Health Care Summit discussion

[Sheherezade]

Anyone else listen/watch yesterday?

I was impressed. I thought both sides did a good job of actually talking about the issue. Solutions differ (of course) but for once, I thought the politicians were doing a fairly decent job of being serious.

That said, I thought the immediate media coverage was shameful, inaccurate and clearly written before the summit took place. The coverage this morning has been more thoughtful and accurate.

My thoughts: I'm happy that the medical malpractice issue seems to have jumped out as a piece of common ground that both sides can get behind. That might actually happen. Yeah for all of us on this site. The differences in approach to solving a problem that both sides agree exist seem to be

1) Do this in small bits or as a comprehensive bill?

2) Increase competition via decreased regulation for across state line sales of insurance OR creation of a health insurance exchange that has federally based regulation (instead of state) but includes products from all states?

3) Attempt to increase coverage by 3 million or 30 million?

4) Use Catastrophic/HSA plans vs. Preventative-paid/traditional insurance products?

More, I'm sure. Anyone want to discuss? (Seriously? I'm not up for a BS partisan word/personality/culturewars fight on here - or in Congress.)

I did not have the opportunity to watch, so I can't comment on what was discussed. I'll look forward to reading through the discussion here.

I did want to chime in and say I absolutely LOVE that the thing was televised. I feel it's the closest we'll ever come to a feet-to-the-fire discussion. I hope progress is made.

[PrincessFiona]

I listened to it on streaming video on my laptop yesterday throughout the day. I heard bits and pieces and sometimes sat down to watch/listen.

I agree with you, Angie, that it was pretty impressive on both sides. I was also very impressed with how Obama managed it. He allowed input from both sides and was very willing to hear ideas that contradicted his own party's plan. I really liked his openness. I also agreed with him when he came out and pointed out that everyone at the summit was in a higher income bracket and could afford health savings accounts, etc better than those earning 40k/year or less.

As to your questions:

1. I think this is such a big issue that it would be better for us to go a step at a time, to be honest. I think that if we try and make a huge sweeping change at one time that we are more likely to make mistakes .... and as has been demonstrated over and over again by our government, once something is passed, it's hard to make changes! This would also allow us to examine individual issues in greater detail before making said changes.

2. Decreased regulation across states allowing companies to compete across state lines. Why? I just don't trust how our government works. If companies can't bring prices down, then the govt might step in as a next step...but I look at how our government is managing medicare/medicaid and wonder how medicine will change for doctors, mid-levels, nurses AND patients if the government steps in with plans that make payments at the levels of medicare/medicaid. Actually, medicaid is now paying better than medicare in many areas. Money isn't everything, but I think many of us here will agree that after an expensive education and years of training, some financial reward would be nice. I know our plumber didn't feel guilty about charging us $100 for a 10 minute fix on our dishwasher.

3. 3 million first. More later. Why? I know several people who have the option to have health care insurance through their employer but choose not to. They can afford it as well as we can when you consider their income and the cost of the plan...they just don't want to spend the extra money. My brother is a good example. The health insurance plan offered to him through his employer (my father) is $178/month for his payment and a little more for my dad. My dad had to force the issue. My brother earns roughly 28,000/year and currently lives rent free with my mom. He didn't want to pay $87/month because he is *healthy...why should I?* Also, I think that we need to look at how we hand out medicare/medicaid currently...ie who are the recipients. For example, we have a large Somali population here because they immigrate into the states to Minneapolis and then are shipped to St. Cloud. Nearly all of them are fully insured (better than our coverage, btw) and at least 1/2 of them are on disability for aches and pains. So, while the older American wal-mart greeter that works the evening shift at Wal-MArt is in a wheel--chair and has some obvious disabilites, the 25 year old Somali man who is in perfect health is allowed to be on disability for the rest of his life for lower back pain. Not. OK. NOT.

A rush to insure 30 million seems to only be realistic if a massive public option were formed....and who do they want to have pay for that? Take a guess. Roughly 50% of Americans don't pay taxes...sure, it might be withdrawn from their checks every month, but many people get big, fat refunds.

There is no country with a public option where even those on the lowest end of the income scale don't have to pay in for it.


