I hate ACA! ObamaCare Sucks!

[GeneralVeers]

Oh my, so much wrong, so little time. The 8.1M is ONLY the number of people who enrolled thru the exchanges. Millions more enrolled directly with insurance companies, millions of under 26ers were covered. http://acasignups.net/graph (graph previously attached). The 6M cancelled policies is almost certainly way too high, and ignores that many of those policies were very poor and the people could replace them with something better. The 80% payment rate is almost certainly way too low (many states reported to the feds only fully paid up policies, and the recent House report has been widely ridiculed for, among other things, counting as unpaid policies whose payment date had not yet arrived). And you deliberately ignore MA and SCHIPS in your analysis, but in your summary you don't qualify for that omission. Plus, as people begin to realize they won't have chips implanted in them when they sign up, more will sign up in future years.

SCHIP is not insurance. It's a form of Medicaid.

My comprehensive policy with $1000 deductible that cost $450/month was not "very poor" and was top notch. It is going away shortly. Apparently I need lactation coverage, OB/GYN care, and contraception. For reasons I will not get into, I will NEVER need any of those things, yet my existing coverage (which I liked) is going away in exchange for an overpriced plan (that I don't like).

In reality the ACA was never about providing people with private insurance. It's all about expanding Medicare, Medicaid and subsidies to us closer to the single-payer future that the administration would certainly enact if it had the power to do so.

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[GeneralVeers]

I could see Henge up there with Jay Carney spouting lies and misrepresentations with the best of them. Good show! Can you possibly have any discourse without resorting to the same tired old talking points?

 

[henge]

SCHIP is not insurance. It's a form of Medicaid.

In my state, MA is run thru HMOs and some of those HMOs also provide coverage to commercial and individual enrollees. Those are the very same HMOs, and they have the same care protocols and the same docs and hospitals signed up for MA, commercial and individual. I can't speak for other states, but it is evident that the stark division between MA and insurance you speak of is not a function of the ACA.

 

[henge]

I could see Henge up there with Jay Carney spouting lies and misrepresentations with the best of them. Good show! Can you possibly have any discourse without resorting to the same tired old talking points?

Great, let's discourse about how you determined the net loss of insureds under ACA. I pointed out that your 8.1M number is incomplete, since it is limited to persons who signed up thru the exchanges and ignores people who got coverage thru other means. You chose not to respond to that criticism, but rather to make a statement about me spouting lies and distortions. But let's discuss your methodology.

Under your methodology, if one person (you) had insurance pre-ACA, lost it because the plan's grandfather clause was negated thru a policy change, and then bought a policy directly from an insurer without going thru an exchange, there would be a net coverage drop of 1: lost policy = -1, ACA policy = 0; -1+0 = -1. Clearly, that is wrong; there were as many covered people--one--before and after ACA. The mathematically (but not conservatively) correct answer is that there was no change: lost policy = -1, ACA policy = +1; -1 +1 = 0. That IS the answer, yet your methodology comes up with another answer. So, your methodology is wrong. Sweet and simple, needs no numbers over 1, no math beyond addition and subtraction.

Now, let's for a moment talk about lies and distortions. You used a flatly incorrect methodology, then, when I pointed out you were wrong, you accused me of spouting lies and distortions. That is just too rich.

 

[henge]

In response to birdstrike's post: My two kids and I used to share the henge name; some old posts are from me, some from my two kids. Now, they don't use SDN , so I am the exclusive user of the name. I even changed henge's status to non-student. Mystery solved!

 

[RustedFox]

 

[GeneralVeers]

The problem is that the administration won't release any numbers that disagree with their narrative (that being that the ACA is successful). There are a lot of things we should know to determine if it is doing what it is supposed to do: provide health insurance (not medicaid) to previously uninsured Americans. No one has the data to say if the law was successful or not. To be successful it would have to net insure more Americans and measurably bring down costs (both to consumers AND the government).

1. We don't know exactly how many people were kicked off their existing insurance. In fact the administration refuses to acknowledge that the ACA is even responsible for cancellations. They blame the insurers for issuing the cancellations. The insurers blame the government. Who do we believe? The independent analysts who have looked at it are saying it is about 6-7 million. (Source: Kaiser, not exactly a conservative-leaning organization) http://www.kaiserhealthnews.org/Dai...r/07/cancellations-of-insurance-policies.aspx

2. Healthcare.gov had no system to track what coverage (if any) those signing up previously had. As such we don't know how many "sign-ups" are people who previously had no insurance, or are just people kicked off of their plan who were forced into the ACA. If it was just kicking people off insurance to provide them with ACA insurance, then the point has been entirely defeated.

3. Medicaid, SCHIP and the heavily subsidized plans count as a "failure" as far as I am concerned. They don't reduce costs, and they require more government money, and taxpayer money as well as subsidies from higher premiums for the healthy. If we really wanted to bring down healthcare costs, meaning decrease the amount government spends, then enrolling MORE people on government plans is not the way......unless that was the point of the law all along.

 

[@JackShephard]

But why not blame Bush or Clinton who didn't deal with the issues, or the House or the Senate who haven't dealt with them, or the Medicare prescription drug expansion or the hundreds of other bills that also did not address those issues?

