Obama's Plan...

[shahalam]

I know that there have been previous talks about this topic and how it will affect EM practice/salary in this forum. However, those all seem to have been before there was an actual plan present. Yeah, I know there is still really nothing set in stone with the bill but with the forces aligning against us, I just feel like we've lost the fight already against it. I'm pretty disheartened but looking for some hope. Any of you all take a look at the thing and know how it will affect those of you in EM and those of us pursuing EM in the future? All comments appreciated!

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[diphenyl]

I'll put it out there that I am not a supporter of universal health care. I just have to get it across that the scare mongering done by the conservative right at fox if down right outrageous. They flip out over a 3 cent tax on cans of soda to fund health care reform? They act like a 3 cent tax is robbing them of half their income. Grow up! Personally if a 3 cent tax on soda meant that medicare would be funded adequately to stop shrinking reimbursements I would start Rx'ing pepsi. Secondly this argument that Obama is going to kill senior citizens. Absolutely outrageous! I wish he would start putting restrictions on what care we could give people. I think everyone over the age of 70.. automatic DNR. I'm sorry little timmy but the taxpayers shouldn't have to pay 12 grand per day to keep your 90 yo grandmother on a vent when her dementia is so advanced she lost what made her a person when the first Bush was in office! This scare mongering makes me sick. Some of these thing that they are using to influence people actually should go into policy.

 

[bulgethetwine]

I'll put it out there that I am not a supporter of universal health care. I just have to get it across that the scare mongering done by the conservative right at fox if down right outrageous. They flip out over a 3 cent tax on cans of soda to fund health care reform? They act like a 3 cent tax is robbing them of half their income. Grow up! Personally if a 3 cent tax on soda meant that medicare would be funded adequately to stop shrinking reimbursements I would start Rx'ing pepsi. Secondly this argument that Obama is going to kill senior citizens. Absolutely outrageous! I wish he would start putting restrictions on what care we could give people. I think everyone over the age of 70.. automatic DNR. I'm sorry little timmy but the taxpayers shouldn't have to pay 12 grand per day to keep your 90 yo grandmother on a vent when her dementia is so advanced she lost what made her a person when the first Bush was in office! This scare mongering makes me sick. Some of these thing that they are using to influence people actually should go into policy.

I think it's two separate arguments. I have, clearly, been one of the SUPPORTERS of some sort of "universal health care" - notably a single payer system - but I think Obama's plan is going to put too much of the burden on "cost-cutting" rather than any revolutionary thought. Read: Shrinking physician reimbursement.

Yes, the whole 'spin' the Republicans put on the movement to provide funding for a one-day course in family conversations - effectively calling it a course on euthanasia was ridiculous.

 

[It'sElectric]

I'll put it out there that I am not a supporter of universal health care. I just have to get it across that the scare mongering done by the conservative right at fox if down right outrageous. They flip out over a 3 cent tax on cans of soda to fund health care reform? They act like a 3 cent tax is robbing them of half their income. Grow up! Personally if a 3 cent tax on soda meant that medicare would be funded adequately to stop shrinking reimbursements I would start Rx'ing pepsi. Secondly this argument that Obama is going to kill senior citizens. Absolutely outrageous! I wish he would start putting restrictions on what care we could give people. I think everyone over the age of 70.. automatic DNR. I'm sorry little timmy but the taxpayers shouldn't have to pay 12 grand per day to keep your 90 yo grandmother on a vent when her dementia is so advanced she lost what made her a person when the first Bush was in office! This scare mongering makes me sick. Some of these thing that they are using to influence people actually should go into policy.

If you can up that DNR to 80, I'm on board. I mean seriously, does anyone really care to live much beyond 85?

On a side note, I'm neither Repub or Dem, but I have to say that fear mongering is universal throughout politics.

 

[GeneralVeers]

I think it's two separate arguments. I have, clearly, been one of the SUPPORTERS of some sort of "universal health care" - notably a single payer system - but I think Obama's plan is going to put too much of the burden on "cost-cutting" rather than any revolutionary thought. Read: Shrinking physician reimbursement.

Yes, the whole 'spin' the Republicans put on the movement to provide funding for a one-day course in family conversations - effectively calling it a course on euthanasia was ridiculous.

