2009 at 12:01:44 PM EST
    have labeled treatments that were FDA approved still experimental and denied coverage and payment.  You are wrong on that too.

    Er, what you mean "we" Kemosabe? (5.00 / 1) (#49)
    by gyrfalcon on Mon Nov 02, 2009 at 01:41:06 PM EST
    No "death panels" resonating here, thank you very much.  Anybody with a lick of sense and any experience with the medical system knows, to the contrary, how hard it is to get them to stop.

    It is easy to get them to stop (none / 0) (#93)
    by jimakaPPJ on Mon Nov 02, 2009 at 08:25:10 PM EST
    quit paying them.

    That's what the $500 billion theft of Medicare funds does.

    And that is what creates the shortages.

    And when you have shortages you always wind up with gate keepers.... aka "Death Panels."


    Twaddle (none / 0) (#105)
    by gyrfalcon on Mon Nov 02, 2009 at 11:54:28 PM EST
    As you know very well, that's not how it works in real life.

    wow, he just found out? (5.00 / 1) (#2)
    by Stellaaa on Mon Nov 02, 2009 at 10:22:07 AM EST
    No one wants to talk about this issue.  All the Europeans control prices of procedures and medications.  This is clearly one area where all the free market talk just does not work.  

    Yes they do (none / 0) (#11)
    by jimakaPPJ on Mon Nov 02, 2009 at 11:31:40 AM EST
    Now. Name me some breakthroughs that have came out of their system?

    When I was investigating Joshua's (5.00 / 0) (#20)
    by Militarytracy on Mon Nov 02, 2009 at 11:49:03 AM EST
    foot problems Jim, it looks like the Swiss have done the first prosthetic implants of a calcaneus (heel of your foot).  In my experience being the mother of a child seemingly always pushing the innovation curve, new breakthroughs usually come to us through the undying passionate research of singular people or groups of people sharing a passion, and has little to do with what country you are from or living in or practicing in.  The passionate can't help but seek out the resources they need to continue, and if it improves lives they usually find those resources.

    Do you know the cost (none / 0) (#24)
    by jimakaPPJ on Mon Nov 02, 2009 at 11:58:28 AM EST
    of getting something through the FDA?

    That takes resources.


    Europe has no such agencies? (5.00 / 1) (#28)
    by Militarytracy on Mon Nov 02, 2009 at 12:03:21 PM EST
    I'm sure they do (none / 0) (#36)
    by jimakaPPJ on Mon Nov 02, 2009 at 12:57:40 PM EST
    but that wasn't my point. The point was dedicated people/groups et al require resources just like undedicated people/groups.

    That was your point? (none / 0) (#63)
    by Militarytracy on Mon Nov 02, 2009 at 02:10:58 PM EST
    Because I believe that I said the same thing as well as pointing out that dedicated people find resources outside of the United States to develop new treatments and tech.

    You need to answer that question, Jim (5.00 / 1) (#74)
    by Inspector Gadget on Mon Nov 02, 2009 at 04:14:24 PM EST
    Do YOU know the cost of getting something through the FDA?

    I have 3 years experience in the Regulatory Affairs department of a major invasive device manufacturer, so I'd be really interested in hearing your answer.


    of getting something through the FDA?
    it sounds like you are saying the FDA is paid by the medical manufacturers.

    Huh?? (none / 0) (#81)
    by jimakaPPJ on Mon Nov 02, 2009 at 05:52:27 PM EST
    Then you have a tin ear.

    My point was that the people doing the trial must have resources. A company must stay in business while the FDA does its bit, etc., etc. etc...


    IVF (5.00 / 2) (#56)
    by Ga6thDem on Mon Nov 02, 2009 at 01:57:19 PM EST
    was developed in Great Brittain. Interferon treatment for cancer was developed in Switzerland. Those are two just off the top of my head.

    Quit dumbing down your mind with those losers on talk radio. They'll do nothing but tell you lie after lie.


    you mean like this one (none / 0) (#13)
    by cawaltz on Mon Nov 02, 2009 at 11:35:12 AM EST
    Thank you for proving my point (none / 0) (#16)
    by jimakaPPJ on Mon Nov 02, 2009 at 11:43:02 AM EST
    about where the breakthroughs come from....

