Health Care Question for Rapunzel

[pmd8]

I practice Emergency Medicine, so I can't offer an opinion on the CMS scale.

As far as market-based care, if you look at the above statistics we spend about twice as much per capita as the other countries listed with little or no improvement in quality.

I know that my internist friends in private practice spend 50-60% of their gross on overhead. They need two employees to do the byzantine coding and billing. They spend an inordinate amount of time on documentation or on the phone with HMO's. The HMO's feel that 15 minutes is the most you should spend with a patient, including paperwork.

I see patients who have to change doctors every time their employer gets a new insurance plan. Yesterday five patients (out of 24) asked if I could be their primary care doctor.

As far as quality assurance, the hospitals tend to have more to do with it than the insurance companies, at least in my experience.

 

[rapunzel]

I practice Emergency Medicine, so I can't offer an opinion on the CMS scale.

I know that my internist friends in private practice spend 50-60% of their gross on overhead. They need two employees to do the byzantine coding and billing. They spend an inordinate amount of time on documentation or on the phone with HMO's. The HMO's feel that 15 minutes is the most you should spend with a patient, including paperwork.

I see patients who have to change doctors every time their employer gets a new insurance plan. Yesterday five patients (out of 24) asked if I could be their primary care doctor.

As far as quality assurance, the hospitals tend to have more to do with it than the insurance companies, at least in my experience.

There is no doubt massive reform is needed, and I could write for days about the waste and inefficiency and how that needs a complete overhaul. I just do not think migrating everyone to the FEP system will make anything better for anyone. Ask your internist friends (or their billing people) how they enjoy working with FEP v. the average HMO.

I just believe deeply in markets and consumer choice. I can't think of one example where a single provider has resulted in the best value or service.

It's like saying Mediacom's single cable provider service is the best way to provide value and quality to South Walton, when it's really all about access and graft.

 

[pmd8]

This is from an article in the Washington Monthly in March of 1999. I believe it's still pertinent.

Medicare has been able to beat the private sector at cost containment because Medicare has very low overhead costs (Medicare spends a mere 2 percent of its revenues on overhead versus at least 13 to 15 percent for private-sector insurers), and because Medicare reimburses doctors and hospitals at rates below those paid by private-sector insurers. Medicare's overhead is much lower than the private sector's because it does not pay for marketing, utilization review (jargon for unsolicited insurance company advice to doctors about how to take care of patients), obscene salaries, and myriad costs associated with influencing public policy. Moreover, Medicare does not have to make a profit for stockholders.

Yet it's also important to note the cost-control techniques Medicare does not use. Traditional Medicare does not use the techniques so beloved by the private sector that now threaten quality of care--restricting the freedom to choose one's doctor, overturning physician-patient decisions, and exposing doctors to financial incentives to deny care.

The real problem with Medicare is not that it is inefficient but that it relies so heavily on regressive taxes. Medicare's method of financing hospital services--payroll taxes on working people--is regressive and increasingly insufficient as the ratio of retirees to workers rises. The problem with Medicare's method of financing physician services is that a fourth of the financing comes from monthly premiums paid by Medicare enrollees. These premiums are even more regressive than the payroll tax. The upcoming Medicare debate should include a discussion about whether to abandon payroll taxes and premiums in favor of a progressive, general tax.

 

[Bobby J]

Thanks so much for taking the time Rapunzel. This is good info.

 

[pmd8]

I just believe deeply in markets and consumer choice. I can't think of one example where a single provider has resulted in the best value or service.

Well, the Netherlands and Germany come to mind. We spend twice as much per capita and they have excellent health care.

Please also refer back to the above article.

In my experience, the most common complaint about "choice" is that patients have to change doctors when they've found someone they like.

They usually don't have a choice if they have insurance through their employers.

 

[rapunzel]

Well, the Netherlands and Germany come to mind. We spend twice as much per capita and they have excellent health care.

Please also refer back to the above article.

In my experience, the most common complaint about "choice" is that patients have to change doctors when they've found someone they like.

Well, I worked with breast cancer patients from all over the world. I've seen how those systems work. I'm sure you've heard the statistic that 80% of health care dollars are spent by 20% of the people. Well, Germany, the Netherlands, and other countries with socialized medicine work great for the 80% of the people that are just seeking basic healthcare. It's when people are really sick that those systems begin to show cracks.

In countries with socialized healthcare, medical decisions are made with a cost/benefit analysis -- they aim to use their dollars (or Euros I should say) to do the greatest good for the greatest number. I can think of ten women off the top of my head who were patients from Europe, Canada, and Israel (plus one from California) that went on to develop metastatic disease. They had lung, bone, or spine tumors that were not likely to be cured by further treatment, and so they died. If they had been Americans (but not from California, Kansas, or Missouri) at least a couple of them would still be alive today.

Further, I believe our system has subsidized the rest of the world to a huge extent and far as medical innovation is concerned.

Your example of musical providers is a great example of one of the very broken parts of our current system. It's not a very good example of free markets, however. One of the fundamental flaws of our current system is the lack of consumer driven healthcare decisions. Your patients had no say in which healthplan they bought, it was decided for them by an employer group. The employer group looks only at price, not the quality of the network or access to providers. In a perfect world, I'd support HCSA and high-deductible indemnity insurance but I think that would require a revolution. I know a great deal of reform is needed, but I really don't think the government is going to be able to administer the entire healthcare system and do a good job.

I guess we'll just have to agree to disagree on this.

 

[pmd8]

The US does have a greater 5-year survival rate for breast cancer, but 30-day acute myocardial infarction case-fatality rates are below 7% in Denmark, Iceland, and Switzerland, compared with almost 15% in the United States. Incidence of major amputations among diabetic patients in Finland, Australia, and Canada is less than 10 per 10 000 compared with 56 per 10 000 in the United States. And Australia, Canada, England, and New Zealand all have a better 5-year kidney transplantation survival rate than the United States.

 

[rapunzel]

The US does have a greater 5-year survival rate for breast cancer, but 30-day acute myocardial infarction case-fatality rates are below 7% in Denmark, Iceland, and Switzerland, compared with almost 15% in the United States. Incidence of major amputations among diabetic patients in Finland, Australia, and Canada is less than 10 per 10 000 compared with 56 per 10 000 in the United States. And Australia, Canada, England, and New Zealand all have a better 5-year kidney transplantation survival rate than the United States.

Don't you think that has much to do with the difference in patient population and lifestyles in those populations? Further, do you not believe US rates would be greatly improved if more people had access to healthcare, regardless of whether it was single payor or free market in nature?

I'm just firmly convinced that the healthcare delivered by our system to privately insured Americans is the best in the world, and we should try to find ways to expand access to that care by taking resources that are going to excessive profits for corporate hospitals and pharmaceutical companies or compliance with outdated accreditation and legislation and re-channeling those resources into expanded coverage.

 

[pmd8]

No doubt our rates would be improved by universal health care and healthier lifestyles.

Very few hospitals make any profit, especially those with a high percentage of indigent patients.

In 2005 United Health Care's CEO William McGuire made $124.8 million, Aetna's CEO $22.2 million, Wellpoint's CEO $25 million, and Cigna's CEO $13.3 million.

Add to that what they pay lobbyists.

 

[pmd8]

I was just thinking, if we encouraged smoking, heavy drinking and unprotected sex, we could reduce average life expectancy and save Social Security!