Single-payer is technically unconstitutional. It would require government to outlaw all forms of private enterprise within medical care, which is clearly a violation of States' rights.

That being said, Obama's "Health Insurance Reform" does little to reform anything. All it does is place millions of Americans on a public health plan, thereby increasing the cost to taxpayers.

He hasn't addressed malpractice, end-of-life care, hospice, and emergency-department overuse, which would be huge areas to achieve savings.

If we just charged all patients $1 for parking (as someone else on this forum suggested) we could probably eliminate a huge portion of inappropriate ED visits. Likewise charge them $1 for ambulance transport.

 

[DoctorMedic]

Single-payer is technically unconstitutional. It would require government to outlaw all forms of private enterprise within medical care, which is clearly a violation of States' rights.

That being said, Obama's "Health Insurance Reform" does little to reform anything. All it does is place millions of Americans on a public health plan, thereby increasing the cost to taxpayers.

He hasn't addressed malpractice, end-of-life care, hospice, and emergency-department overuse, which would be huge areas to achieve savings.

If we just charged all patients $1 for parking (as someone else on this forum suggested) we could probably eliminate a huge portion of inappropriate ED visits. Likewise charge them $1 for ambulance transport.

Haha just like the ER, supposed to get paid, we bill em, they don't pay. Big surprise. Reminds me of the 2am toothache literally 500 yrds from the hospital called an ambulance.

 

[bulgethetwine]

Single-payer is technically unconstitutional. It would require government to outlaw all forms of private enterprise within medical care, which is clearly a violation of States' rights.

That being said, Obama's "Health Insurance Reform" does little to reform anything. All it does is place millions of Americans on a public health plan, thereby increasing the cost to taxpayers.

He hasn't addressed malpractice, end-of-life care, hospice, and emergency-department overuse, which would be huge areas to achieve savings.

If we just charged all patients $1 for parking (as someone else on this forum suggested) we could probably eliminate a huge portion of inappropriate ED visits. Likewise charge them $1 for ambulance transport.

Not sure how you draw the line that 'single payer' = unconstitutional leading to outlawing all forms of private enterprise ?!? It might be bad for the current insurance companies, but it's hardly unconstitutional. In fact, it would be a big boon for a lot of other health care-associated enterprises.

Otherwise, agree with everything you said, particularly what it DOESN'T address!

Incidentally, the parking thing is pretty funny.... for a long time the biggest complaint (frequency) on the Press Gainey cards at my old hospital was 'parking'. And we had f* ck &ing VALET!

 

[Jeff698]

Not sure how you draw the line that 'single payer' = unconstitutional leading to outlawing all forms of private enterprise ?!?

I think this is a definitional thing. If it is truly SINGLE payor, that means, by definition, there is only ONE payor. Since most single payor plans envision the government being that payor, the only way to enforce the "single payor" part is to outlaw private insurance.

Nice straw man in the current conversation, of course, since nothing with any real chance of passing is actually talking about that.

You could (and many are) making the argument that a public option is tantamount to single payor but I think that's a bit of hyperbole. Plus, it doesn't look like anything resembling a public option will ever live long enough for anyone on either side to be able to say "I told you so".

Take care,
Jeff

 

[NinerNiner999]

The only thing bigger than the mess this bill will create is the tub of K-Y jelly we're going to have to pass around to make it's implementation a little less painful.

- Mark Twain

 

[GeneralVeers]

I think it's two separate arguments. I have, clearly, been one of the SUPPORTERS of some sort of "universal health care" - notably a single payer system - but I think Obama's plan is going to put too much of the burden on "cost-cutting" rather than any revolutionary thought. Read: Shrinking physician reimbursement.

Single-payer by definition means there is only one party that pays for healthcare, that being the Federal government. You cannot have a single-payer system and have any privately run healthcare, by definition. Now you can have a "public option" and have private healthcare, but it's not the same as single payer.

Obama has stated on numerous occasions both before and during the campaign that he would favor a single-payer system. I have no reason to believe that he's since changed his mind on this, and thus I believe his intent is to have the "public option" eventually crowd out private insurers.