4. I favor preventative care/traditional plans. Though I know that many say that preventative care and annual physicals aren't necessarily effective, my opinion is that establishing a working relationship with a primary care physician is beneficial because patients are more likely to go in if something doesn't feel right.... Again, this is all my personal opinion...but catastrophic plans might make consumers "better...because they won't go to the doc for every ache and pain" but it also might make them reluctant to go in and miss something important. If I had had catastrophic coverage only, I would be dead. I would never have gone in to see my primary care doc yet again over shortness of breath...and I probably wouldn't have established a relationship with her either...so she wouldn't have called to check up on me, found out I wasn't doing well and insisted on an appt. I think if someone is not feeling well that they should be able to go in and see the doctor and have some form of minimum coverage for that. Everything doesn't need to be paid for .... ie...not everyone who comes into the ER with abdominal pain needs a CT scan...but basic covereage IMO must be there.

[Sheherezade]

So here's my take on the issues I'd mentioned.

1) I could go either way on doing a comprehensive bill or doing this in bits. I know that the democratic argument is that piece meal hasn't worked so far and that the system just bends around any bits of legislation. That said, I think passing smaller easier to understand legislation would be more palatable to the public and the Congress. For example, why can't we pass a law against bumping people off insurance at any time based on their current health status? If you have insurance, contracts must be binding on both sides forever.....if it cost the company X dollars to insure you, you can pick up that cost if you are terminated but remain part of that pool. Insurance companies can not dump you once you develop a chronic condition -- they took the bet, they need to stand by it when it goes 'sour'. This is just a small bit, of course, but I think passing smaller pieces might work better in a climate of total government distrust. Of course.....I can understand the comprehensive package argument as well.

2) Here, I fall firmly on the side of the health care exchange. If there is no public option and this will work strictly through the private market, we need some federal regulation. I can easily see insurers flocking to a state that decides to do what Delaware and South Dakota did when they deregulated banking. Reduce regulations on insurance to nil and let anyone open shop. Cheap insurance that offers nothing would become the insurance version of predatory credit cards with 30% interest rates. We'd end up protecting the consumer retroactively after many horror stories. Insurance is too complicated to follow simple "Buyer Beware". We don't do that with drugs, why information products?

3) I (and DH) are both proponents of the full monty plan. We need to insure the healthy as well as the sick to truly bring down costs. The more brought in to the plan early, the better. Of course, we both favor the public option...or a system of government run health clinics to provide free care. Either way, covering a small portion of those overlooked by the current system will only postpone this problem again. I can't imagine leaving this one to my kids.....like my parents left it to my generation to actually deal with.

4) We have HSA and we like it. That said, it has covered about a third of our out of pocket medical expenses this year - and when you are in the top tax bracket, any tax free set-aside is a good deal. I'm not sure this will play as well with people that make less than 100 K a year. Also, I do believe the statistics and argument that those with catastrophic care only tend to come in with a blown kidney or foot amputation instead of being treated for diabetes earlier. They end up costing more and receive poor quality of life for the waiting. I'd like to see the HSA/Catastrophic option available in the health exchange (ie not ruled OUT by gov regulations) but have some controls for issues we know are treatable and lead to catastrophic events later.

My favorite line from yesterday's event: Health care is complex. That's why the bill is more than 1000 pages. Once we flesh out the Republican proposal to actual law, it would also reach 1000 pages. So true.

When you look at all the tangles in this system, I'm amazed it ONLY took 2000 pages. Hell, the ACGME resident work hour regulations come in at 50.

[Sheherezade]

Kris: cross posted.

On issue 2, it was my understanding that the plans within the health care exchange are private plans -- the government will just subsidize the cost to individuals and small businesses through some type of tax shifting so that the individuals and smaller pools of workers get the same benefit of being within a large group. They'd also use admission to the "market" as a way to regulate a floor for basic care. In the context of yesterday's discussion, it took the form of not allowing drive by deliveries and such. Apparently, a large part of the variation in costs between states results from different states allowing less care, etc. Horrid example: the rep from NY that stated that 16 states (or so) regard domestic violence as a pre-existing condition. So, as she stated, if you have the misfortune of being beaten in a relationship, you can pay for it for the rest of your life because apparently you are predisposed to getting hospitalized by the ones you love. That kid of stuff should be illegal....and I'd imagine a federal "base" level would help keep a state from being "insurance company friendly" and not very patient friendly. Maybe I misunderstood-- but I don't think the exchange would be publicly paid to the vendor (as in gov. negotiates rates as in Medicare). If so, I see your point about government monopoly.