Oh, sure. I blame all of them too. Politicians hardly want to solve problems. They just want things good while they are in office, or enough to get them re-elected.

I do think the blame of our healthcare system goes on all the parties you mentioned. Obamacare is in the spotlight because it's the most recent legislation passed.

 

[GeneralVeers]

Oh, sure. I blame all of them too. Politicians hardly want to solve problems. They just want things good while they are in office, or enough to get them re-elected.

I do think the blame of our healthcare system goes on all the parties you mentioned. Obamacare is in the spotlight because it's the most recent legislation passed.

You blame politicians for doing too little. The assumption is that government can fix the problems with our system, namely:

1. Cost
2. Access
3. Morbidity

I am not certain how politicians can fix all of these things. You can increase access, but cost necessarily has to increase as well. You can decrease costs, but not without rationing treatments and narrowing provider networks. As for morbidity, well Americans are a bunch of big fatties, and there's not much any government can do about that.

 

[@JackShephard]

You blame politicians for doing too little. The assumption is that government can fix the problems with our system, namely:

1. Cost
2. Access
3. Morbidity

I am not certain how politicians can fix all of these things. You can increase access, but cost necessarily has to increase as well. You can decrease costs, but not without rationing treatments and narrowing provider networks. As for morbidity, well Americans are a bunch of big fatties, and there's not much any government can do about that.

I think that a government can control costs, it's been done in other countries.

The government also sets in place laws that limit malpractice claims. This affects healthcare expenditures, not only by insurance costs but the cost of defensive medicine.

Access. I think the government meddling in the documentation of every last thing done medically leads to waste - inefficient systems and documentation limits access by making healthcare workers inefficient (this is also a consequence of the malpractice environment). Look at how brilliant our technology companies in America are: Google, Apple, Yahoo, Microsoft... are you telling me that a group of physicians from each specailty and some of the top minds in technology couldn't make a simple and efficient EMR? Sure they could. And by getting input from physicians, maybe even a national vote by physicians, there could be a system implemented that made sense and wasn't tedious.

As for morbidity, you're right. The government has little control over this. And America is killing themselves with poor health. I don't know a good solution for that. But I do believe we have incredibly intelligent people working in the medical field that could solve these problems. Having the government implement random policies without broad support from physicians has lead to this terrible system that is incredibly inefficient and costly. The video I posted above showing better and faster results in independent shops shows how convoluted and corrupt our system is today.

You're right, there is no perfect system. But we're hardly moving in the right direction.

 

[GeneralVeers]

You are talking about the U.S. government, remember? It is one of the most wasteful, least efficient governments in the world. I have no faith that they will EVER control spending on anything. In order to do that we have to have rationing, and our cowardly politicians are not going to risk their re-election by telling Grandma Smith that she can't have a particular medication or procedure done.

 

[Rendar5]

Rendar, while I appreciate you pointing out EMTALA definitions, I believe I will take more faith in the healthcare attorneys who have advised us that patient's EMTALA obligations are met once they are stabilized, and they are being transferred to a hospital that provides an equal level of care.

If you come in as a STEMI, need an ICU bed, emergent surgery (e.g., thoracic aortic dissection, ruptured viscous, etc.), then those patients are admitted and dealt with. We are not refusing to care for patients whom we have no contractual obligation with their insurer. If they want to stay, they can stay. They are responsible for the bill and filing anything with their insurer.

This goes on around the country on a frequent basis, particularly with Kaiser Permanente patients. Many of the health exchange plans are now doing this with hospitals around the nation.

Just because a patient needs further inpatient treatment doesn't mean they are unstable for transfer.

Never said they were medically unstable for xfer. Just saying the definition of stability for us and for emtala purposes seems to vary, and having the reason for transfer being "we don't take their insurance" is putting your hospital at risk of a major violation as soon as the first bs lawsuits of "I lost my leg from the delay of care, not from the diabetes and chronic osteo that I left untreated for years" inevitably rolls around. Hopefully for your hospitals sake their lawyers are right, but honestly not taking insurance as the reason for xfer just doesn't pass the sniff test when it comes to whether or not a judge would say it was a-ok. That said, you do what your hospital makes you do, not saying you yourself should be fighting this battle.

 

[EctopicFetus]

http://www.forbes.com/sites/theapot...ring-the-uninsured-a-glass-half-empty-moment/

Great info in there.

 

[WilcoWorld]

Never said they were medically unstable for xfer. Just saying the definition of stability for us and for emtala purposes seems to vary, and having the reason for transfer being "we don't take their insurance" is putting your hospital at risk of a major violation as soon as the first bs lawsuits of "I lost my leg from the delay of care, not from the diabetes and chronic osteo that I left untreated for years" inevitably rolls around. Hopefully for your hospitals sake their lawyers are right, but honestly not taking insurance as the reason for xfer just doesn't pass the sniff test when it comes to whether or not a judge would say it was a-ok. That said, you do what your hospital makes you do, not saying you yourself should be fighting this battle.

As someone who accepts these transfers my experience has been that the documented reason for transfer is almost always "patient request". The veracity of that statement is often dubitable, like when the patient has late stage dementia. However, there are occasionally financially responsible patients who request transfer due to insurance reasons.