    The U.S. drugmaker has said the injectable drug, called Bridion, is one of the biggest advances in anesthesiology in the past generation.

    And I have no idea as to where it stands in the FDA approval queue..


    ummm . . . (none / 0) (#17)
    by nycstray on Mon Nov 02, 2009 at 11:47:13 AM EST
    Bridion was approved for reversal of neuromuscular block induced by the widely used drugs rocuronium and vecuronium.

    It was obtained in Schering-Plough's $14.5 billion purchase last year of Organon Biosciences.

    That would be the Dutch Organon Biosciences  ;)


    Glad to know that (none / 0) (#21)
    by jimakaPPJ on Mon Nov 02, 2009 at 11:49:54 AM EST
    we have enough resources to fund purchases of companies that are in trouble.

    Or would you turn that over to the government?

    Wanna buy a Volt?? ;-)


    Could you show me info (none / 0) (#27)
    by nycstray on Mon Nov 02, 2009 at 12:01:53 PM EST
    on the company being in trouble?

    Interesting that SP is now merging with Merek . . .


    Can you show me it wasn't? (none / 0) (#37)
    by jimakaPPJ on Mon Nov 02, 2009 at 12:58:50 PM EST
    Well . . . . (none / 0) (#45)
    by nycstray on Mon Nov 02, 2009 at 01:21:34 PM EST
    here's a bit of background info

    That's a nice press release (none / 0) (#47)
    by jimakaPPJ on Mon Nov 02, 2009 at 01:24:59 PM EST
    and some of it may be true.

    And you've got what? (none / 0) (#57)
    by nycstray on Mon Nov 02, 2009 at 01:59:41 PM EST
    From what I've gathered, the parent corp was planning on going public with the pharm corp, but got a buy offer instead (SP gains but no mention of that loss you speak of). Parent corp was sep-ing the pharma from the chemical.

    How's Rover?


    Rover is fine (none / 0) (#79)
    by jimakaPPJ on Mon Nov 02, 2009 at 05:49:07 PM EST
    And I hope you don't make financial decisions based on press releases...

    or your Rover may go hungry.


    I read more than a press release. (none / 0) (#88)
    by nycstray on Mon Nov 02, 2009 at 06:36:14 PM EST
    It's really not that hard, ya know?

    My Rover is in absolutely no danger of going hungry and resorting to other nourishment.


    Whether or not (none / 0) (#90)
    by BackFromOhio on Mon Nov 02, 2009 at 07:08:12 PM EST
    a company has fallen into financial trouble has little to do, ipso facto, with whether or not it has developed breakthrough medical treatments

    That isn't the question (none / 0) (#95)
    by jimakaPPJ on Mon Nov 02, 2009 at 08:26:03 PM EST
    What does a Volt have to do with (none / 0) (#30)
    by Militarytracy on Mon Nov 02, 2009 at 12:05:35 PM EST
    health-care realities?

    Of course there is... (none / 0) (#35)
    by jimakaPPJ on Mon Nov 02, 2009 at 12:54:09 PM EST
    the Belgium owner of Budweiser has developed a new bottle that keeps the beer super cold...

    I mean, speaking of important things.


    My original comment was that controlling/cutting prices would have unintended consequences. One of them is reduced innovation. That should be of no surprise to anyone.


    It was an example (none / 0) (#41)
    by jimakaPPJ on Mon Nov 02, 2009 at 01:13:21 PM EST
    of what Government Motors can produce....

    And you can't see the (none / 0) (#46)
    by jimakaPPJ on Mon Nov 02, 2009 at 01:21:51 PM EST
    analogy of a car that is over priced with marginal performance to be produced by the government and what might happen if we turn health care over to the government?

    If you can't keep up, please don't attack me. Let's ignore each other.


    Since you are well known (none / 0) (#80)
    by jimakaPPJ on Mon Nov 02, 2009 at 05:50:45 PM EST
    to follow me everywhere I think you have a personal problem. You have become much worse since I banned you from my blog.