 

[DoctorMedic]

actually specifically says in the constitution
"The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

Tenth ammendment. I don't believe they mention healthcare in the constitution as a federal power.

 

[EM2BE]

The only thing bigger than the mess this bill will create is the tub of K-Y jelly we're going to have to pass around to make it's implementation a little less painful.

- Mark Twain

love it!

 

[pseudoknot]

That being said, Obama's "Health Insurance Reform" does little to reform anything.

You don't think it would be helpful if people didn't have to lose their insurance when they switched jobs, or became sick (i.e. pre-existing condition exclusions)? I know you're not capable of admitting that anything Obama does is beneficial, but I'm just pointing this out for others.

He hasn't addressed malpractice, end-of-life care, hospice, and emergency-department overuse, which would be huge areas to achieve savings.

Studies have shown that malpractice reform and aggressive limitation of end-of-life care would bring minimal savings. Certainly these are not the areas driving the massive cost increases in healthcare spending. According to ACEP, there is very little ED overuse, but rather a large amount of appropriate use combined with a decline in both ED capacity and admission capacity (leading to boarding).

 

[GeneralVeers]

You don't think it would be helpful if people didn't have to lose their insurance when they switched jobs, or became sick (i.e. pre-existing condition exclusions)? I know you're not capable of admitting that anything Obama does is beneficial, but I'm just pointing this out for others.

While it would be great for everyone with pre-existing conditions to be covered, I'm not so sure how you can make that happen and keep the insurance companies in business.

I would favor a solution requiring insurance companies to cover someone for a minimum of 1 year, after which they could drop the patient if the patient did not meet health improvement guidelines like weight loss, blood sugar control or cholesterol control. Unfortunately I don't see that happening as government likes to pay for free things for people without requiring any ounce of responsibility from those receiving benefits (see Welfare, food stamps, Medicare, Medicaid).

I thought Obama's decision on stem cells was correct. The rest....well

Studies have shown that malpractice reform and aggressive limitation of end-of-life care would bring minimal savings. Certainly these are not the areas driving the massive cost increases in healthcare spending. According to ACEP, there is very little ED overuse, but rather a large amount of appropriate use combined with a decline in both ED capacity and admission capacity (leading to boarding).

So what you're telling me is that there is no way to enact health savings without massive rationing or vastly reducing provider reimbursement? Obama seems to think otherwise.

 

[Jeff698]

As much as I've wanted a reform of our health system, what I'm seeing so far is a reform of our health insurance system.

Sure requiring a minimum set of benefits, eliminating pre-existing conditions exclusions, requiring a single unified reimbursement form (something I haven't seen in any proposals yet) and aggressively enforcing prompt pay regulations is a good start, I don't think it gets to the underlying economic issues (although it may, and likely will, increase coverage).

The best way for our system to hold down costs is to set up incentives for physicians AND patients to utilize less/more appropriately. IMHO, the patient role in this is the larger of the two. Patients must have an up-front stake in the costs of healthcare. Otherwise, they want everything and want it know.

How many of those 1 hour old knee injuries that you see will insist on an emergent MRI once they have to plop down $1K for it?

Take care,
Jeff

 

[Druggernaut]

Studies have shown that malpractice reform and aggressive limitation of end-of-life care would bring minimal savings. Certainly these are not the areas driving the massive cost increases in healthcare spending.

You wouldn't happen to have links or anything to those studies, would you? Not trying to be adversarial, I'd honestly like to see something like that. The last thing I've seen put care delivered in the last year of life at 10-12% of all healthcare spending, with 40% of that in the last 30 days. It seems a lot of that could be limited and provide substantial savings.

 

[pseudoknot]

You wouldn't happen to have links or anything to those studies, would you? Not trying to be adversarial, I'd honestly like to see something like that. The last thing I've seen put care delivered in the last year of life at 10-12% of all healthcare spending, with 40% of that in the last 30 days. It seems a lot of that could be limited and provide substantial savings.

Sure.