 

[GeneralVeers]

As someone who accepts these transfers my experience has been that the documented reason for transfer is almost always "patient request". The veracity of that statement is often dubitable, like when the patient has late stage dementia. However, there are occasionally financially responsible patients who request transfer due to insurance reasons.

At my former job in Vegas we had the same problem. We had out-of-network patients for whom a hospital admission would be a financial burden. I would give them two options: 1. We transfer you to a hospial in your network, or 2. You get admitted here and potentially have a much larger bill. I gave them the choice, and documented as such. Expect to see a lot more of this under the ACA as the networks covered under the insurance become increasingly narrow. In my former job in Henderson, NV, all 3 hospitals in the city opted out of the state exchange. That meant anyone signing up for Obamacare couldn't go to their local hospital but had to drive 20-30 minutes to a hospital in Vegas. Is that fair to patients?

 

[anbuitachi]

I think we are moving away from private insurance from insurance companies to big hospital networks (North Shore LIJ, mt sinai, etc) that provide insurance along with healthcare to cut the cost that's going to the middle man at some other company. It sounds like a decent plan as long as hospital administrators dont abuse it.

 

[Hercules]

I would give them two options: 1. We transfer you to a hospial in your network, or 2. You get admitted here and potentially have a much larger bill. I gave them the choice, and documented as such. ?

I think this is the only honest and ethical way to handle this situation. If you know the patient is going to incur a huge out of pocket expense by being admitted to your facility (as opposed to another facility), you owe it to them to let them know on the front end. As to the danger of transfers, let's be real; what percent of your admissions are going to decompensate and suffer serious harm by a 30-60 min transfer? For that exceedingly rare subset, I don't think any of us are going to transfer them out.

 

[deleted109597]

I've had people sign out AMA when they're told they're going to be observation status. I can't imagine that people won't do the same for full hospitalizations. All the more reason for more transparency in pricing and accepted plans.
I wonder what they're doing in Cali, since balanced billing is "illegal" per their courts.

 

[EctopicFetus]

IN my experience in the last 6 months more and more people are asking about Obs status. Obviously this is because medicare doesnt pay for this. It does seem that people must have watched some new TV show or something. I never had this question until recently.

What we have are the canadian snowbirds. Dealing with them and their insurance issues is quite painful.

 

[WilcoWorld]

I'll admit to using OBS status to bring in through the backdoor what I think is (one of) the real solution(s) to the healthcare crisis (adjusting public expectations), and hopefully protecting myself in the process:

Me: "Sir, your chest pain doesn't sound like a heart attack, and your EKG and blood tests don't show any evidence of problems. Odds are that you're OK, but I can't be sure that you won't have a heart attack in the future. If we want to get closer to 100% certainty, and we can never get all the way to 100%, I'll put you on OBS status over night for further testing. We keep you in the hospital so we can intervene right away if something bad happens. I think that's unlikely to happen, but if it does, you could die, or end up with brain damage. On the other hand, if you go home, you can come back at any time if you're feeling worse or have new symptoms. In either case, I want you to follow up ___ (always within 72 hours, if they have no PMD, I give them a referral)."
Patient: "What does OBS status mean?"
Me: "It means that you stay in the hospital overnight, but your insurance may or may not cover the visit."
9/10 Patients: "Um, I want to go home."

Even though it's super easy for me to OBS chest pain, these days I rarely do when it's low risk.

My standard documentation is something like "Patient offered observation to avoid delayed or missed diagnosis and informed of the risks of death or permanent disability if such occurs. Patient expressed understanding, but prefers d/c with close outpatient follow up. Pt will take aspirin daily and avoid exertion until cleared by PMD. Advised to return to ED immediately for new, worsening, or otherwise concerning symptoms."

Is it bulletproof? No. But I think it's the right thing to do for the patient.

 

[deleted547339]

In my state, MA is run thru HMOs and some of those HMOs also provide coverage to commercial and individual enrollees. Those are the very same HMOs, and they have the same care protocols and the same docs and hospitals signed up for MA, commercial and individual. I can't speak for other states, but it is evident that the stark division between MA and insurance you speak of is not a function of the ACA.

Dude, you gotta stop drinking the kool-aid. It's fine to be for a very flawed program, but even if you're for it, you have to admit how flawed it is. No one, not even Obama himself, thinks its great. Most of my lib friends think its bad but better than the alternative.

Put down the Pom-poms.

 

[WilcoWorld]

I think our pre-ACA system was clearly broken. Healthcare costs were a leading cause of bankruptcy, and most people who went bankrupt had insurance when they got sick! Add to that the opacity and variability of charges and it wasn't just broken, it was uncapitalistic. Clearly things needed to change. However, I think the ACA is highly flawed, perhaps fatally flawed. In order to get passed the ACA got watered down beyond recognition, and it not only failed to get rid of one of the major sources of waste in our system, it increased it - administration. But the reason I think it's flawed is because it didn't go far enough. I would like to see universal coverage, rationing of care, death panels (because I think dignified death is more compassionate than futile care), an ending to fee for service and Safe Harbors.

 

[henge]

Dude, you gotta stop drinking the kool-aid. It's fine to be for a very flawed program, but even if you're for it, you have to admit how flawed it is. No one, not even Obama himself, thinks its great. Most of my lib friends think its bad but better than the alternative.