    Your continual trailing me around is (none / 0) (#96)
    by jimakaPPJ on Mon Nov 02, 2009 at 08:27:49 PM EST
    obvious. I am merely reminding you of what you are doing. Be my guest. It defines who you are.

    Unfortunately, since public option advocates... (5.00 / 1) (#3)
    by lambert on Mon Nov 02, 2009 at 10:25:45 AM EST
    .. refuse to explain how the public option will be administered, it's hard to know how the government will end up negotiating prices, and hence, what cost savings, if any, there will be. Possibly that's because, as the HHS actuary predicted, that the Democratic plan will increase total costs, rather than decrease them. [Yes, this is HR3200, not HR3960] In any case, without detail on what the concrete, actual negotiating process will be, it's impossible to tell one way or another (though a wilful refusal to save the $400 billion a year that single payer would save should tell people what the real priorities are here, since they can't be cost saving).

    Regulating Insurance Company fees (5.00 / 1) (#8)
    by samsguy18 on Mon Nov 02, 2009 at 11:15:06 AM EST
    Is a simple first step....the second step Attach public option, medicare and medicaid fees to Quality care....This will improve the delivery and quality of medicine throughout the country. Patients get very confused with the many fee stuctures and co-pays they are faced with when a healthcare crisis arises. Just because they are paying top dollar doesn't mean they are getting the best medicine.I just spent two months working in a hospital in Canada. We need healthcare reform!!! However the present Bill is not the answer.There is too much hidden in the 1900 pages.

    Oh, I don't know (5.00 / 1) (#14)
    by jimakaPPJ on Mon Nov 02, 2009 at 11:37:42 AM EST
    I have never had any problem understanding the fees, copays, etc. I suspect the average patient is no dumber than me.

    Like the sop to (none / 0) (#52)
    by Wile ECoyote on Mon Nov 02, 2009 at 01:49:36 PM EST
    the trial lawyers.

    Even if the government set all payment rates, we'd (5.00 / 0) (#48)
    by steviez314 on Mon Nov 02, 2009 at 01:34:53 PM EST
    still have the main unresolved dilemma of health care.

    That is, the end consumer of the product, having paid the monthly premium, has no incentive to minimize their demand of the product.

    And from a moral standpoint, I'm not sure I'd want them to.  The last thing I want is for a poor person to have to choose between food and a co-pay for a needed service.

    Yet, when is the excess demand for medical care too much?  I sure don't want to leave it in the hands of the insurance industry which ONLY wants to maximize their profits.  I'm not sure government will ever really want to deny a service to a constituent.  And it shouldn't fall on the individual to consider every medical service as a money drain.

    Yet there ARE unneeded medical procedures, and there are cheaper drug alternatives.  I just have no idea how to really incentivize individuals to strike the "right" balance.

    I have no idea how (5.00 / 2) (#54)
    by gyrfalcon on Mon Nov 02, 2009 at 01:54:42 PM EST
    individuals are supposed to know what's an "unncessary" procedure.

    Case in point, "severe" H1N1.  We are being told daily that the H1N1 deaths are happening because people who become seriously ill with it aren't getting medical treatment soon enough.

    If you're the average mom with a sick little kid, what are you going to do?  You're going to take your sick little kid to the doctor at least, if not the emergency room. pronto-- just in case.  Wouldn't you?  Presto, one more "unnecessary" medical service provided.

    Don't put this on the patients.  They're not competent to make medical decisions about what's necessary and what's unnecessary.  With physicians now being required most of the time to shuttle patients in and out every 15 seconds, there isn't even time to educate them.  I suspect that's why most of the docs who prescribe antibiotics for colds do it, to get the patient out the door quickly so the next one can come in.


    15 minutes (5.00 / 1) (#55)
    by gyrfalcon on Mon Nov 02, 2009 at 01:55:35 PM EST
    not seconds.  It's bad, but it's not that bad...

    And that 15 minute - if that - visit (none / 0) (#60)
    by Anne on Mon Nov 02, 2009 at 02:07:13 PM EST
    is preceded by a long wait in the waiting room, followed by another long wait in the examining room.

