How would you go about fixing the healthcare system?

[Homoochan]

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I'm just putting up a poll to see what people are thinking..

 

[NightSwim]

I liked this article about a potential "all-payer system": http://content.nejm.org/cgi/content/full/NEJMp0907487
Essentially, the private health care insurance companies are no longer profit driven, but rather, have a primary motive of keeping costs low and fair.

 

[ChiDO]

Other: tort reform

 

[LiveUninhibited]

Two-tier:

Delivery remains mostly private. Budget-dependent basic and catastrophic care funded by the government, and controlled by regional panels of experts (would obviously include MD/MPH and specialist physician representatives, but not 100% doctor-controlled). Supplemental allowed, ideally non-profit. Government funds would come from income taxes (progressive), and excise taxes on unhealthy foods (regressive) for a roughly proportional or slightly progressive system for the first tier. The second tier picks up the slack that will occur when the government doesn't approve enough money, as has happened for the VHA and most single payer systems.

Special courts run by panels of experts, mostly doctors without a direct stake in the case at hand, should manage no-fault medical injury arbitration.

 

[LiveUninhibited]

I liked this article about a potential "all-payer system": http://content.nejm.org/cgi/content/full/NEJMp0907487
Essentially, the private health care insurance companies are no longer profit driven, but rather, have a primary motive of keeping costs low and fair.

Yeah all payer regulation would certainly be helpful, though a less attractive phrase to describe it would be price controls, and Americans would be uneasy about that (not that they would be any less uneasy about my ideas).

 

[cardinal2010]

Yeah all payer regulation would certainly be helpful, though a less attractive phrase to describe it would be price controls, and Americans would be uneasy about that (not that they would be any less uneasy about my ideas).

All payer sounds like an interesting idea, but doesn't seem like it would lower costs that much to me. My guess is that insurance reimbursements would go down while medicare reimbursements would go up, meeting somewhere in the middle. The ability to control costs using an all-payer system, however, is limited, as reimbursement needs to be dynamic and reflective of costs of treatment, as shown by current issues where medicare reimbursements are often below cost for the physician.

Savings via lowered reimbursements would only be sustainable if costs of treatment were decreased as well (Perhaps via tort reform or decreased medical education costs), allowing physicians to maintain reasonable margins. An all-payer system also does little to nothing to control the backwards incentives present in our fee-for service system, where physicians benefit from individuals being sicker. So where we would end up is paying less per procedure, but perhaps having an even larger volume of procedures done with more of them being unnecesarry (In the short run, studies show that the income effect of decreased reimbursement (performing more procedures to maintain income levels) often outweighs the substitution effect (switching to another specialty or performing other procedures due to lower reimbursement).

In short, I believe that reimbursement caps are not the way to solve the problem. Rather, a change in incentives is needed (fee per patient/illness rather than fee for service, so one benefits by keeping the patient healthier), combined with mechanisms to overhead costs of medical practice (tort reform, pooled malpractice insurance, etc.).

 

[Homoochan]

I don't know why people don't like single-payer system that much..

I've been in Canada for 7 - 8 years and have yet encoutered a single problem. Rather, I had knee surgery, hospitalized, took CT & MRI, got like 10000 morphine shots, had pain medications, ate hospital food, etc etc etc. And the cost = $0.

 

[LiveUninhibited]

I don't know why people don't like single-payer system that much..

I've been in Canada for 7 - 8 years and have yet encoutered a single problem. Rather, I had knee surgery, hospitalized, took CT & MRI, got like 10000 morphine shots, had pain medications, ate hospital food, etc etc etc. And the cost = $0.

Single payer systems are probably the most efficient in terms of administrative overhead, which may seem paradoxical to Americans. This is the case because single payer systems don't have to spend a lot of money figuring out how much to charge people in premiums, whether they have a legal basis to deny people (lawyers = $$$), profit, advertising, etc. On the provider side it also reduces efficiency because of the plethora of disparate policies one must deal with. But single payer is vulnerable to shortfalls induced by the government not spending enough on healthcare. I believe America is especially vulnerable to this even if we could pass a single-payer system due to Republicans when they come back into power. That's why I suggested two-tier.