Put down the Pom-poms.

I was responding to another post that simply disregarded MA as a form of insurance for purposes of how much the ACA had expanded (or, in the other poster's opinion, contracted) insurance coverage. My point was not that MA was not flawed, it was that in my state, some HMOs peddle MA thru the exact same vehicles as they peddle essentially identical commercial and individual coverage. From the point of view of enrollees, that MA coverage is no more or less flawed than the coverage from those commercial or individual policies; it's the same. For purposes of determining the number of persons who have coverage, it is wrong to treat the commercial and individual policies from those HMOs as insurance but not to treat the MA from those HMOs as insurance, and I think that is the case without regard to kool aid consumption or manipulation of pom poms.

 

[Birdstrike]

I think our pre-ACA system was clearly broken. Healthcare costs were a leading cause of bankruptcy, and most people who went bankrupt had insurance when they got sick! Add to that the opacity and variability of charges and it wasn't just broken, it was uncapitalistic. Clearly things needed to change. However, I think the ACA is highly flawed, perhaps fatally flawed. In order to get passed the ACA got watered down beyond recognition, and it not only failed to get rid of one of the major sources of waste in our system, it increased it - administration. But the reason I think it's flawed is because it didn't go far enough. I would like to see universal coverage, rationing of care, death panels (because I think dignified death is more compassionate than futile care), an end for service and Safe Harbors.

I'm assuming in your last line you mean ending "fee for service"?

If so, good luck. That's like telling a patient, "Sir, the source of you disease is simple, it's your flawed DNA. The solution is simple, we'll just get rid off it."

Fee for service is a part of every single healthcare visit, treatment, dollar and transaction we, the hospitals and the insurance companies (including government ones) have.

No one, not Barack Obama, Nancy Pelosi, the Republicans, The HHS director, the AMA, Dr Oz or any other physicians including those blogging on the internet has an even remotely credible suggestion as to how to end "fee for service," other than the complete and total elimination of any private practice, private hospitals, and private insurance companies. Even eliminating private insurance and putting everyone on Medicare doesn't eliminate fee for service. All of Medicare billing is on fee for service, and still doesn't prevent patients and physicians from option out, ie, concierge/cash practice which is growing.

ACOs don't eliminate fee for service (it just lumps bigger "fees," for "grouped" services together).

"Pay for performance" (which is a complete joke since no one has come up with a valid or objective way to rate physician performance) doesn't eliminate fee for service. It just adds small penalties on top of your fee, to take away a small portion of your payment for failing to jump through some hoop (PQRS, meaningless EHR use, patient sat metrics).

So if your solution is to ban any private practice, private insurance, private hospitals, cash/concierge practice a la true, hardcore single payer, then taking about eliminating fee for service is wasted breath. If that is your goal, good luck that passed in this country (even European socialist systems allow a private tier to opt out).

I agree that fee for service is a massive fuel source for cost inflation. Pay more, for more tests, treatments and services and you'll get more tests, services and treatments. Even in the ED, it is fee for service that drives the frenetic obsession with door to doctor times, "throughput," metrics and generally "moving the meat." Pay an ER doctor more per patient, RVU, or even more per hour and he'll generate more patient visits, more RVUs, more charges and work more hours to make more money (and as a result see more patients total, and more fees).

Prior to the ACA, our system was a train running down the tracks down a hill. As much as I'd love to have all patients covered, costs controlled and everyone happy, all the ACA has done is add a heavier load to that train running out of control, down the mountain, to gain greater speed. I don't care who "wins" or "loses," Obama or the Republicans (because I think all politicians suck and I'm determined to adapt and thrive either way), but this just isn't working.

Even if everyone gets "coverage" it's a train going off the track. There's no cost controls in this thing, only $1 Trillion more dollars pumped in over 10 years.

We will end up with a 3 tier system.

Tier 1- The wealthy. Always taken care of: Cash for concierge care (plus traditional insurance for back up).

Tier 2- Those in the middle, with decent private insurance (but not enough expendable cash for concierge care).

Tier 3- Token government insurance that covers very little, that very few doctors will take other than overwhelmed hospitals with an intolerable wait time, or ACA plans with deductibles so high and networks so narrow that the coverage is mostly worthless except as catastrophic care. This will resemble current Medicaid or the VA system, or likely worse due to the strain on the system.

That's how I see it.

 

[@JackShephard]

I think our pre-ACA system was clearly broken. Healthcare costs were a leading cause of bankruptcy, and most people who went bankrupt had insurance when they got sick! Add to that the opacity and variability of charges and it wasn't just broken, it was uncapitalistic. Clearly things needed to change. However, I think the ACA is highly flawed, perhaps fatally flawed. In order to get passed the ACA got watered down beyond recognition, and it not only failed to get rid of one of the major sources of waste in our system, it increased it - administration. But the reason I think it's flawed is because it didn't go far enough. I would like to see universal coverage, rationing of care, death panels (because I think dignified death is more compassionate than futile care), an ending to fee for service and Safe Harbors.

I agree here completely.

I think we should move to a 2 tiered system. Medicare for all on one side, then private insurance for enhanced care and more options.