    It's like sitting in petri dish, for crying out loud.


    Well, I sure don't want to put the decision on the (5.00 / 1) (#62)
    by steviez314 on Mon Nov 02, 2009 at 02:08:13 PM EST
    insurance company.  And not even the doctors--unless they are on salary and not getting paid by the procedure or outcome--they have to balance what is "right" vs. what to do.

    Here is an example:  Six months ago, I noticed my mother was dragging her leg a bit and somewaht drooping her left side.  I'm not a doctor, but I said she probably had a mini-stroke.

    Last week, her condition was the same--no better or worse, and NO OTHER SYMPTOMS of anything, but she decided to go to a neurologist.  He thought it was a stroke and ordered an MRI.  The MRI showed it was.  The treatment--physical therapy.

    Which she could have gotten with out the MRI.  Was the MRI really necessary?  Who knows?

    Another example:  my 26 year old son got swine flu 2 weeks ago.  He has good insurance and can afford the co-pay.  He decided it wasn't bad enough to go to the doctor.  But, he could have--the decision to see the doctor or not was totally voluntary by him and would cost him nothing.  But if he went, total medical spending would have gone up.

    How are these choices made?  And what are the right ones?  It can't be "always go" or "never go" or not even "only go if you can afford it".

    At least with other price-inelastic goods, like gas and food, there can be SOME substitution made (store brands, car pooling, etc.)  But health care should be a bisic right.  But is it an unlimited one?


    What if the MRI had shown (5.00 / 2) (#68)
    by Anne on Mon Nov 02, 2009 at 02:58:04 PM EST
    something less benign?  Like a slow bleed in her brain, or a growth pressing on an area of the brain that was affecting her gait, or that another stroke looked imminent?  How would you feel about the MRI then?  

    My mother had a stroke in 2003 - it was the size of an egg in an area of her right brain.  She was lucky - she suffered some left-side "neglect" - she was unaware of anything happening on her left side - which mostly resolved over time, and she has attentional problems, but she suffered no speech problems or paralysis.

    About six months later, she had what turned out to be a TIA; she got an MRI and an MRA because (1) she has a history of stroke and (2) TIA's are often precursors to major stroke.  A year after the initial stroke, we think she had a seizure, which is not uncommon in the first year after a stroke.  Because we weren't there when this happened, she got another MRI, and other tests, and fortunately, all was well and she's never had another one.

    So, there's cost, and then there's benefit, and the benefit isn't just peace of mind.  And I don't think she was qualified, nor were my brother and I, to declare that she really didn't need these tests.  Heck, when she had the original stroke, she didn't want to go to the hospital, and while the type of stroke she had was "dry" and the damage had already been done, we had no way of knowing if that was the end of the event, or the beginning of something worse.

    I'm glad your mother is okay, and now, thanks to that MRI, you don't have to worry about her as much.


    Before the MRI, the doctor knew pretty much that (5.00 / 1) (#70)
    by steviez314 on Mon Nov 02, 2009 at 03:34:02 PM EST
    it was a mini-stroke, as did I as a layperson.  Remember, there were no new symptoms or impairment.

    The point was, sure, we can do enough medical tests to be 100% sure (well, actually, we can't--the healthiest person's CT scan will show something), but is that wise?  If it is, then how will it get paid for on a monthly premium rather than a per use charge?

    It is impossible to fix the cost of something (re-imbursements), the price (premiums), the supply (doctors) AND demand all at the same time.

    The health care system can be improved tremendously over what we have now, but until we come to grips with this basic dilemma and think outside the box (massive preventative care, outcomes-based systems, etc.) we will still have problems.