Defensive medicine:
http://www.factcheck.org/president_uses_dubious_statistics_on_costs_of.html

End of life care:
http://content.nejm.org/cgi/content/full/330/8/540

Note also that the biggest problem with healthcare costs isn't that they are currently so high, but that they are increasing faster than almost any other sector of the economy. I don't see how this can be explained by defensive medicine, unless the rate of malpractice suits were also increasing.

In my view, tort reform would not to do much to change practice since "defensive medicine" either reflects the standard of care (not missing MIs, for example) or physician paranoia and ignorance of the law. It has also been shown that most victims of actual malpractice don't sue and that the strongest predictor of who will sue is poor communication between doctor and patient. This isn't something that will be prevented by ordering more CT scans.

 

[GeneralVeers]

Note also that the biggest problem with healthcare costs isn't that they are currently so high, but that they are increasing faster than almost any other sector of the economy. I don't see how this can be explained by defensive medicine, unless the rate of malpractice suits were also increasing.

Healthcare costs are not actually "increasing". I'm sure I could provide 1950's care: Chest X-ray and Penicillin, for much cheaper cost than in 1950 (after adjusting for inflation). Who would seriously want to get 50 year old medicine? The costs are perceived to be increasing because we have new technologies, new drugs, and new procedures that save lives, and patients expect to get them. A CT scanner is a hugely costly machine to purchase, operate and staff, something they didn't have to deal with even 25 years ago.

In my view, tort reform would not to do much to change practice since "defensive medicine" either reflects the standard of care (not missing MIs, for example) or physician paranoia and ignorance of the law. It has also been shown that most victims of actual malpractice don't sue and that the strongest predictor of who will sue is poor communication between doctor and patient. This isn't something that will be prevented by ordering more CT scans.

In my experience 80% of the x-rays, and 50% of the CT-scans are not ordered by me because of significant clinical suspicion, but because I want to cover my ass. Why do some surgeons still demand a CT scan for a young healthy male with acute appendicitis?

Say I order 10 CT scans per day. If they are all medicare patients, what is the cost of each scan to Medicare, perhaps $200? Imagine if I could cut out 5 of those. That is $1000 I have just saved on every shift I work, which amounts to $180,000 per year. That seems like real cost savings to me, and that's just one frivolous test I've eliminated.

 

[pseudoknot]

Healthcare costs are not actually "increasing". I'm sure I could provide 1950's care: Chest X-ray and Penicillin, for much cheaper cost than in 1950 (after adjusting for inflation). Who would seriously want to get 50 year old medicine? The costs are perceived to be increasing because we have new technologies, new drugs, and new procedures that save lives, and patients expect to get them. A CT scanner is a hugely costly machine to purchase, operate and staff, something they didn't have to deal with even 25 years ago.

Well, they are increasing, and have been for quite some time, and that is far beyond dispute. Note also that despite having the highest per capita costs, we have many of the worst outcomes in the industrialized world.

In my experience 80% of the x-rays, and 50% of the CT-scans are not ordered by me because of significant clinical suspicion, but because I want to cover my ass. Why do some surgeons still demand a CT scan for a young healthy male with acute appendicitis?

Say I order 10 CT scans per day. If they are all medicare patients, what is the cost of each scan to Medicare, perhaps $200? Imagine if I could cut out 5 of those. That is $1000 I have just saved on every shift I work, which amounts to $180,000 per year. That seems like real cost savings to me, and that's just one frivolous test I've eliminated.

Uh, so what you're saying is that your decisions as a physician are what drive the costs in our system, and that you could choose to spend less of other people's money without affecting outcomes. I think that should answer your question above about how to reduce costs without "rationing."

 

[GeneralVeers]

Well, they are increasing, and have been for quite some time, and that is far beyond dispute. Note also that despite having the highest per capita costs, we have many of the worst outcomes in the industrialized world.



Uh, so what you're saying is that your decisions as a physician are what drive the costs in our system, and that you could choose to spend less of other people's money without affecting outcomes. I think that should answer your question above about how to reduce costs without "rationing."

I can't reduce those costs because the system won't let me....the legal system that is. If it was much harder to sue (think Texas "Negligence" or "wanton disregard" language), I would not do a lot of these studies.

 

[GeneralVeers]

Well, they are increasing, and have been for quite some time, and that is far beyond dispute. Note also that despite having the highest per capita costs, we have many of the worst outcomes in the industrialized world.