Of course, that assumes the government can make a competent and efficient model - which may be impossible.

 

[Birdstrike]

Chronic VA Failures A Sign Of What's To Come For ACA?

http://www.ft.com/intl/cms/s/0/328546c0-dd10-11e3-8546-00144feabdc0.html#axzz31vysJUVM

"Amid contrived outrage over Benghazi and the improving fortunes of its healthcare reform, the Obama administration could be facing a genuine scandal about its treatment of military veterans that has the potential to attract broad political condemnation of its competence.

The Department of Veterans Affairs (VA) is facing mounting evidence that some of the hospitals it runs have been keeping two sets of books to make it look as if they were reducing waiting times to see a doctor.

More damning, the department is investigating the claims of a whistleblower doctor in Arizona that dozens of patients at one hospital died while they were languishing on a hidden waiting list without ever being given an appointment.

Richard Griffin, the department’s acting inspector general, admitted on Thursday that its review could lead to criminal charges. In the first political casualty of the scandal, Robert Petzel, the department’s undersecretary for heath, resigned on Friday.

If the evidence of mismanagement continues to accumulate, the Obama administration will find itself not in another partisan knife-fight, but under fire from both parties in a Congress where the uniformed military is venerated.

The veterans’ healthcare scandal is, in part, one of the unintended consequences of the wars in Afghanistan in Iraq, which have created “our 9/11 generation who have served with honour in more than a decade of war,” as President Barack Obama described them on Thursday.

More than 970,000 veterans from those wars have filed disability claims, taking the total enrolled in the VA system to 8.57m by the end of 2012.

At the same time, the healthcare system is dealing with the fact that many of the 6m veterans from the Vietnam era are now reaching the age when they start to require a lot of medical services. In 2010, the administration expanded coverage to exposure from Agent Orange, the chemical used during the war in Vietnam, prompting another surge of claimants.

The result has been a constant struggle to meet new demands, despite big spending increases. The budget for the VA has risen from $73.1bn in 2006 to $153.8bn this year. However, the number of outpatient visits at its facilities has increased from 46.5m in 2002 to 83.6m in 2012. “I am amazed this is still happening, given the big increase in resources that the department has received,” said Phillip Carter, a former army officer who researches veterans’ issues at the Center for a New American Security in Washington.

I am amazed this is still happening, given the big increase in resources that the department has received
- Phillip Carter, Center for a New American Security
The VA, which runs 152 hospitals and 817 outpatient clinics, has long suffered from delays and a dysfunctional bureaucracy. In 2010, it introduced a new appointments system which promised a 14-day wait for an appointment with a primary care doctor or a specialist.

While there have been reports for several years that the new waiting line system was being abused, the subject really began to gather steam three weeks ago when CNN interviewed Sam Foote, who had recently retired as a doctor after working for 24 years for VA hospitals in Phoenix, Arizona.

He said that as many as 40 patients had died after being placed on a hidden waiting list that could last for up to a year, while officials at the hospital shredded documents and faked evidence to make it seem as if waiting times were under control.

Three officials in Phoenix have been put on leave, although Mr Griffin said there was no evidence yet that patients had died because of delayed appointments.

Since then, whistleblowers have alleged similar practices at least seven other VA hospitals around the country and claimed that officials at the hospitals were sometimes paid bonuses for reducing declared waiting times.


The political impact of the scandal has been somewhat muted so far, in part because of the respect still enjoyed by the veterans affairs secretary, retired four-star general Eric Shinseki who was himself wounded twice in Vietnam. Appearing before a Senate hearing on Thursday, Mr Shinseki received pointed questioning, but in a tone more respectful than almost any other cabinet member would have encountered. “I am mad as hell,” he told the committee.

However, if Congress concludes that efforts to manipulate waiting lists have become systemic – or if the allegations that patients died while waiting for phantom appointments are proved – Mr Shinseki will face huge pressure from both parties to resign.

Richard Blumenthal, a Democratic senator for Connecticut, said there was “solid evidence of wrongdoing within the VA system”, while his colleague from Washington Patty Murray told Mr Shinseki: “The standard practice at the VA seems to be to hide the truth.”

In a sign of how serious the White House believes the political fallout could become, the president’s deputy chief of staff Rob Nabors has been dispatched to the VA to help manage the fallout."

 

[deleted109597]

I get the medical students who haven't seen them but believe the schtick that the VA has better outcomes, etc. But come on now. Every one of us that has worked at a VA during medical school or residency can't be surprised by any of this. I'm surprised it took this long for people to get upset.

 

[RustedFox]

I agree here completely.

I think we should move to a 2 tiered system. Medicare for all on one side, then private insurance for enhanced care and more options.

Of course, that assumes the government can make a competent and efficient model - which may be impossible.

Dude, I agree in the fullest... but its only a matter of time before you get to some odd-ass position or set of circumstances where people from tier (2) decide that they're entitled to tier (1). It has happened again and again over history; and it gets worse when every so often you have films like "Elysium" (recent Matt Damon film) that reinforce the idea that "because it exists, it is my right."

"Elysium" in a nutshell... ready? Go.