    Many years ago (5.00 / 1) (#91)
    by BackFromOhio on Mon Nov 02, 2009 at 07:20:05 PM EST
    I had a colleague, a young woman, who shared with me one day that she was driving her husband crazy.  What did she mean?  She could not sleep; she had had pretty bad headaches for months and no over-the-counter pain medication was working. Some of her friends had gone so far as to suggest she was a hypochrondriac.  I suggested she go see an internist, who at the time, worked at a major teaching hospital hand-in-glove with orthopedic & neurosurgeons.  He immediately sent her to a neurologist, who ran tests and found a gigantic tumor.  Within short order, the tumor was successfully removed.  Had she waited, who knows what.  
    As a layman, I too, am often right in my suspicions.  But I'd sure rather have a competent medical professional run the appropriate tests to check.  It's my understanding that tumors can start, stop growing for a while & then begin again.  Why take a chance assuming something is a "minor stroke"?  And how do we know that today's minor stroke is not caused by conditions that can lead to multiple minor strokes, etc.

    Well (5.00 / 3) (#69)
    by Steve M on Mon Nov 02, 2009 at 03:03:37 PM EST
    your examples help show that people don't tend to consume free health care the same way they might consume, say, free M&Ms.  Even if there's no cost whatsoever, the vast majority of people are not going to drop by the doctor's office every day just for fun.  Even sick people like your son often decide that it's just not necessary.

    Sure there will be hypochondriacs and other over-cautious people, but I don't see any reason to believe it would be a huge factor overall.  Maybe one of the many foreign countries that have single-payer health care has studied the question in a rigorous way, I dunno.

    Ultimately, I think most people are not very good at calculating a rational tradeoff between health care and dollars.  I don't think we'd gain much in terms of efficiency if we left the decision up to consumers, and certainly I'd feel morally uncomfortable about such a regime.


    And I don't want to leave it up to the insurers or (none / 0) (#71)
    by steviez314 on Mon Nov 02, 2009 at 03:35:36 PM EST
    politicians either.

    That's why, even after we get universal coverage and competition, we still will have problems.


    There's (5.00 / 2) (#73)
    by Emma on Mon Nov 02, 2009 at 04:11:27 PM EST
    never going to be a problem-free solution.  To anything.  Ever.

    So, it's a question of picking the problems one wants to live with.  You can't consider the drawbacks of solution A without considering the drawbacks of solution B at the same time.

    And, regardless of which solution you're considering, health care costs money.  It's always going to cost money.  It will never be free -- which is what this "deficit neutral" talk wants to imply. We're going to cover millions and millions and it will be FREE!!  No. It won't.  

    And, within the parameters of "it's never, ever going to be free" and "the cost of healthcare isn't going to go down", then it seems to me you figure out which cost controls are the most fair and most in line with one's commitment to basic human rights.


    So who's to make it? (none / 0) (#72)
    by Steve M on Mon Nov 02, 2009 at 03:57:56 PM EST
    Do Medicare coverage rules typically get made by politicians?  I didn't realize such things were legislated.  I assumed civil servants make the call.

    Gee, I know that. (none / 0) (#77)
    by Fabian on Mon Nov 02, 2009 at 05:46:56 PM EST
    After my son was diagnosed at 12 months with hemiplegic cerebral palsy (it only affects one side of his body) his pediatrician asked if we wanted to do an MRI.  Well, the injury was assumed to have happened at or shortly after birth, due to the conditions.  So...twelve months later, what good would it have done to do an MRI which would have required sedation?  I passed.  Perhaps it would have been nice to have that baseline MRI, but having it or not having it wouldn't have changed anything.

    DING DING DING DING DING (none / 0) (#103)
    by FreakyBeaky on Mon Nov 02, 2009 at 11:43:32 PM EST
    And not even the doctors--unless they are on salary and not getting paid by the procedure or outcome--they have to balance what is "right" vs. what to do.

    It is in this direction of salaries instead of fee-for-procedure that cutting costs without cutting care lies.


    I'll take the docs (none / 0) (#104)
    by gyrfalcon on Mon Nov 02, 2009 at 11:53:08 PM EST
    Obviously, not the insurance co.  If we can't trust most of the docs to decide in our best interests rather than monetary rewards, we should just give the he** up.

    And FYI, in many HMO situations, the docs aren't rewarded, they're penalized for ordering more tests than the bureaucrats have decided they should order for their patient load.  Doctor friend of mine who ended up quitting the profession altogether worked for a major HMO in Mass. that put a quota on tests, and every month, any overage was taken out of her pay.