They are only increasing because the quality of care is increasing, as well as the complexity, manpower, and technology needed. As I stated earlier, for equivalent treatments the cost has probably come down over time.

You keep confusing MEDICAL CARE with HEALTH CARE. They are two different things. The studies show that when you actually get sick, our outcomes are better. Cancer and heart disease are two examples. In terms of actual healthcare (including risk factors, prevention, diet, exercise, smoking) we fair worse than other countries, because Americans make terrible, terrible decisions about their own health. That is not something that likely can be altered or modified with any amount of spending.

 

[bulgethetwine]

I think this is a definitional thing. If it is truly SINGLE payor, that means, by definition, there is only ONE payor. Since most single payor plans envision the government being that payor, the only way to enforce the "single payor" part is to outlaw private insurance.

Nice straw man in the current conversation, of course, since nothing with any real chance of passing is actually talking about that.

You could (and many are) making the argument that a public option is tantamount to single payor but I think that's a bit of hyperbole. Plus, it doesn't look like anything resembling a public option will ever live long enough for anyone on either side to be able to say "I told you so".

Take care,
Jeff

Only in America will we defend the insurance companies based on a visceral, indoctrinated feeling that it "just isn't right" because it is so un-American and unconstitutional to "restrict capitalism" in this arena.

We'll cling to our ill-defined notion of what is "constitutional" while we watch the insurance companies escape reform once again.

I'm betting take home pay in emergency medicine falls a minimum of 20%, maybe as much as 50% in some community jobs.

 

[gman33]

They are only increasing because the quality of care is increasing, as well as the complexity, manpower, and technology needed. As I stated earlier, for equivalent treatments the cost has probably come down over time.

You keep confusing MEDICAL CARE with HEALTH CARE. They are two different things. The studies show that when you actually get sick, our outcomes are better. Cancer and heart disease are two examples. In terms of actual healthcare (including risk factors, prevention, diet, exercise, smoking) we fair worse than other countries, because Americans make terrible, terrible decisions about their own health. That is not something that likely can be altered or modified with any amount of spending.

Disagree with a lot of GV's points, but I think both of these are spot on.
When people complain about insurance premiums, etc increasing each year, they forget to account for all the new expensive services that are being covered. Sometimes these products don't provide a significant enough improvement in outcomes to justify the cost. Somebody has to pay for all these advances and as it is now, a lot of that burden falls on the US.

 

[GeneralVeers]

Only in America will we defend the insurance companies based on a visceral, indoctrinated feeling that it "just isn't right" because it is so un-American and unconstitutional to "restrict capitalism" in this arena.

We'll cling to our ill-defined notion of what is "constitutional" while we watch the insurance companies escape reform once again.

I'm betting take home pay in emergency medicine falls a minimum of 20%, maybe as much as 50% in some community jobs.

There is nothing ill-defined about the Constitution. It states quite clearly that something like national single-payer insurance would be unconstitutional. Although the Consitution is something our government has long since ceased to care about, respect, or adhere to.

 

[It'sElectric]

You keep confusing MEDICAL CARE with HEALTH CARE. They are two different things. The studies show that when you actually get sick, our outcomes are better. Cancer and heart disease are two examples. In terms of actual healthcare (including risk factors, prevention, diet, exercise, smoking) we fair worse than other countries, because Americans make terrible, terrible decisions about their own health. That is not something that likely can be altered or modified with any amount of spending.

The above is why I will forever resist what the current government is trying to do to our country - institute a cloak of entitlement.

I mean when I think about the fact that 1/3 of all adult Americans are obese, more than double what it was 20 years ago, I'm absolutely amazed by how our medical system is keeping them alive. No other country has a population as unhealthy as ours, yet our system continues to extend the lives of these people.

Similar to education, you can throw millions upon millions of dollars at something (i.e. prevention, technology), but ultimately it starts at home. People need to start taking responsibility for themselves and the decisions they make.

 

[Stitch]

Sure.