"Oh, wow.. rich people have life-saving healthy stuff. Poor people don't. Kill rich people, because they "won't share". Get some cool cybersuits to make it sellable to every 15 year old out there. LOLZ. !!!111!!!1! Socializzzm FTW! K download it to my iPod kthyxbye. Vote for Lolzicrats."

 

[GeneralVeers]

Going back to "ending fee for service", how well would that work out in real life? If you are an orthopedic surgeon, why would you even bother operating? If you're collecting a fat paycheck regardless of the number of procedures you do, human nature would dictate that you do the minimum number possible to stay employed. The result would actually be a far less efficient system because productivity would drop and you would need to employ more providers to provide the same number of services as under the fee-for-service model. Capitalism and free markets are simply the least imperfect of all the imperfect systems. There has never been a better system invented or employed. Whenever you try to change or remove incentives for productivity the entire system becomes worse off.

 

[DermViser]

Wait.... Politicians Lie?

Honestly, I think the people get what they deserve. I am ecstatic when people buy their Obamacare insurance plans and realize the very narrow networks and piss-poor doctors they have on those plans. You voted for the man bc you thought your healthcare was going to be "free"? Congrats - your reward is a ****ty insurance plan.

 

[Hercules]

If you're collecting a fat paycheck regardless of the number of procedures you do, human nature would dictate that you do the minimum number possible to stay employed. The result would actually be a far less efficient system because productivity would drop and you would need to employ more providers to provide the same number of services as under the fee-for-service.

This has been the case in every flat hourly rate ED I've been in. Without productivity or fee for service, human nature takes over and people get lazy.

 

[southerndoc]

Going back to "ending fee for service", how well would that work out in real life? If you are an orthopedic surgeon, why would you even bother operating? If you're collecting a fat paycheck regardless of the number of procedures you do, human nature would dictate that you do the minimum number possible to stay employed. The result would actually be a far less efficient system because productivity would drop and you would need to employ more providers to provide the same number of services as under the fee-for-service model. Capitalism and free markets are simply the least imperfect of all the imperfect systems. There has never been a better system invented or employed. Whenever you try to change or remove incentives for productivity the entire system becomes worse off.

Isn't this how the UK's NHS is set up? There is a private system as well, and people don't have an "Elysium" attitude.

 

[Apollyon]

This has been the case in every flat hourly rate ED I've been in. Without productivity or fee for service, human nature takes over and people get lazy.

You're in the deep south, and our friends in Arizona say similar, but I've only worked in "flat hourly rate" EDs, in South Carolina, Hawai'i, and Pennsylvania. We get pushed, pushed, pushed, don't get RVU bonuses (was starting in SC just as I left 5 years ago), and DON'T sit around getting lazy, unless 2pph is "lazy".

$300/hr would be just grand and dandy and lovely, but, where I've been, that just ain't it.

 

[WilcoWorld]

I'm assuming in your last line you mean ending "fee for service"?

Yes, I did - corrected the typo in my post. Thanks.

Now, my apologies for not being more clear - I didn't actually expect any of the things I described to happen. I was just listing the things that I think would meaningfully help the situation. Unfortunately, none of them would enrich those currently in power, so I'm not holding my breath.

While I'm at it, I'll wish that Julian Casablancas would stop being such a self-absorbed ass and that The Strokes would record another record as good as the 1st two...

 

[WilcoWorld]

I'm not a policy wonk, so I'm not going to be able to go into detail, but getting rid of fee for service doesn't have to mean just paying people to just sit around and being docs.

Instead of:
Paying hospital A $36k to use an expensive hip, more expensive meds, have longer stays, and to place a PICC line necessitated by the pneumonia the patient got on post op day 4.
-while-
Paying hospital B $8k to use a cheaper hip (with equivalent longevity), give cheaper meds (that are equivalently effective) and a having shorter stays (minus the PICC line and the pneumonia), but plus some early PT...
Someone smarter than I am could look at the hospitals that do hip replacements well, see how much it costs them, and then pay everyone that price to replace a hip. The hospitals that can do it well stay open, those that don't won't.

There's actually pretty good data out there (sorry, no ref. on hand) showing that hospitals that have better outcomes tend to cost less.

In healthcare more is not better, but fee for service incentivizes hospitals to do more, so what do you expect them to do?

 

[dpmd]

I'm not a policy wonk, so I'm not going to be able to go into detail, but getting rid of fee for service doesn't have to mean just paying people to just sit around and being docs.

Instead of:
Paying hospital A $36k to use an expensive hip, more expensive meds, have longer stays, and to place a PICC line necessitated by the pneumonia the patient got on post op day 4.
-while-
Paying hospital B $8k to use a cheaper hip (with equivalent longevity), give cheaper meds (that are equivalently effective) and a having shorter stays (minus the PICC line and the pneumonia), but plus some early PT...
Someone smarter than I am could look at the hospitals that do hip replacements well, see how much it costs them, and then pay everyone that price to replace a hip. The hospitals that can do it well stay open, those that don't won't.

There's actually pretty good data out there (sorry, no ref. on hand) showing that hospitals that have better outcomes tend to cost less.

In healthcare more is not better, but fee for service incentivizes hospitals to do more, so what do you expect them to do?

