Ideas to fix broken payor system

[IntelInside]

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I was thinking today about some of the things the govt can do to fix this horrific system that doctors are subjected to.

1) Eliminate emergency department required coverage for illegal immigrants

2) Tort reform - capping damages and setting up a healthcare court

3) Prescription Drug abuse reform - required data submission by all hospitals where all 3+ time drug seekers (who had no emergent condition at each visit) within a span of 1 year are put into a federal database system and all subsequent emergency departments visits for the next 1.5 years are not covered nor required by the emergency department to treat.

4) Ability to purchase insurance across state lines

5) SGR fix from money saved from troop withdrawals overseas

If all these ideas were implemented do you think the system would be much better?

 

[GeneralVeers]

There is no perfect way to fix our system. Every system has its drawbacks and benefits. Want everyone covered? Go to a single payor system, but accept that you will have limited ability to make choices about your own care. Likewise if you want freedom to make your own medical decisions and purchase your own insurance, then you have to accept that some people won't be covered either by choice or by finances. As far as your ideas go:

1. How would you do this? Require citizenship check at the door? Police aren't even allowed to do this when they stop an illegal for speeding (see U.S. Attorney General V. State of Arizona)

2. Federally mandated tort reform would be unconstitutional as malpractice and tort reform are state issues. Each of the states would have to pass their own bill separately.

3. This would be a scary opening for the Feds. They tell you that you are not allowed to give medications to a patient that is on their "list"? This would give them the foothold they need to direct every medical decision you make based on a "database". Granny can't have another stress test because she just had one last year.

4. This is a good idea. If the politicians can successfully fight the insurance lobby we can get this done. There's no reason why insurance companies should carve up monopolies within states.

5. There is no money. We already borrow money to pay for the wars in Afghanistan and Iraq. The "savings" we are getting from bringing them home are phony. You want to pay for SGR fix with that phony money? We still have have to borrow it.

One of the keys I think to fixing our system would be changing how insurance works. In most industries insurance is a risk stratification designed to pay for a catastrophic (but rare) event. Your auto insurance doesn't pay for oil changes, tire changes or routine maintenance. Why should health insurance. We should change health insurance in the following ways:

1. De-link health coverage from an employer making it portable. Essentially you buy your own insurance and it stays with you wherever you go as long as you pay the premiums.

2. Once you buy insurance when you are young, your premiums can't increase.

3. All policies would be "high-deductible" just like auto insurance. The insurance wouldn't start covering medical costs until you hit $2000 or so in a single years. This would force consumers to self-ration to some degree, but still protect them from a catastrophic event.

4. Get rid of Medicare and have a true health savings account. Workers can take 2-3% of their salary and place it in their own account which they can access at age 50. If used for medical costs it would be tax free and would accrue interest over time.

5. Poor and very sick people can get a voucher that will allow them to purchase health insurance a reduced cost.

 

[Tiger10]

I was thinking today about some of the things the govt can do to fix this horrific system that doctors are subjected to.

1) Eliminate emergency department required coverage for illegal immigrants

2) Tort reform - capping damages and setting up a healthcare court

3) Prescription Drug abuse reform - required data submission by all hospitals where all 3+ time drug seekers (who had no emergent condition at each visit) within a span of 1 year are put into a federal database system and all subsequent emergency departments visits for the next 1.5 years are not covered nor required by the emergency department to treat.

4) Ability to purchase insurance across state lines

5) SGR fix from money saved from troop withdrawals overseas

If all these ideas were implemented do you think the system would be much better?

Some good points, but 1) drug seekers get sick too and 2) we're not "saving" money by withdrawing troops, we're just losing less of it.

 

[goodoldalky]

One of the keys I think to fixing our system would be changing how insurance works. In most industries insurance is a risk stratification designed to pay for a catastrophic (but rare) event. Your auto insurance doesn't pay for oil changes, tire changes or routine maintenance. Why should health insurance.

I disagree. The reason you cannot use this analogy is because in healthcare, lack of primary care or primary prevention leads to higher costs and more catastrophic healthcare needs in the long term.

What health insurance SHOULD do is mandate primary care and primary prevention, as a responsibility of the insuree, and should certain metrics fail or not be met (i.e.: go to your PCP once in x timeframe, get screening labs, stop smoking crack), then you forefit your right to access certain care down the road. How you implement that is a nightmare, but the point is that insurance SHOULD be covering things on the front end (with some combination of incentives etc) because THAT is where cost saving happens. All this crap about dialysis, repeated ICU admissions, repeated CP rule outs for cocaine addicts, and expensive care in the last 6 months of life is what needs to go away.