[PrincessFiona]

Re: #2, Angie...I would agree that there would have to be rules in place. Healthcare *Exchange* I'm not so sure about. If the Federal Govt said "Have at it...insurance companies may cross state lines and have free market competition, BUT may not deny coverage for pre-existing conditions, can not cancel insurance when treatments become too costly and can not have a maximum cap on what they will pay, and can not raise rates beyond a standard inflation increase" then I am ok with that.

Re: #3...Define public option for me. If you are talking about a plan like the UK, I will invite you to email my dear friend Fionnuala about her experiences getting badly needed pediatric urology and now nephrology care for her daughter as well as speech therapy for her son. The quagmire of public option hell resulted in a need for surgery for her daughter due to inadequate care for years despite how hard she fought for it, decreased kidney functioning and ... after 2 years of fighting for speech therapy for her son she still does not have it. He is unable to be understood in his preschool class...even by his teachers. Obviously, this has now caused huge social problems as well as acting out behavior.

We have people come from Canada across the boarder to MN all the time for health care. Those who CAN pay the fully monty cost come here for the *best* care. Here's the problem. With the plan our government has, we will not be able to sustain the level of care that we can offer people. The money will not be there. So...after 10 years of having a public option that slowly moves companies and people to dump private insurance and leads to nationalized health care, you will see clinics and hospitals close because they can't afford to stay afloat. Without making med school free, you will not see the best and brightest jump into medicine for their 60-90k/year paycheck... Hospitals won't be able to pay nurses better salaries, will hire fewer nurses and will continue to look for cheaper staff.

How do I know? I been a consumer and have worked in systems with govt. run health care. In Germany, for example, there is a single charge nurse in the evening to cover an entire floor. I use the term nurse loosely, because nurses there are not like nurses here. They can't start IV's, etc..that all falls to the doctors. Nursing is not a skilled profession and it pays poorly. Think of an entire Gyn Onc floor being staffed at night by one or two Medical Assistants. This is part of the reason Thomas' dad died. Also, it is the reason that I laid in labor with Andrew for over 24 hours after premature rupture of my membranes before finally being seen by a doctor and having to have an immediate section. It's a good thing we had a good outcome.

This goes back to question #1 then which is piece it together or make sweeping changes. Piece it together...go slowly...research other countries beyond scare tactics or cheerleading campaigns...and be honest with the american people about where money might be cut (86 year old grandma with alzheimers will NOT get hip replacement surgeyr...won't happen) and work to get the best possible coverage while making it possible for as many people as possible to gain access to good care. AND...EVERYONE pays...just like social security...no opt outs for low income or middle class or any of that. If you have to pay for it in Canada, the UK and Germany, you pay for it in America. Let's see how fast the democratic underground implodes if Obama suggests that.

4. We also have HSA. I am not that crazy about it. LOL Our annual out of pocket expenses before coverage are now ~ 1750/person with a family maximum of ~7000. That is a lot of money no matter what. Do we earn more than some...yes...but we also pay not just more in taxes, but a higher percentage in tax dollars and do not receive any of the benefits for which much of that money is earmarked. I think I've just reached my pain limit when it comes to hemorrhaging money.



Kris

[Sheherezade]

Imagine this - but it won't happen never, ever ever. Too much economic impact, ie job losses. What if we had only one insurance company (government) and there were no coders, no billing people, no what have you to pay. If there was not a need for a hospital to buy an underused multimillion dollar Davinci robot for surgery because all the other area hospitals own one and they need it to be competitive, would that reduce costs? If they weren't all throwing up a new building in various parts of town to gain market share, would that reduce costs? What if they didn't have advertising budgets and electronic billboards all over town?