Except that patient A was getting a revision hip that needed to be customized and had 4 different medical comorbidities that had to be managed with those expensive meds, one of which was copd which predisposed him to the pneumonia he got (and also made getting up with pt difficult). This is the sort of stuff that gets overlooked when people talk about the best outcomes coming from places where the care is cheapest. If you want ever to only take care of the healthiest most straightforward cases then paying the same for all care is the way to go. If you want complicated patients to get the care they need you are going to have to br a little more flexible.

 

[Birdstrike]

R i g h t . . .

So then why does this current government (CMS), that you expect to "fix" things, routinely pay 100%-600% more for the same elective procedures in a hospital, as opposed to the more efficient outpatient cost?

Are you even aware that's going on, and the norm?

Would you pay 6 times more for the car at one dealer over another?

Our government does everyday.

I have zero confidence in these people and their bureaus and "agencies" to fix the system they've already brought to shambles.

Every year, Medicare cuts payment to doctors (to cut costs), which drives doctors to work for hospitals, where the hospital charges 2-6 times MORE for the same procedures done by the same doctors, which RAISES costs dramatically, and for no good reason. This is what they are doing now with your "Affordable" Care Act. In any real job, in the real world, these people would be fired the first week on the job.

The same epidural steroid injection in a hospital vs in a private doctors office? Your government (which you rely on to "fix" things) pays 500% more if the same shot is done in a hospital vs. a private doctors office. That's not a misprint, it's not 5%, or 50% more, it's 500% more!!!! (About $100 to a doctor in his office, vs almost $700 to a hospital)

http://www.asipp.org/2014 Final Rule Links/documents/FactSheeton2014Cuts.pdf

Same Derm procedure in hospital as opposed one done in doctors office: costs way more= Medicare (your government) is okay with it.

http://www.kansascity.com/2013/12/29/4719471/facility-fees-add-billions-to.html

The same thing is going on with Cardiology and the other subspecialties:

http://www.kansascity.com/2013/12/29/4719484/heart-test-costs-rise-as-cardiologists.html



"Insanity is doing the same thing, over and over again, but expecting different results."

-from the Basic Text of Narcotics Anonymous

 

[WilcoWorld]

Except that patient A was getting a revision hip that needed to be customized and had 4 different medical comorbidities that had to be managed with those expensive meds, one of which was copd which predisposed him to the pneumonia he got (and also made getting up with pt difficult). This is the sort of stuff that gets overlooked when people talk about the best outcomes coming from places where the care is cheapest. If you want ever to only take care of the healthiest most straightforward cases then paying the same for all care is the way to go. If you want complicated patients to get the care they need you are going to have to br a little more flexible.

I'm aware that not all patients are the same. Again, I don't have the references (or good lit access) currently on hand. From what I recall (which is admittedly fallible) these low cost/good outcome places were sites like Case Western, where you can hardly say they cherry pick the simple patients. If you can produce a reference that demonstrates your point then I'll happily concede.

 

[GeneralVeers]

I'm aware that not all patients are the same. Again, I don't have the references (or good lit access) currently on hand. From what I recall (which is admittedly fallible) these low cost/good outcome places were sites like Case Western, where you can hardly say they cherry pick the simple patients. If you can produce a reference that demonstrates your point then I'll happily concede.

Your arguments suppose that bureaucrats will make financially responsible decisions that are ALSO in the patient's best interest. Sure, hip replacement "A" could be equally effective and less costly than hip replacement "B". But what if hip replacement "A" is only 80% as effective but costs half as much? Do you really think the bureaucrats will pay for option "B"?

Just as we are finding out with the current VA scandal, government healthcare budgets are set annually based on political fiat and not patient need. There is always more demand under these systems than can be provided with the available funding. The results are cost cutting by bureaucrats. Do any of you on this forum really trust them to make the right decisions for you and your family? If so, then I have a bottle of snake oil to sell you.

 

[WilcoWorld]

Your arguments suppose that bureaucrats will make financially responsible decisions that are ALSO in the patient's best interest. Sure, hip replacement "A" could be equally effective and less costly than hip replacement "B". But what if hip replacement "A" is only 80% as effective but costs half as much? Do you really think the bureaucrats will pay for option "B"?

Just as we are finding out with the current VA scandal, government healthcare budgets are set annually based on political fiat and not patient need. There is always more demand under these systems than can be provided with the available funding. The results are cost cutting by bureaucrats. Do any of you on this forum really trust them to make the right decisions for you and your family? If so, then I have a bottle of snake oil to sell you.

I have made no such suppositions. I have said that these things are conceivable and that they could address the poor cost/benefit ratio of US healthcare spending, but I never expressed optimism that these policies are likely to be enacted effectively by the current bureaucracy.

 

[dpmd]

I'm aware that not all patients are the same. Again, I don't have the references (or good lit access) currently on hand. From what I recall (which is admittedly fallible) these low cost/good outcome places were sites like Case Western, where you can hardly say they cherry pick the simple patients. If you can produce a reference that demonstrates your point then I'll happily concede.

A reference that complicated care costs more money, or one that shows if you don't compensate for that providers won't want to offer the care? Sure, right after I find one dealing with whether you should wear a parachute if you are going to jump out of a plane.