1. De-link health coverage from an employer making it portable. Essentially you buy your own insurance and it stays with you wherever you go as long as you pay the premiums.

I am not sure this works. The reason employer sponsored healthcare coverage exists (one of them) is because it is a built in pool of people where the risk of insuring a person who is a liability is offset by insuring other employees who are healthy.

What you will have with this suggestion is healthy people obtaining health insurance, and those who need it will find it too expensive or difficult to access. There is no incentive for an insurance company to take these patients and they will invest their resources in avoiding that.

 

[GeneralVeers]

I disagree. The reason you cannot use this analogy is because in healthcare, lack of primary care or primary prevention leads to higher costs and more catastrophic healthcare needs in the long term.

Not generally true. The only prevention that has been found to be cost effective is smoking prevention. If you put 100 people on Lipitor at $1000 per year, how many heart attacks will you prevent? Not enough to offset the cost of lipitor for 30+ years on the remaining majority. That is why prevention is generally more expensive.


[/QUOTE]
I am not sure this works. The reason employer sponsored healthcare coverage exists (one of them) is because it is a built in pool of people where the risk of insuring a person who is a liability is offset by insuring other employees who are healthy.

What you will have with this suggestion is healthy people obtaining health insurance, and those who need it will find it too expensive or difficult to access. There is no incentive for an insurance company to take these patients and they will invest their resources in avoiding that.[/QUOTE]

Why can't healthy people just buy it? People need to take personal responsibility. If they refuse to get into the insurance pool when they are young and healthy, then too bad for them once they get old and/or sick. Why should government tell me what to do because many people are too stupid to look out for themselves?

 

[TrumpetDoc]

"Poor and very sick people can get a voucher that will allow them to purchase health insurance a reduced cost."

Yeah, but that cuts into their rather expensive car/clothes, and cell phone budget!
Just a poke at "that guy/gal" we have all seen in the ED. I know there are ppl in true need out there. 😉



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[TrumpetDoc]

Good
Good points, and I have railed on that concept of PCP prev care Pre recs a bunch of times with friends.

But govt then that just makes too much sense. On the same token, food stamps and the like should NEVER be able to buy junk food, etc.
The Libs have such a hardend govt dept voting base that we are in a death spiral, and I just don't see a way out with out drastic change that won't happen.



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[link2swim06]

Not generally true. The only prevention that has been found to be cost effective is smoking prevention. If you put 100 people on Lipitor at $1000 per year, how many heart attacks will you prevent? Not enough to offset the cost of lipitor for 30+ years on the remaining majority. That is why prevention is generally more expensive.

I am not sure this works. The reason employer sponsored healthcare coverage exists (one of them) is because it is a built in pool of people where the risk of insuring a person who is a liability is offset by insuring other employees who are healthy.

What you will have with this suggestion is healthy people obtaining health insurance, and those who need it will find it too expensive or difficult to access. There is no incentive for an insurance company to take these patients and they will invest their resources in avoiding that.[/QUOTE]

Why can't healthy people just buy it? People need to take personal responsibility. If they refuse to get into the insurance pool when they are young and healthy, then too bad for them once they get old and/or sick. Why should government tell me what to do because many people are too stupid to look out for themselves?[/QUOTE]

Smoking prevention doesnt even save money in the long run. It saves alot of money to die from a heart attack in your 60s than to make it to age 90 with a ton elective surgeries.

I forget the figure I read but smoking substantially will save medicare in the long run.

 

[IntelInside]

What would you forfeit down the road if certain pre-reqs werent met?

 

[Birdstrike]

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[deleted109597]

What makes those in government think that punishing and attacking doctors will improve the health care system, I'm not sure, but clearly doing so is forcing us to take the above steps.

I've said it before, but I'm afrad the slope has already been greased by CMS.
Right now, not enough docs are taking new Medicaid/Medicare patients. The number of docs opting out will grow, and the number of patients will also continue to grow, thanks to Obamacare. Eventually, we will reach critical mass, and the government will force docs to accept CMS monies either for a certain time after graduation, or more likely permanently, as part of licensure. Then many docs close to retirement will simply retire rather than lose money the last few years of their careers.
NPs will make headway as the new CMS providers, and it will continue to snowball.

 

[Arcan57]

I disagree. The reason you cannot use this analogy is because in healthcare, lack of primary care or primary prevention leads to higher costs and more catastrophic healthcare needs in the long term.