    But my point is still that the average patient is in absolutely no position to decide what's necessary and what isn't.  You and your mom made an informed guess, which might or might not have been correct.  If it had been totally up to you to decide and you had been wrong, you might very well have killed her.

    And let's stop for a minute and think about how many people in this country are competent to make the (correct, as it turned out) evaluation you made.


    My grandson has had H1N1 (none / 0) (#84)
    by jimakaPPJ on Mon Nov 02, 2009 at 06:00:23 PM EST
    He was given antibiotics, according to the Doctor, to fight any secondary bacterial infection that might develop.

    Fish in a Barrel (5.00 / 0) (#59)
    by DancingOpossum on Mon Nov 02, 2009 at 02:06:34 PM EST
    Name me some breakthroughs that have came out of their system?

    OK, from Canada (those evil socialists), we get the discovery of insulin to treat diabetes, and from England (with even more socialistical health care) we get the CT scan:

    Sir Godfrey Newbold Hounsfield CBE, FRS, (August 28, 1919 - August 12, 2004) was an English electrical engineer who shared the 1979 Nobel Prize for Physiology or Medicine with Allan McLeod Cormack for his part in developing the diagnostic technique of X-ray computed tomography (CT).

    His partner Cormack, by the way, was a naturalized American originally from South Africa--but his work on the CT scan was done in South Africa, not in the U.S.

    Speaking of Canada and Type 1 diabetes, we in the U.S. are still toying around with the notion of an artificial pancreas--the latest, most promising breakthrough in diabetes research--while lucky Canadians get now get the experimental device, for free, from their oh-so-scary and backwards national health care system (http://www.citytv.com/toronto/citynews/life/health/article/3777--could-an-artificial-pancreas-cure-d iabetes).

    Canada too "socialist" for ya? How about Brazil?

    Among other things, a doctor there has pioneered a treatment for Type 1 diabetes. Oh but:

    Burt, who wrote the study protocol, said the research was done in Brazil because U.S. doctors were not interested in the approach....

    Burt and other diabetes experts called the results an important step forward.

    "It's the threshold of a very promising time for the field," said Dr. Jay Skyler of the Diabetes Research Institute at the University of Miami.


    Brazil's insistence on controlling costs for poor people--those dirty anti-innovation commies--has led to some other interesting results:

    PROVIDENCE, R.I. [Brown University] Brazil's nearly two-decade effort to treat people living with HIV and AIDS shows that developing countries can successfully combat the epidemic. Inexpensive generic medicines are a large part of the solution, say researchers from Brown University and the Harvard School of Public Health.

    Brazil did this, researchers said, largely by pursuing controversial policies that prompted pharmaceutical companies with exclusive drugs to lower their prices dramatically and generic companies to develop lower-cost alternatives for use in emerging markets.

    http://www.breakthroughdigest.com/aids/brazil-proves-developing-countries-can-use-generic-medicines- to-fight-hivaids-epidemic/

    My own research tends to be in the area of Type 1 diabetes (which afflicts Mr. DO), but pick your ailment. Those other countries have shown they can be just as creative as the U.S. when it comes to medical innovations, and in some cases more so.

    Oh and... (5.00 / 1) (#64)
    by DancingOpossum on Mon Nov 02, 2009 at 02:12:37 PM EST
    Much of the push for the artificial pancreas here in the U.S. is being done through the auspices of the Juvenile Diabetes Research Foundation, at the University of Virginia. If you go to that project's web site, you'll see this heartfelt plea on the first page, regarding continuous glucose monitors:

    JDRF is working with health plans to provide coverage for CGMs, but we need your help!  Plans need to hear directly from their beneficiaries about this revolutionary technology.  The first step is to tell us your health insurance provider.

    Yeah. Good luck with that.

    Of course, if you're lucky enough to live in a country with national health care, no worries.