In my view, tort reform would not to do much to change practice since "defensive medicine" either reflects the standard of care (not missing MIs, for example) or physician paranoia and ignorance of the law. It has also been shown that most victims of actual malpractice don't sue and that the strongest predictor of who will sue is poor communication between doctor and patient. This isn't something that will be prevented by ordering more CT scans.

I can't wait until you get out of your safe little classroom and actually start practising medicine. You're in for a shock, and it's always fun to watch the new residents have an eye opener in terms of litigation reality. I do agree, however that caps won't fix the problem, or at least that there's no evidence they do.

Here's a perspective on defensive medicine. The problem is (and Fact Check mentions this) what's defensive is extremely difficult to guage because it's become so tied up in standard of care.

But perhaps more pertinent to the ER is access to emergent ancillary services. There's ample data describing how fear of or involvement in litigation results in limited access to things like neurosurgery, hand surgery or other specialists. You can argue that it's simply 'physician paranoia' or 'ignorance of the law' but the fact is we live in a litigenous society, and when you see a good collegue (or two or three)successfully sued for good decision... well you get the idea.

 

[Random Anesthesiologist]

actually specifically says in the constitution
"The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

Tenth amendment. I don't believe they mention healthcare in the constitution as a federal power.

Good call. I'm glad you put that out there. More people in this argument need to read our Constitution and what powers the president can use exactly. Our current president has overstepped his boundaries moreso than any other president, including the previous one where the opposing parties argued unconstitutionality.

In addition, I don't feel employers should be forced to provide health care benefits. It's a nice benefit, but should not be mandatory.

I went from being self-employed for years to opting out of health insurance benefits and have had very affordable care with good coverage on my own.

 

[Random Anesthesiologist]

They are only increasing because the quality of care is increasing, as well as the complexity, manpower, and technology needed. As I stated earlier, for equivalent treatments the cost has probably come down over time.

You keep confusing MEDICAL CARE with HEALTH CARE. They are two different things. The studies show that when you actually get sick, our outcomes are better. Cancer and heart disease are two examples. In terms of actual healthcare (including risk factors, prevention, diet, exercise, smoking) we fair worse than other countries, because Americans make terrible, terrible decisions about their own health. That is not something that likely can be altered or modified with any amount of spending.

it's also hard to compare since America vs. other countries have different population sizes, different immigration standards, and, like you mention, different lifestyles.

If America were truly a federation of states (as was intended), with states making their own decisions, it would be more easily comparable.

 

[bakanoisha]

Uh, so what you're saying is that your decisions as a physician are what drive the costs in our system, and that you could choose to spend less of other people's money without affecting outcomes. I think that should answer your question above about how to reduce costs without "rationing."

I think his intent was to state he has to run uneccessary tests to avoid falling victim to an ambulance chaser (losing everything he's worked incredibly hard for), and that it's very expensive.

 

[bakanoisha]

You keep confusing MEDICAL CARE with HEALTH CARE. They are two different things. The studies show that when you actually get sick, our outcomes are better. Cancer and heart disease are two examples.

I've heard this piont being made before, that our medical outcomes are very good, and I've heard some pretty shocking numbers supporting it.

Has anybody seen the numbers personally? I would love to have a study with that info available to me. Thx

 

[pseudoknot]

In terms of actual healthcare (including risk factors, prevention, diet, exercise, smoking) we fair worse than other countries, because Americans make terrible, terrible decisions about their own health. That is not something that likely can be altered or modified with any amount of spending.

Our population isn't generally sicker than those of other industrialized nations, and in fact we have one of the lowest smoking rates.

Also, you can certainly change behavior with education and incentives. Smoking and seatbelts are two good examples (although I'm sure if you had your way we would have neither seatbelt laws nor automotive safety regulations since they are so intrusive).

 

[pseudoknot]

I do agree, however that caps won't fix the problem, or at least that there's no evidence they do.

Here's a perspective on defensive medicine. The problem is (and Fact Check mentions this) what's defensive is extremely difficult to guage because it's become so tied up in standard of care.

So, we mostly agree here: caps won't lower costs (as they didn't in Texas). And some of the stuff people ascribe to defensive medicine is actually just done to adhere to a standard of care that the physician considers unreasonable (i.e., never missing an MI).