What health insurance SHOULD do is mandate primary care and primary prevention, as a responsibility of the insuree, and should certain metrics fail or not be met (i.e.: go to your PCP once in x timeframe, get screening labs, stop smoking crack), then you forefit your right to access certain care down the road. How you implement that is a nightmare, but the point is that insurance SHOULD be covering things on the front end (with some combination of incentives etc) because THAT is where cost saving happens. All this crap about dialysis, repeated ICU admissions, repeated CP rule outs for cocaine addicts, and expensive care in the last 6 months of life is what needs to go away.

Mandate catastrophic coverage (something decently high, possibly $10-20k) and give everyone a health savings account. If your income is below a certain amount, then the government puts money into the account for you. The HSA works like a flex account (tax-free), but the money rolls over year to year so you're not forced to guess at the beginning of the year how much you're going to spend on health-care and lose any excess.

Until we have some rational limit on the demand of healthcare, it will continue to grow unchecked. The government is big on supply-side solutions, but even in single-payor with significant socialist leaning systems the lack of payor risk leads to unsustainable inflation. The HSA pays for maintenance care, while discouraging profligate spending because the citizen still views themselves as the payors rather than some abstract company/government agency. I suspect this would lead to a significant reduction in "threefer" visits to the ED for childhood URIs.

I am not sure this works. The reason employer sponsored healthcare coverage exists (one of them) is because it is a built in pool of people where the risk of insuring a person who is a liability is offset by insuring other employees who are healthy.

What you will have with this suggestion is healthy people obtaining health insurance, and those who need it will find it too expensive or difficult to access. There is no incentive for an insurance company to take these patients and they will invest their resources in avoiding that.

That's why you need to scrap the current insurance system. It's a relic of wage-freezing during WW2, and exists only because of the significant tax incentives given to companies that offer employee insurance. Insurance is pooling of risk, and I think the risk of catastrophic care should be spread across the country and the risk of chronic maintenance should be largely on the individual.

 

[GeneralVeers]

Mandate catastrophic coverage (something decently high, possibly $10-20k) and give everyone a health savings account. If your income is below a certain amount, then the government puts money into the account for you. The HSA works like a flex account (tax-free), but the money rolls over year to year so you're not forced to guess at the beginning of the year how much you're going to spend on health-care and lose any excess.

You can't mandate people buy ANYTHING. It's unconstitutional to do so. The reason states can mandate that you buy car insurance is 1. They are states and can do this under the constitution, and 2. Driving is privilege, and you can choose not to drive if you don't want to pay for it.

Until we have some rational limit on the demand of healthcare, it will continue to grow unchecked. The government is big on supply-side solutions, but even in single-payor with significant socialist leaning systems the lack of payor risk leads to unsustainable inflation. The HSA pays for maintenance care, while discouraging profligate spending because the citizen still views themselves as the payors rather than some abstract company/government agency. I suspect this would lead to a significant reduction in "threefer" visits to the ED for childhood URIs.

I'm all for rationing. If you're on taxpayer-based medical coverage, then when you're 96, bedbound and demented you're not going to get any care other than comfort measures. We could save billions, as 80% of healthcare costs are accumulated at end of life.

That's why you need to scrap the current insurance system. It's a relic of wage-freezing during WW2, and exists only because of the significant tax incentives given to companies that offer employee insurance. Insurance is pooling of risk, and I think the risk of catastrophic care should be spread across the country and the risk of chronic maintenance should be largely on the individual.

I agree completely. Why we cover chronic maintenance is beyond me. It's foolish and provides an incentive to seek MORE care. If patients have to pay out of pocket they will choose what they want to have done, and ration their own care.

 

[TrumpetDoc]

You can't mandate people buy ANYTHING. It's unconstitutional to do so. The reason states can mandate that you buy car insurance is 1. They are states and can do this under the constitution, and 2. Driving is privilege, and you can choose not to drive if you don't want to pay for it.



I'm all for rationing. If you're on taxpayer-based medical coverage, then when you're 96, bedbound and demented you're not going to get any care other than comfort measures. We could save billions, as 80% of healthcare costs are accumulated at end of life.



I agree completely. Why we cover chronic maintenance is beyond me. It's foolish and provides an incentive to seek MORE care. If patients have to pay out of pocket they will choose what they want to have done, and ration their own care.

Ahhh a man can dream cant he


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[docB]

Since the government clearly refuses to listen to the physician viewpoint on these issues, and now has made it clear they view us as the enemy and the source of the problem and wish to punish us for the disastrous system they created, the only way I can see right now, to "fix" the system, is to opt out of the system as much as possible:

1. Cash only practices (boutique EDs or urgent cares).
2. Concierge practices (outpatient docs).
3. Leaving, or refusing to go to, states that punish doctors, i.e. Washington State and abusive med-mal states (all docs).
4. Leaving, or refusing to go into, specialties most abused (young docs and those still in training).
5. Refusing to take the most abusive insurances such as Medicaid/Medicare (docs not bound by EMTALA).