I wonder if that would also reduce some of the costs in the system. I can't help but notice how much the business costs of medicine have grown since I was a teen working in my father's medical office. How much of a hospital's budget goes to healthcare (physicians, drugs, beds, nursing, etc) and how much goes to accessory staff (managers, coders, admissions form processors, computer systems for billing/insurance management), advertising, building funds, etc? How has that percentage changed over the years? I've seen anecdotal evidence that it is approaching one manager to one doctor. Back in the day, my dad's office of six pediatricians had a single biller/manager, several nurses and a few assistants. It is my personal bias that a large part of the increase in health care costs is a result of the great growth in the health care job sector....and that these jobs/benefits are not directly providing care.

"Public option" for us really means that we have no middle man. No private company. Take capitalism out of health care and see how that reduces costs. I'd like to see the theoretical costs and benefits. Like I said, that won't ever happen, because it goes against America's blind faith in Adam Smith's invisible hand and ultimate altruism of the market. I don't buy that for science or medicine...and frankly, Wealth of Nations doesn't say it either.

[McPants]

Re: #3...Define public option for me. If you are talking about a plan like the UK, I will invite you to email my dear friend Fionnuala about her experiences getting badly needed pediatric urology and now nephrology care for her daughter as well as speech therapy for her son. The quagmire of public option hell resulted in a need for surgery for her daughter due to inadequate care for years despite how hard she fought for it, decreased kidney functioning and ... after 2 years of fighting for speech therapy for her son she still does not have it. He is unable to be understood in his preschool class...even by his teachers. Obviously, this has now caused huge social problems as well as acting out behavior.

Dismissing an entire system based on one individual person's experiences is not particularly scientific. Brits are in general very proud of their national healthcare system and this is reflected in, to my knowledge, every single person I know over here. If you want, I'll again post statistics that prove this, or would e-mail addresses of satisfied NHS customers be preferable perhaps?

I do not for a second believe that the United States could adopt a national healthcare system such as the UK one, however. Your culture is in my opinion completely incompatible with such public solutions.

[PrincessFiona]

Well, I agree with you about a lot of what you bring up, Angie. But...for the sake of the debate forum (you know I adore you, right!) let's break it down.

1. There are no health insurance companies. OK...the govt. pays upfront for services rendered. I'll jump on board for a minute.
2. There are no billers or coders. Ok...how does the govt. know what to pay for? Do we trust doctors to bill the government directly? Maybe. Do we differentiate between specialty and generalist care anymore in regards to fees? How do we set up a fee schedule? Do we just have the govt. pay a general salary to each doctor and mandate that they see x number of patients/year? Who gets to decide how many patients? Do we not mandate they see x number of patients for x dollars? What motivation will they have to come in at 2am or stay and go the extra mile? Also, do we forgive all medical school debt?
3. Buying an underused Davinci robot because everyone has one? I agree with you that it would cut costs. At the same time, I saw in Northern Ireland how it was to have one MRI/Pet Scanner for alll of Northern Ireland. The waiting list was crazy and even though they tried to prioritize when they could, it meant that people sometimes waited so long that it was too late to help them. Maybe we accept that. Also, if we remove the desire to be as good as....or better...than others...what do we lose in inovation that might not be able to be written out in dollars and cents but could impact quality of life or mortality? I don't know the answers...I'm just wondering out loud.

I agree with you about the costs rising and what I'm going to say will sound terrible. Too many docs are spoiled. Here, we have 1:1 nursing care..that means one nurse per doctor in the clinic. That could be easily cut. When I go up to the clinic to see, many of the nurses are just standing around chatting. Our hospital has hired hospitalists who earn >200k/year and work one week on and one week off so that the internists don't have to come in and admit patients, etc. This is definitely a quality of practice/life issue, BUT...then perhaps they need to work more than 9-4 and want the same pay and benefits? Perhaps the income vs work hours is a little blown out of proportion for the hospitalists?

I think that whatever health care is passed, btw, must mandate coverage....nothing can work without it. I'm just not a fan of our government and their mismanaging of our money.

And btw....medicare and medicaid have not reduced health care costs at all. Some estimates put the cost of medicare/medicaid as much as 25%higher than private plans/dollar spent since 1970.