However, I think that if we're going to lower the standard of care for things like that, it is far better to do it with experts reviewing the evidence and making decisions in a transparent and accountable way, than to have individual physicians do whatever they want without fear of legal consequences.

But perhaps more pertinent to the ER is access to emergent ancillary services. There's ample data describing how fear of or involvement in litigation results in limited access to things like neurosurgery, hand surgery or other specialists.

I'm quite certain that the unwillingness of specialists to take emergency call is primarily due to the number of uninsured patients they would have to see. There is a risk of being sued with any patient, but it's less worth it if they aren't getting paid in the first place. Universal coverage would fix this. It's also the right thing to do.

 

[Jeff698]

So, we mostly agree here: caps won't lower costs (as they didn't in Texas). And some of the stuff people ascribe to defensive medicine is actually just done to adhere to a standard of care that the physician considers unreasonable (i.e., never missing an MI).

As a practicing EP in Texas, I can tell you our reform certainly lowered costs. It's just that the costs were ours (liability premiums) and not those of patients. It was never sold as a way to lower health care costs but rather as a way of improving access to specialists who couldn't get affordable insurance and, as a result, weren't taking call. In this regard, it achieved exactly what it set out to do.

I also think you're right about the difficulty of defining what defensive medicine really is. Sure, part of it is being afraid of being sued but I don't think (from my personal experience in Texas, anyway) that's the biggest part.

As physicians, we're scared of being wrong. As EPs, we're scared of missing the 'badness'. We have accepted the zero miss rate that has been imposed on us by society and test accordingly. Obviously, there is a huge variation in how risk averse individual physicians are but I think that overall this holds true.

I'm not much of a tester but I'll admit I order tests I don't always think are necessary. Partly it is "to be sure I'm not missing" diagnosis X.

The other factor pushing us to order tests that we don't think are necessary is patient expectation. If I feel a patient expects test X, I may or may not try to talk them out of it. If it is a potentially harmful intervention (CT scans) I'll do my best or just put my foot down. If it isn't harmful but just not needed and I'm getting my ass kicked in the department I'll often take the path of least resistance, order the test and move on.

Sometimes it just ain't worth saving "the system" money at the expense of my department backing up and me loosing even more of my soul.

Take care,
Jeff

 

[old_boy]

Studies have shown that malpractice reform... would bring minimal savings.

Um, so basic math proves you're wrong. The entire malpractice insurance industry is "waste" in our system if you consider the alternative no malpractice insurance industry. Let's assume the average physician pays $20,000/yr in malpractice (we'll ignore additional malpractice paid by hospitals). Multiply that by 800,000 physicians in the US, and you get $16 BILLION /yr. Of course even in a reformed system with intelligent caps and special malpractice courts there would still be a malpractice insurance industry, but even if it were halved in size and the savings were filtered through the system we'd be looking at $80 billion in savings for our health care system over the next 10 years. Oh, by the way, that's what big pharma promised Obama.

Note that this does not even bring into account defensive medicine. Arguing about defensive medicine misses much of the cost savings from malpractice reform.

 

[pseudoknot]

Um, so basic math proves you're wrong. The entire malpractice insurance industry is "waste" in our system if you consider the alternative no malpractice insurance industry.

That would require completely eliminating malpractice suits, which is certainly not a reasonable or desirable goal (nor, I suspect, a constitutional one). There are bad physicians and there is malpractice, and there must be both consequences for the doctors involved and redress for the victims. Indeed, since published studies have shown that between 40 and 95% of malpractice suits are well-founded, I'm not so sure there is a huge problem with the system (although I agree it could be improved).

 

[ReefTiger]

I spoke with a few different docs today about this plan. One of them said they actually spoke with someone who has actually read the 1100 pg document known as Obama's plan.

In it, according to her, is the mechanism for abolishing insurance companies. Essentially, once national care goes into effect anyone who has private insurance gets to keep it.....UNTIL their medical status changes. So, if I develop HTN I get booted from my private plan and automatically enrolled in the national plan. ?????? Really???

Also, if you want to pay me cash for service I cannot accept it under the Obama plan. Why? Because it is viewed as favoritism and you'd be skipping in line. I understand stuff about everyone being equal, but this is dictating services. WTF?