    I have never heard of anyone going outside the (none / 0) (#85)
    by jimakaPPJ on Mon Nov 02, 2009 at 06:04:24 PM EST
    country for medical treatment that was not on the fringe... Peach pits for cancer, etc. I would guess that someone with lots of money who is desperate for a transplant might try China. I understand they have a huge black market in kidneys, etc.

    Umm, people are leaving the country for (5.00 / 1) (#87)
    by nycstray on Mon Nov 02, 2009 at 06:34:07 PM EST
    health care. Routine health care at that. Our neighbor to the south seems to be treating Americans and other countries are also.

    So on one side it is cheaper (none / 0) (#97)
    by jimakaPPJ on Mon Nov 02, 2009 at 08:34:47 PM EST
    and the other side it is language.

    Yes, that convinces me that people are leaving for BETTER care, which was the assumed discussion point.


    It's called medical tourism, (5.00 / 1) (#101)
    by caseyOR on Mon Nov 02, 2009 at 10:10:15 PM EST
    and it is big business in India, Malaysia, Costa Rica and many points in between. Some U.S. insurance companies are pushing their policyholders to fly off to a foreign land because the cost is so much less than here.

    A person in need of a hip replacement, for example,  could fly to India (roundtrip), have the procedure and check into a luxury resort near the hospital for several weeks of recovery, and it would still be cheaper than paying for the hip replacement here in the good old USA.

    People are leaving the U.S. for heart valve replacements (Charlie Rose, who probably has great insurance had his replacement done in Paris), joint replacements, eye surgeries, just about anything that is not emergency surgery.

    Read this link.


    Its more than just CA folks (none / 0) (#102)
    by nycstray on Mon Nov 02, 2009 at 10:40:05 PM EST
    traveling south of the border now. TX, NM, AZ etc.

    I should brush up on my Spanish since I'll be residing in CA in the future . . .


    Another line that could've been bolded (none / 0) (#19)
    by vicndabx on Mon Nov 02, 2009 at 11:48:42 AM EST
    The health-care reform debate has done a good job avoiding the subject of prices.  The argument over the Medicare-attached public plan was, in a way that most people didn't understand, an argument about prices

    I.e. a public plan is not the only way to cut costs and insure a whole bunch more people less expensively.  Controlling what is paid cuts costs for EVERYBODY.

    Simpler solution would've been to setup a gov't agency that all payers would turn to for guidance on what is considered effective treatment and rate of reimbursement for said services.  IMHO.  This happens in a kind of round about way today already - at least as it relates to WHAT is covered.  

    Your post about Medicaid the other day re: it's success....is in large part due to the pittance Medicaid, i.e. we, pay to providers.  Let's be honest, currently, w/regard to taxpayer funded insurance, there is no negotiation, it's take it or leave it.  Hence why there are more doctors that stomach Medicare than there are that stomach Medicaid.  Rate of reimbursement is higher.  That "for whatever reason you may want to attribute" works because providers know they can make up their shortfalls either thru increasing patient volume, or higher reimbursement from non-gov't insurers.  Take that away however.....How many doctors, hospitals, labs, therapists, etc. would be willing to take a pay cut for the team?

    How many anypone who has (5.00 / 1) (#29)
    by jimakaPPJ on Mon Nov 02, 2009 at 12:03:26 PM EST
    extensive training in a field with a huge demand would be willing to take a pay cut?

    Shall we also regulate attorney fees? Baseball player salaries??


    So doctors are only doctors to be (5.00 / 2) (#31)
    by Militarytracy on Mon Nov 02, 2009 at 12:07:36 PM EST
    rich?  I think that doctors will make what the social structure will allow.  Just like soldiers do Jim.

    If there (none / 0) (#38)
    by TeresaInSnow2 on Mon Nov 02, 2009 at 01:02:01 PM EST
    was no pay incentive for the medical profession, I suspect many brilliant doctors would partake in other professions....

    Four yours of undergrad school requiring high GPA plus volunteership. Overloads of coursework for 2 years, residencies requiring excessive overtime.  Huge student loans  Then the pay is relatively low?

    Would common sensical people choose that route if there was no pay incentive in the end?