Here's an interesting, though not unbiased, documentary:

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

 

[Omni]

no tort reform?
are you a lawyer?

 

[armybound]

Any plan that doesn't start with cutting excesses is poorly thought-out.

 

[BerlinDude]

uhh...those poll options aren't mutually exclusive.

 

[oaklandguy]

Cash for Clunkers on Health insurance, give everyone up to $4,500 to switch to different healthcare (insurance) providers as long as their old health-care plan was less efficient.

 

[motorola]

reduce costs. big time..............

 

[Steeler7588]

Work to get rid of employer-based coverage.

 

[Contrarian]

Cash for Clunkers on Health insurance, give everyone up to $4,500 to switch to different healthcare (insurance) providers as long as their old health-care plan was less efficient.

might be a somewhat silly question, but how do you determine efficiency of a health care plan?

 

[armybound]

might be a somewhat silly question, but how do you determine efficiency of a health care plan?

I think it was a joke.

 

[Contrarian]

haha that's embarrassing.

 

[LiveUninhibited]

no tort reform?
are you a lawyer?

I addressed tort briefly at the bottom of post 4, if that was directed at me. My suggestion would be much worse for lawyers than caps on contingency fees or pain and suffering.

 

[fsjune2009]

preventative health care seems like the best way to go, but what about the costs of things such as colonoscopies and mamograms that do catch cancer early on, but the majority of the people they screen are fine, thus adding to the cost of health care?

 

[Substance P]

uhh...those poll options aren't mutually exclusive.

You can click multiple options. 😉



I would say finding some type of global catastrophic coverage and then having patients pay their docs out of pocket for individual visits. This could be set up in a number of ways, but essentially it would utilize a capitalism model and force cost reductions through competition.

MRI's, CT's, Labs, etc. are all overpriced because there is no consumer shopping them for the best deals. If there were, they would be significantly less expensive.

 

[Substance P]

preventative health care seems like the best way to go, but what about the costs of things such as colonoscopies and mamograms that do catch cancer early on, but the majority of the people they screen are fine, thus adding to the cost of health care?

It is a fact that preventative care is more expensive, BUT it seems like the juice is worth the squeeze. If you are saving thousands of lives by these screenings it seems worth the additional expenditure to me. Now the question is really, how many lives are being saved and which procedures are worthwhile and which are not. That's the more difficult question.

 

[GTV]

-Get everyone insured somehow (possibly make everyone buy insurance, single tier probably not the best option in America, IMO)
-Open state borders and let insurance companies compete to drive down prices
-Online medical records (reduce inefficiency)
-Change the physician payment system for Medicare
-Encourage healthy lifestyles via insurance incentives and/or taxes on junk foods
-Regulation of insurance companies to prevent them from dropping sick patients, not accepting b/c of preexisting conditions, etc
-And for the love of all that's holy, TORT REFORM

 

[fsjune2009]

as far as tort reform goes, obama doesnt seem to touch it because he thinks people who are truly screwed over deserve to get as much as they can in compensation. There is also the idea that if doctors aren't as worried about getting sued for millions, they wont be as careful and diligent in their work...?

 

[Contrarian]

as far as tort reform goes, obama doesnt seem to touch it because he thinks people who are truly screwed over deserve to get as much as they can in compensation. There is also the idea that if doctors aren't as worried about getting sued for millions, they wont be as careful and diligent in their work...?

those don't seem like very good arguments. the notion that if I don't have to worry about getting sued, I'd be less concerned about killing a patient represents a pretty cynical way of looking at things.

I think it has more to do with the fact that trial lawyers make up a sizable voting block of the democratic party.

 

[ohsmash]

as far as tort reform goes, obama doesnt seem to touch it because he thinks people who are truly screwed over deserve to get as much as they can in compensation. There is also the idea that if doctors aren't as worried about getting sued for millions, they wont be as careful and diligent in their work...?