 

[Hercules]

You're in the deep south, and our friends in Arizona say similar, but I've only worked in "flat hourly rate" EDs, in South Carolina, Hawai'i, and Pennsylvania. We get pushed, pushed, pushed, don't get RVU bonuses (was starting in SC just as I left 5 years ago), and DON'T sit around getting lazy, unless 2pph is "lazy".

$300/hr would be just grand and dandy and lovely, but, where I've been, that just ain't it.

You could be right, and I didn't mean to offend. I could be biased by my location and the fact that the majority of jobs here pay productivity. The physicians I have been exposed to have chosen to avoid being paid productivity and go with the flat hourly rates instead. This makes them a self-selected group that has voluntarily decided they don't want to work harder to be paid more (barring other scenarios that have affected their decision).

 

[WilcoWorld]

A reference that complicated care costs more money, or one that shows if you don't compensate for that providers won't want to offer the care? Sure, right after I find one dealing with whether you should wear a parachute if you are going to jump out of a plane.

A reference showing that places that achieve better outcomes with less money are only doing so by cherry picking.

 

[Deadlifts]

I'm not a policy wonk, so I'm not going to be able to go into detail, but getting rid of fee for service doesn't have to mean just paying people to just sit around and being docs.

Instead of:
Paying hospital A $36k to use an expensive hip, more expensive meds, have longer stays, and to place a PICC line necessitated by the pneumonia the patient got on post op day 4.
-while-
Paying hospital B $8k to use a cheaper hip (with equivalent longevity), give cheaper meds (that are equivalently effective) and a having shorter stays (minus the PICC line and the pneumonia), but plus some early PT...
Someone smarter than I am could look at the hospitals that do hip replacements well, see how much it costs them, and then pay everyone that price to replace a hip. The hospitals that can do it well stay open, those that don't won't.

There's actually pretty good data out there (sorry, no ref. on hand) showing that hospitals that have better outcomes tend to cost less.

In healthcare more is not better, but fee for service incentivizes hospitals to do more, so what do you expect them to do?

Places like Intermountain Health are doing great things with reducing variation and getting better outcomes while lowering cost of care. However, they have to petition the middle-men insurance companies to share some of those savings. Institutions are regularly taking pay cuts by improving their provision of care while insurance companies reap the benefits.

You have a noble idea in setting the Medicare reimbursement rate for a procedure based on evidence-based (yay buzzwords) best practices at places like IMH. Who determines what is best practice? Evidence-based?

I was responding to another post that simply disregarded MA as a form of insurance for purposes of how much the ACA had expanded (or, in the other poster's opinion, contracted) insurance coverage. My point was not that MA was not flawed, it was that in my state, some HMOs peddle MA thru the exact same vehicles as they peddle essentially identical commercial and individual coverage. From the point of view of enrollees, that MA coverage is no more or less flawed than the coverage from those commercial or individual policies; it's the same. For purposes of determining the number of persons who have coverage, it is wrong to treat the commercial and individual policies from those HMOs as insurance but not to treat the MA from those HMOs as insurance, and I think that is the case without regard to kool aid consumption or manipulation of pom poms.

Is it the same though? Are we seeing the same increased ED utilization in privately insured patients as we are in new MA enrollees (40% in Oregon's Medicaid experiment)?

 

[GeneralVeers]

I have made no such suppositions. I have said that these things are conceivable and that they could address the poor cost/benefit ratio of US healthcare spending, but I never expressed optimism that these policies are likely to be enacted effectively by the current bureaucracy.

It is an important supposition. Bureaucrats in the U.S. again and again display their inability to make wise decisions. The VA, Medicare, Medicaid are all examples. Why do we think that "this time" it will be different if only we gave them complete control?

 

[WilcoWorld]

It is an important supposition. Bureaucrats in the U.S. again and again display their inability to make wise decisions. The VA, Medicare, Medicaid are all examples. Why do we think that "this time" it will be different if only we gave them complete control?

I don't, please stop putting words in my mouth.

 

[GeneralVeers]

I don't, please stop putting words in my mouth.

I'm confused then. You seem to be supporting single-payer health systems. If I am incorrect, then I apologize.

 

[Pons Asinorum]

I agree here completely.

I think we should move to a 2 tiered system. Medicare for all on one side, then private insurance for enhanced care and more options.

Of course, that assumes the government can make a competent and efficient model - which may be impossible.

Don't agree w/all in Wilco's quote (medical-related debt being the driver of most bankruptcy has been debunked, for one) but I do agree with the Jack here. Adequate floor, and then available coverage above and beyond that keeps a strong incentive to achieve financial success.

 

[EctopicFetus]

This has been the case in every flat hourly rate ED I've been in. Without productivity or fee for service, human nature takes over and people get lazy.

If I was in a system like this being lazy makes sense. Less liability exposure, higher patient sat and less stress.

 

[EctopicFetus]

If we pay the same for all procedures the complex ones will be harmed. When I was a resident we took some of the sickest patients in all of arizona. They were the ones who were too complex for the guys in the middle of nowhere. What would be the incentive for this. One case stands out immediately. While rotating in the trauma/surgery ICU i took a transfer of a lady with some gallbladder issue who was septic from candida. She had about 10 other problems and was sick as snot. Surely her cost of care was sky high but I could envision as system where no one wants to touch this patient because it would ruin their numbers.