    So they would be poor? (none / 0) (#53)
    by Militarytracy on Mon Nov 02, 2009 at 01:52:08 PM EST
    You're (none / 0) (#66)
    by TeresaInSnow2 on Mon Nov 02, 2009 at 02:22:48 PM EST
    using quite an extreme to make your point.  No, they wouldn't be poor.  Neither is a soldier.

    If they were average middle class, or even upper middle class, I don't think that would be incentive to choose the medical profession, over, say, nursing.

    If the loans were high, if the lost income was large (from 8 years of school and 3 years of residency), do you really think it would be worth it to many if the living standard were merely, "not poor"?

    You may, but I don't.


    So the other countries with (none / 0) (#75)
    by Militarytracy on Mon Nov 02, 2009 at 04:18:45 PM EST
    cost controls....they have a problem getting people to be doctors?

    Do you ever wonder where and why we have (none / 0) (#82)
    by jimakaPPJ on Mon Nov 02, 2009 at 05:54:27 PM EST
    so many doctors from other countries practicing here?

    Of all of the doctors my son has seen, (none / 0) (#106)
    by Militarytracy on Tue Nov 03, 2009 at 07:09:48 AM EST
    every single one was an American born white male.  The one who wasn't was an American born white female.  I have not had one doctor who was not U.S. born and educated.  My grandfather had a doctor who had originally been born in India....you mean that guy Jim?  And Europe doesn't have any doctors practicing who were born in other countries do they?  With as racist as this country works so hard to be, why would America be an immigrating doctor's first pick?

    Most doctors are not rich (none / 0) (#43)
    by jimakaPPJ on Mon Nov 02, 2009 at 01:15:57 PM EST
    And most work a grinding 50 + hours week.

    Didn't say they'd be willing. (none / 0) (#34)
    by vicndabx on Mon Nov 02, 2009 at 12:52:05 PM EST
    Not sure if I think they should.  It is a slippery slope.  I just want us to be honest and rely on the facts as opposed to hyperbole borne out of personal anecdotal experiences, tragic as they may be.  I'm hoping people finally look at all the cost drivers, particularly those that have the greatest impact.  Personally, I think we may just to have to suck it up and pay more than everyone else.  When you get right down to it, unless you have a chronic illness bought on thru no fault of your own, we are our own worst enemy w/regard to our health and the care we require.

    We don't need another government agency, (5.00 / 1) (#58)
    by Anne on Mon Nov 02, 2009 at 02:04:05 PM EST
    much less one that would provide "guidance on what is considered effective treatment and rate of reimbursement for said services;" and it for sure would not be the "simpler" solution.

    In countries where there is single-payer, or some hybrid system with significant regulation, the population seems to be able to get good, high-quality health care, with better overall outcomes, for less than half of what is being spent in this country.

    Why is that?  Do you think part of it could be that in those countries, doctors and hospitals and imaging centers and labs and the panoply of providers do not have to spend 30 cents of every dollar on overhead?  Do you not think that cost of the actual service - an exam, a blood test, a surgery - has to be artificially inflated in order to accommodate the high administrative overhead, and the low reimbursement rates, so that the provider can have something to put in his or her pocket at the end of the day?  I mean, there's a reason why an aspirin in a hospital costs $10.00, when for that amount, you can buy a bottle of 500 of them in the local grocery store.  

    Negotiating payment rates is not the answer if that's all that's going to happen; as long as there are those heavy administrative costs, the only thing that is likely to happen in there will be a shortchanging on the CARE end, or an increase in cost-sharing - co-pays and deductibles - in order to keep the status quo on what the provider gets to keep at the end of the day.  Both of those things will mean fewer people getting the care they need, which is antithetical to what I believed reforming the system was supposed to improve.

    Silly me.


    Or maybe they, like everyone else, just like money (none / 0) (#67)
    by vicndabx on Mon Nov 02, 2009 at 02:50:41 PM EST
    The Dartmouth researchers say that high-cost hospitals -- spurred by "volume-based payment systems" -- are oriented toward providing more tests, like CT scans and M.R.I.'s; more surgeries; and more admissions, and that evidence suggests that patient outcomes are better in low-spending regions.