Actually, tort reform was part of his health care reform proposal during the Presidential campaign. He backed off that, mainly because lawyers are big contributors to Dems. But it looks like tort reform will be back on the table as a concession to Republicans.

 

[Vihsadas]

I don't know why people don't like single-payer system that much..

I've been in Canada for 7 - 8 years and have yet encoutered a single problem. Rather, I had knee surgery, hospitalized, took CT & MRI, got like 10000 morphine shots, had pain medications, ate hospital food, etc etc etc. And the cost = $0.

Single payer systems are probably the most efficient in terms of administrative overhead, which may seem paradoxical to Americans. This is the case because single payer systems don't have to spend a lot of money figuring out how much to charge people in premiums, whether they have a legal basis to deny people (lawyers = $$$), profit, advertising, etc. On the provider side it also reduces efficiency because of the plethora of disparate policies one must deal with. But single payer is vulnerable to shortfalls induced by the government not spending enough on healthcare. I believe America is especially vulnerable to this even if we could pass a single-payer system due to Republicans when they come back into power. That's why I suggested two-tier.

Here's an interesting, though not unbiased, documentary:

http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

Single-payer systems definitely have their drawbacks, but when you compare them to the state of healthcare costs and spending in the US they start to look pretty good.

Another important point: Although everyone uses Canada as an example of a single-payer system, this is not the case. Canada is a two-tier system that leans heavily toward the government side. Ontario, BC, Alberta and QC all have private healthcare options. (See the recent legal case Chaoulli vs. Zeliotis)

 

[LiveUninhibited]

It is a fact that preventative care is more expensive, BUT it seems like the juice is worth the squeeze. If you are saving thousands of lives by these screenings it seems worth the additional expenditure to me. Now the question is really, how many lives are being saved and which procedures are worthwhile and which are not. That's the more difficult question.

That's not a fact in general. Some forms of prevention save money directly and some cost money. Mammograms do, IIRC, cost more money on the aggregate than later detection of cancer. However, I don't think that most of those measurements take lost productivity into account. If you have one that does, I'd like to see it. Some things could increase per capita spending while decreasing %GDP spending due to decreased morbidity and increased productivity.

You can click multiple options. 😉



I would say finding some type of global catastrophic coverage and then having patients pay their docs out of pocket for individual visits. This could be set up in a number of ways, but essentially it would utilize a capitalism model and force cost reductions through competition.

MRI's, CT's, Labs, etc. are all overpriced because there is no consumer shopping them for the best deals. If there were, they would be significantly less expensive.

With out of pocket, one would get decreased prices at the cost of underutilization, particularly of primary prevention where something is asymptomatic or only mildly irritating. Though I guess that's barely a disadvantage now, as we don't have enough primary care doctors anyway.

If anything, though, MRIs are overpriced because of defensive medicine and provider-driven demand. They're especially cheap in Japan because of price controls.

 

[Parts Unknown]

Actually, tort reform was part of his health care reform proposal during the Presidential campaign. He backed off that, mainly because lawyers are big contributors to Dems. But it looks like tort reform will be back on the table as a concession to Republicans.

Here were his exact words from the speech he gave to the AMA back in June:

Now, I recognize that it will be hard to make some of these changes if doctors feel like they are constantly looking over their shoulder for fear of lawsuits. Some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue. And while I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed, I do think we need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine, and encourage broader use of evidence-based guidelines. That’s how we can scale back the excessive defensive medicine reinforcing our current system of more treatment rather than better care.

As both a physician and someone who has experienced malpractice from the patient/family member's viewpoint, I think it's possible to design a fair and reasonable system both with and without caps on non-economic damages. In that regard I can't fault him.

I would agree that tort reform has a number of positive benefits, including reduced malpractice insurance rates, lower litigation expenses, and general attractiveness to physician practice. However, much of the costs savings that advocates regularly point to flow from a leap in logic rather than any solid data. The simple fact is that nobody knows how much defensive medicine is actually practiced, or if doctors would significantly change their behavior in a less litigious environment. Perhaps tort reform is necessary but simply not sufficient.