So here is a question I might pose. Along with regulatory changes, mandates and health reform, what else can we change to lower costs?

How about we look at ourselves?! Patients come to the doc demanding MRI's for back pain, antibiotics for ear infections...we all know this. Often the consequence of a "no" even when it is preceded by and followed up with lengthy explanations can mean that a patient switches providers until they get what they want. Also, what about the idea of "if it can be done, it should be done". People need to understand the limitations of life span and costs of care. Yes, 86 year old grandma with end stage cancer can have dialysis....please see the business office to pay for that in full first, because it can't be the job of govt. sponsored care to extend the death of someone by a few days or weeks for the feelings of a family member. I know that sounds harsh, but our dollars can only be spent one time. Where do we spend them...the last 6 weeks of someone's life where medicare craps out more money than ever to extend the dying process?

There are so many hard questions and I get the feeling that many people who want govt. health care think they will have what we have now, they just won't have to pay for it because the rich dawkter's wives will. <cynicism>

Kris

[PrincessFiona]

Actually, McPants, I don't dismiss an entire system based on one person's experience. I don't dismiss it at all. I am being upfront about some of its weaknesses...and I also lived several years within the German and UK system and I can speak as a consumer of healthcare there (ie patient) as well as to what my husband experienced as a resident working in the hospitals (and my own experience working in one system).

What the UK can do quite well is primary care. Access to primary care is pretty good and as long as nothing goes wrong, you're good to go...the problems we experienced personally and that people (not just one person) that we know that live there still experience is when something more serious goes on.

I can also be honest about the weaknesses in the American system. A for-profit industy alienates people without the financial means to pay. That is morally reprehensible. At the same time, here, many people want what you have in the UK for FREE...they don't want to pay. They want people who have more than they do to pay and to limit their own responsibility. I think that is unfair and wrong.

I do believe very, very strongly that changes need to come in America. I believe that every American shoul have access to good primary and specialty care, but I'm not convinced yet that the only way to achieve that is through a public system based on my experiences living within those kinds of systems.

What do you see as some of the weaknesses in the UK medical system?

In America, I find that people without financial means can sometimes get inferior care, can't pay for their prescriptions (and the cost of prescription drugs as dictated by the pharma industry and supported by our govt. is OUTRAGEOUS. You can get the same drugs in the UK for pennies on the dollar!). I also find it absolutely appalling and unacceptable in America that people can have their health insurance dropped when they become ill or reach a maximum cap. Also, I know that in the UK, the process of becoming a doctor involves 6 years of education, not 8. I also know that the cost is minimal to the student and that residents are compensated much more generously for their work. In America, the avg. student loan debt is exceeding 150k now...and residents work 80+ hours a week with no union support and are not paid as well.

I think that you have heard maybe...what you want to hear...and not what I'm saying. Our system needs reform. I'm just questioning the reform.

So...no more drivebys on this one allowed. Pony UP! I think it's kind of insulting for someone to imply that there is something wrong with us or bad about the idea of debating the type of reform needed. Sweeping statements like

Your culture is in my opinion completely incompatible with such public solutions.

are intended to be offensive. I could never allow myself to make an equal/opposite statement in regards to the people of the UK for example...

Kris

[poky]

Also, if we remove the desire to be as good as....or better...than others...what do we lose in inovation that might not be able to be written out in dollars and cents but could impact quality of life or mortality?

Frankly, I'd be happy to give up some future innovation until we can provide *everyone* with the opportunity to take advantage of the innovations we *already have* that are too expensive for most of the people who need them. Spend the money catching everyone up, making sure every gets at least a basic level of coverage first, THEN encourage innovation. And how about innovating in areas that will make the most difference to the most people, rather than the ones that will bring in the highest profits? Yeah, I know that part's a pipe dream.

[PrincessFiona]

And how about innovating in areas that will make the most difference to the most people, rather than the ones that will bring in the highest profits? Yeah, I know that part's a pipe dream.

Totally, Totally agree. Seriously, do we NEED another viagra?