What makes those in government think that punishing and attacking doctors will improve the health care system, I'm not sure, but clearly doing so is forcing us to take the above steps.

I think that many, including the current administration, like the fact that the system is becomming more unstable and they think it would be great if we would all try to opt out. Their stated goal is single payer, universal healthcare. Once the current system fails completely they will be able to fulfill their long term goal by inserting a fully socialized system into the vacuum.

 

[gman33]

The system seems so screwed up in it's current state, I'm almost inclined to try and pursue a career in health policy instead of clinical medicine.
Feel like I'd probably be beating my head into a wall in that as well.

Currently doing an elective in plastic surgery.
I'm at an inner city program where almost everyone is medicaid/medicare.
Haven't seen a surgery yet that I thought should be pain for by the taxpayers.

Anyway.

I agree that we need a solution that limits the demand for healthcare.
The only way I see this happening is to have a financial component on patients.
I'd be fine with getting rid of insurance all together and going to a cash only system.
I just don't see an "insurance" model that will control spending.
Maybe some type of high deductible model.
Someone above discussed that you can't force anyone to buy insurance under the constitution. How about a government funded single payer system, but with a very high annual deductible? (like in the $5-10k/year range)
This would provide a national safety net, but would make patients think about costs.

In any case, someone has to come up with a solution as the current system is unsustainable for all parties involved.

 

[GeneralVeers]

The system seems so screwed up in it's current state, I'm almost inclined to try and pursue a career in health policy instead of clinical medicine.
Feel like I'd probably be beating my head into a wall in that as well.

Currently doing an elective in plastic surgery.
I'm at an inner city program where almost everyone is medicaid/medicare.
Haven't seen a surgery yet that I thought should be pain for by the taxpayers.

Anyway.

I agree that we need a solution that limits the demand for healthcare.
The only way I see this happening is to have a financial component on patients.
I'd be fine with getting rid of insurance all together and going to a cash only system.
I just don't see an "insurance" model that will control spending.
Maybe some type of high deductible model.
Someone above discussed that you can't force anyone to buy insurance under the constitution. How about a government funded single payer system, but with a very high annual deductible? (like in the $5-10k/year range)
This would provide a national safety net, but would make patients think about costs.

In any case, someone has to come up with a solution as the current system is unsustainable for all parties involved.

People have to have "skin in the game" otherwise they will consume more healthcare dollars than they need. If it costs them $50 they will really have to think about whether they really need to go to the doctor or ER for a cough/cold.

A single-payer system is unconstitutional, however the unconstitutionality of federally-run healthcare hasn't stopped Medicare. They would probably legally get away with a British-style two-tier system. A Canadian-style system would be grossly unconstitutional as you would essentially be banning free-market healthcare.

 

[gman33]

I don't know all the economics, but I'm more concerned with stopping the needless big ticket items. Like ICU stays costing $100k+ when all the studies in the world show the patient has 0% chance of meaningful return to function.

If families want this care, let them pay for it. Not a copay or the first $5k, all of it.

I agree that every visit should cost the patient something.

 

[Birdstrike]

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[GeneralVeers]

If you want to fix the broken payor system in America, I'd say we should start here:​

"The New American Dream"​

We live in an entitlement society where the masses want the $100,000 ICU stay, they want it now, they want a 100% guarantee that they'lll recover and they want the right to sue for $1,000,000+ if it falls an inch short of their expectations AND they want it all without having to pay a penny for it, and when they get their full 100% recovery they want disability paperwork filled out documenting they're despite being 100% recovered, they're really at no more than 49% full capacity.

They want to be able to smoke 3 packs per day and get a lung transplant if needed, to be able to drink 12 beers per day and have a liver waiting for them, enough sweets in their stomachs that their esophagus boils over with high fructose corn syrup with an unlimited supply of Nexium and Insulin to stem the tide, to stay happily 50lbs overweight sitting on the couch and get the heart cath q 5 years with HDTV in the hospital with TiVo in a private room, a pain score of zero, and be discharged the next day without missing an episode of American Idol and or they'll threaten you with trashing you on the satisfaction survey and report you to the medical board for violating the new standard we've created.

Why? Because it's owed to them. It's a "right" And it should be paid for by someone else. Life is good in America.

I'd say we're in deep s--t.

Once again, I encourage people to read Atlas Shrugged. Political bias aside, it's eerily prophetic for what's happening with our entitlement society and manufactured "rights".