Aight, lunch over.

 

[fsjune2009]

what exactly are the "health care cooperatives" that Baccus is talking about in his proposal?
oh and i think that mandating coverage is definately a start to avoid high prices for treatment to cover the costs hospitals pay for the uninsured

 

[Lokhtar]

Single Payor

 

[Long Dong]

http://www.washingtonpost.com/wp-dyn...091902575.html

"'Look at what the Mayo Clinic is able to do. It's got the best quality and the lowest cost of just about any system in the country,' Obama said ....

Mayo and a dozen other institutions fired off a letter that ... opposed the "public option" in the House Democrats' bill."

http://www.npr.org/templates/story/s...ryId=113052504

Dr. Denis Cortese is president of the Mayo Clinic.

"We just think everybody should have insurance. When people start talking about the public plan, it wasn't clear what kind of public plan we were talking about. And if a public plan looks like Medicare, I think the country would go broke almost overnight because Medicare is already proposed to go broke by 2015 to 2017.

If what they meant by a government-run public plan was the federal employees' health benefit plan - well, that one's quite good. That is one that could be used to insure people. So we want people to be focused and end up with our citizens insured and that we're starting to pay for value in the near term."

 

[armybound]

what exactly are the "health care cooperatives" that Baccus is talking about in his proposal?
oh and i think that mandating coverage is definately a start to avoid high prices for treatment to cover the costs hospitals pay for the uninsured

You know how large companies get better rates because they have so many policy holders?

Coops are where businesses can band together to become a larger pool, thus decreasing their costs. It would be like trying to insure the workers at a single McDonalds vs all fast food restaurants in your town banding together to get the same plan. More employees = lower premiums.

The issue with these coops has been that companies have often fled their current coop to join some other coop that seems to have a better deal, leaving the other companies in the coop to have to absorb higher premiums.

 

[Long Dong]

Whatever this guy says.

http://minnesota.publicradio.org/display/web/2009/09/18/midday2/

Here's a video of it too, not sure if it will play.

http://npc.press.org/video/player.cfm?type=lunch&id=18601

Long speech I'll try to summarise it later.

 

[GH253]

Abolish the Federal Reserve system, adopt the gold standard, eliminate the income tax, abolish the FDA, and abolish all government involvement in medicine.

 

[homestar]

Regardless of the type of system that the United States ultimately adopts, I believe that some form of universal health care in the United States is an inevitability. Although, the problems inherent in switching to this type of system are multi-partite. From what I understand, nations that provide universal health enter levy a 30% or so tax rate on their citizenry. This may be more than some Americans are willing to handle and the right wing might claim that it takes us one step closer to socialism.

France, from what I understand, has been lauded as having the best health care system in the world, yet their doctors supposedly earn 1/3 the salary that American doctors earn. This could, in my opinion, discourage individuals from entering the medical field who would otherwise be great candidates, because other fields could be more lucrative (a brain drain effect).

Further, a single payer system, in my opinion, could serve to stifle competition. It is antithetical to the capitalist economic paradigm of our nation, which has made is the most influential superpower in the world.

I highly doubt that America will abandon our current health care infrastructure and follow a Swedish model--it would uproot a multi-billion dollar industry overnight. I don't believe that it's practical or in-line with America's political beliefs.

It seems to me that expanding the current two-tiered model or following Massachusett's lead (under Romney--a Republican, surprisingly) by mandating employers to provide care to their employees and imposing taxes on uninsured individuals would be a more pragmatic solution.

In my experience, the current health care "crisis" seems overblown by the media. I have been literally destitute in this country, and have had little problem receiving services when I really needed them. There are free clinics and outreach services offered by many public and private institutions, and virtually every provider that I have visited has offered sliding scale and free care services. Further, statutes exist on the books for emergency care--a provider simply can't turn individuals away in an emergency situation. I have further received Medicaid, and received exceptional care and free prescriptions.

It is true that unexpected illness could theoretically financially crush an individual. If an uninsured, middle-class individual suddenly became stricken with cancer, then the concomitant bills could end in bankruptcy and foreclosure.