[Sheherezade]

I agree with you on many points. I should have said "less billers" not "no billers" although in the system my DH works in, he is paid a salary. He works the hours assigned to him in clinic and the OR time he has blocked or he can get. He turns away patients when they can't fit them in within a reasonable time frame - and they are referred to another doc that may be able to accommodate them. That limits his patient load (but not much!). The amount of work he does is tracked for the year and he has to hit a target....after that, he gets paid a bonus to make up for unpaid patient care. If you don't hit the target, your salary the next year is reduced....and eventually, you are let go. I'd imagine a similar salary based system could work with a single payer. Salaries could differ based on training levels. Or maybe not. I think it could be simplified.

It is EASY for me to see how the bills get so complex. There are so many major economies at play. Health providers, insurance, pharma, government (via Medicare and Medicaid) and medical products....it's a mess. That's what makes me lean towards a piece meal approach. Still, I wonder if doing it piece meal is not possible.

I've also heard good things about British health care, McPants. One of our friends and colleagues defected to Canada during the Bush years and he is happy with the OB/Gyn specialist situation there. Again, anecdotal evidence may not tell the story.

I think it is sad that I know SO many families now that have no health care for their kids. We get a lot of calls asking for advice and DH has ordered lots of X-Rays, etc. to help people avoid going to an ER and to have them evaluate if they need to get care (out of pocket) or not. Sadly, we have one friend that would return to their European country if they had a health issue -- because there they would receive care. Here, they are uninsured and call after every potential broken bone to their athletic son. It's just weird to think of people going to Europe to get better care. That does happen now. (Last pointless anectode: My step mom broke her wrist in Italy and she and my dad were blown away at how good the care was and how efficiently it was delivered. They have both been US doctors for 40 years - and believed that we had the best system in the world. Now, they are open to the idea that other countries may have things to teach us about delivery.)

[poky]

Actually, McPants, I don't dismiss an entire system based on one person's experience. I don't dismiss it at all. I am being upfront about some of its weaknesses...and I also lived several years within the German and UK system and I can speak as a consumer of healthcare there (ie patient) as well as to what my husband experienced as a resident working in the hospitals (and my own experience working in one system).

In all fairness, "if you're talking about a system like the UK, I invite you to email my friend.." *does* sound pretty dismissive of the whole system based on a single anecdote, on the face of it. I'm glad you elaborated. I don't think McPants overreacted based on what you wrote there, though.

And "people without financial means can sometimes get inferior care" here? Can sometimes? try "generally will" or "almost always do". Sure, they're generally treated the same in the ER, because they have to be treated the same... so those without financial means can use the ER, and that's great, but how do they deal with chronic issues, or minor issues before they become major ones? And it's not like the ER won't still bill you till you declare bankruptcy, they just won't refuse to treat you in the first place because you can't pay. How is ER-only care not inferior to the regular checkups and follow-up with specialists that those of us with insurance and/or a lot of money get? (sorry, can you tell this is a hot-button of mine?)

[McPants]

3. Buying an underused Davinci robot because everyone has one? I agree with you that it would cut costs. At the same time, I saw in Northern Ireland how it was to have one MRI/Pet Scanner for alll of Northern Ireland. The waiting list was crazy and even though they tried to prioritize when they could, it meant that people sometimes waited so long that it was too late to help them. Maybe we accept that. Also, if we remove the desire to be as good as....or better...than others...what do we lose in inovation that might not be able to be written out in dollars and cents but could impact quality of life or mortality? I don't know the answers...I'm just wondering out loud.

Currently there appear to be 4 static MRI scanners in Northern Ireland (the red-headed stepchild of the UK with regards to most services) and it is now common practice to refer patients to the mainland or even the Republic of Ireland if queues build up.
http://www.canceruk.net/imgservices/mri/ukmri.htm

I do not for a second regard the UK system as perfect, however I believe I've stated my opinions on it in previous thread on this topic. The reason for my original post was the lack of balance in the one you made above. Given that you rectified that, I see little need for further involvement in the thread on my part and will happily leave.
With regards to my views on the culture of the U.S., if you find my comment offensive, I apologize. I base my opinion on research on national cultures conducted by Geert Hofstede (his individualism/collectivism-spectrum would appear very relevant in this case).