Much like the war in the Middle East, Obama has his work cut out for him, and his reponse to this "crisis" will determine his re-electability. I don't envy the mess with which he was left. Ultimately, he will probably follow the advice of his advisors and pander to his constituents just like his predecessors.

I can't say that I have the solution, but I don't forsee overnight, radical reform of our political and economic ideals.

 

[TheDuder]

Mandatory death panels for old people and ******ed bebes. Also, enslave the entire white race.

But seriously, I like the idea of a single-payer system, but it's just not going to happen in the States.

We all agree that we need to cut costs big time. End of life counseling should be a part of the solution. Huge amounts of money are spent keeping people alive because "do everything" is the default even when chances of survival are slim, right? I think that many people if presented with the option would choose to forgo expensive end of life care when the chances for survival with a reasonable quality of life are low, though obviously different people will choose different things. It's too bad the democrats caved on that common sense issue, imo.

Defensive medicine is a big problem. What incentive do physicians have to NOT run every test imaginable? More information is never a bad thing from the perspective of the doc, especially if they should find themselves in court. I don't know if I'm for caps on damages, but we need to be working towards a scenario in which the standard of care does not necessarily involve doing more more more all the time when evidence doesn't support more being better. Doctors are covering their asses by running every imaginable test, but they're also just trying to get the most info. possible to best care for their patients.

I've got nothin', but let me post this question: what service do insurance companies provide? It seems to me that they provide no real service whatsoever.

 

[FlowRate]

Other: tort reform

Other: insurance reform

Reduce excess? maybe... excess is always bad, but is current excess most definitely "excess"? I don't know, I'm not a doctor.

Also, preventative care is super hard to pin down. It seems to me like really effective preventative care is behavior change, which is moreso a job for MPH's.

 

[Schemp]

First off, for some perspective regarding tort reform:

http://www.scnursinghomelaw.com/200...y-takes-up-046-of-total-health-care-spending/

It accounts for less than 0.5% of health care spending (around 7 billion dollars). This isn't chump change, but tort reform would have a very small impact on health care costs as a whole.

As far as an actual solution, I think the best thing we could possibly do is to financially incentivize highly efficient, low cost, high quality systems such as the Mayo clinic's. And, to a lesser extent de-incentivize the opposite.

It's hard for physicians to choose a salary when they could fairly easily make 50%+ more in private practice, but if the government is taking money from highly inefficient hospitals and networks and paying bonuses to the more effective hospitals, I think we'd see a fundamental shift in the way medicine operates.

Of course, that's easier said than done. Regional differences certainly account for some differences in spending, and we'd have to identify to what extent that is the case. We can be certain that there are simply some areas that are wasting money, however.

By taking money from bad hospitals and the people who operate them and moving it to people who are actually giving the care and creating the results that warrant higher pay, we leave nowhere for greedy doctors to go, and they'll be forced (eventually) into copying the methods of the successful hospitals.

As long as the regulation was phased in slowly so that no hospitals were forced to shut down immediately without time to rectify their problems, or doctors experiencing huge declines in pay without also being able to reconsider their methods, I think this could honestly work.

Not only would we move toward a system of higher quality health care, but by enforcing a goal health care cost (per area) we could directly control those costs indefinitely, really only allowing costs to rise proportion to inflation and the needs of somewhat more effective hospitals/networks.

For example, in any given year we could say that the goal health care spending per person would be that of the spending for the 25th percentile area (on the low end). In other words, say northern California is spending 7.5k per person on health care costs, and they happen to be the 25th percentile. An institution in, say, New York, where they were paying 9.8k, the 75th percentile, would have the goal of 7.5k. If they didn't lower that cost in x amount of time, they'd pay at least part of the difference over time. On the flip side, the people who were operating at the bottom tenth percentile would see huge bonuses due to their cost savings.

All of these payouts would of course also require a high level of quality, above the average we see now, but judging by the research, that seems as though it would bear itself out. Especially since it would need to be an explicit requirement for any incentives.


Okay that turned out way longer than I expected, and I'm sure people will be happy to punch a ton of holes in it, call it socialism, etc. but I think incentives are the only way we can get more doctors to practice how they'd actually like to, and even more know they should.

This is a very rough form, but if you think it has any merit and would like to genuinely discuss any points of contention, agreement, or clarification, I'd really like a genuine debate rather than the typical mudslinging that tends to happen here as everywhere else.

 

[Snowman334]

Other: tort reform

+1 👍

 

[ChiDO]

First off, for some perspective regarding tort reform:

http://www.scnursinghomelaw.com/200...y-takes-up-046-of-total-health-care-spending/

It accounts for less than 0.5% of health care spending (around 7 billion dollars). This isn't chump change, but tort reform would have a very small impact on health care costs as a whole.

.

It's a trickle down effect and also effects different specialties different. OB/Gyn has a high malpractice and their income isn't nearly high enough to cover those costs; thus many are dropping from this practice.

Furthermore, doctors practice DEFENSIVE medicine due to malpractice lawsuits. We order tests X + Y + Z, instead of just ordering X.

Thus, malpractice payouts ($7 billion according to your article) may be only a small part, but add on the unneeded tests/ect in defensive medicine, and I bet the $$$ goes up significantly (will find source soon..last I remember, it was 20%).

Indirectly changing tort reform will change how we practice medicine in ordering tests and that is a big change.

Just a side note, lawyers take 25-35% of the total payout as well. Maybe this %% isn't true across the board, but I know a close family friend who won a lawsuit worth $9 million, but only received $6 million due to lawyers taking the rest (and that is why Obama won't touch this).

For Massachuesetts:


About 83 percent reported practicing defensive medicine, with an average of between 18 percent and 28 percent of tests, procedures, referrals, and consultations and 13 percent of hospitalizations ordered for defensive reasons.



Such practices were estimated to cost a minimum of $1.4 billion per year in Massachusetts.

A study published in the New England Journal of Medicine in 2006 analyzed more than 1,400 malpractice claims and found that in almost 40 percent of cases, no medical error was involved.

The need for tort reform
The current medical liability system neither effectively compensates persons injured from medical negligence nor encourages the addressing of system errors to improve patient safety. The medical liability crisis has had many unintended consequences, most notably a decrease in access to care in a growing number of states and an increase in healthcare costs.



Access is affected as physicians move their practices to states with lower liability rates and change their practice patterns to reduce or eliminate high-risk services. When one considers that half of all neurosurgeons—as well as one third of all orthopaedic surgeons, one third of all emergency physicians, and one third of all trauma surgeons—are sued each year, is it any wonder that 70 percent of emergency departments are at risk because they lack available on-call specialist coverage?

If the Kessler and McClellan estimates were applied to total U.S. healthcare spending in 2005, the defensive medicine costs would total between $100 billion and $178 billion per year. Add to this the cost of defending malpractice cases, paying compensation, and covering additional administrative costs (a total of $29.4 billion). Thus, the average American family pays an additional $1,700 to $2,000 per year in healthcare costs simply to cover the costs of defensive medicine.

With the national health care costs expected to be over $4.5 trillion by 2017, the cost of defensive medicine to the average American could triple in the next 10 years.

​

Sources:

Studdert, DM, MM Mello, WM Sage, CM DesRoches, J Peugh, K Zapert, TA Brennan. "Defensive Medicine among High-Risk Specialist Physicians in a Volatile Malpractice Environment." The Journal of the American Medical Association 293(21)(2005): 2660-2.
Weinstein, Stuart L.. "The Cost of Defensive Medicine." AAOS Now (2008).

Hellinger, FJ, WE Encinosa. "The Impact of State Laws Limiting Malpractice Damage Awards on Health Care Expenditures." American Journal of Public Health 96(8)(2006): 1375-81.

Kessler, DP, N Summerton, JR Graham. "Effects of the Medical Liability System in Australia, the UK and the USA." Lancet 368(9531)(2006): 240-6.

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