The major problem is the mad rush to get this in place. He doesn't even know what is in it, and it's obvious he doesn't care for physicians by his speeches. Furthermore, congress doesn't know what's in it either and once it is in place it is tough to adjust. Why are we rushing so damn fast?

I think Americans want some reform, even I do, but at what cost? The government will have vested power in our financial institutions, the automobile industry, and now your own heath care options (there are no options if it is only one).

This economic situation has people not thinking as clearly as they should. Too much is being decided with emotion. Stop and take a few breaths.

I believe Thomas Jefferson said this, "Any government that can give you everything you want has enough power to take all that you have."

 

[southerndoc]

The change in insurance status isn't when you develop a condition. Insurance companies can't drop your coverage because you developed hypertension, and you won't be forced to get the public plan when you develop hypertension. If you change deductibles, if your coinsurance changes, etc., then you would be required to go through the public exchange, which doesn't necessarily require you to purchase the public plan. There is a difference between the two (one is an insurance, one is a regulatory agency designed to allow you to compare plans).

Nonetheless, not all is well in socialized medicine: http://online.wsj.com/article/SB124958049241511735.html

 

[GeneralVeers]

Our population isn't generally sicker than those of other industrialized nations, and in fact we have one of the lowest smoking rates.

We have higher levels of obesity, more caloric intake, and more sedentary lifestyles, all of which contribute to the epidemic of obesity. I still work occasionally down in South Texas and I'm continually shocked by every patient who has diabetes, hypertension, CAD, high cholesterol, and doesn't exercise. Well over 80% of the patients I see there have diabetes. All of these lifestyle choices directly contributes to our worse overall "health".

Also, you can certainly change behavior with education and incentives. Smoking and seatbelts are two good examples (although I'm sure if you had your way we would have neither seatbelt laws nor automotive safety regulations since they are so intrusive).

Actually I'm for seatbelt laws and automotive regs, provided they are implemented at the state level and not the federal level. Driving is not a right, and nowhere in the constitution does it not give states the right to regulate automobiles. Healthcare should be treated similarly....entirely implemented and monitored at the state level, with the Feds staying out of it entirely.

 

[GeneralVeers]

The change in insurance status isn't when you develop a condition. Insurance companies can't drop your coverage because you developed hypertension, and you won't be forced to get the public plan when you develop hypertension. If you change deductibles, if your coinsurance changes, etc., then you would be required to go through the public exchange, which doesn't necessarily require you to purchase the public plan. There is a difference between the two (one is an insurance, one is a regulatory agency designed to allow you to compare plans).

Nonetheless, not all is well in socialized medicine: http://online.wsj.com/article/SB124958049241511735.html

Interestingly, the plan to force insurance carriers to cover "pre-existing conditions" is the last-ditch effort by the progessives to destroy private industry and enact a large scale public health plan. They know Americans as a whole won't accept single payer, and they know that most won't voluntarily sign up for the "public option" (unless their employer forces them to), so they simply are going to destroy the private industry, thus allowing no alternative to the public option.

By forcing carriers to cover "pre-existing conditions" it will result in one of two outcomes:

1. Private industry goes bankrupt
2. Private health insurance is priced out of the budget of average Americans.

The end result is the same, most Americans would have to sign up for government-controlled plans.

 

[old_boy]

That would require completely eliminating malpractice suits, which is certainly not a reasonable or desirable goal (nor, I suspect, a constitutional one). There are bad physicians and there is malpractice, and there must be both consequences for the doctors involved and redress for the victims. Indeed, since published studies have shown that between 40 and 95% of malpractice suits are well-founded,

I did not say eliminating suits was desirable; i just used the hypothetical example to calculate potential savings. As I mentioned above, I think shrinking the industry by 50% is possible, yielding significant savings (in the neighborhood of $80bn over 10 years by my above back of the envelope calculation). It's not just the percentage of suits that have merit, it's the size of the payouts. With a combination of dedicated medical courts (bringing down the number of lawsuits without merit) and intelligent caps, this kind of savings is both possible and desirable.

I'm not so sure there is a huge problem with the system

If you think that it is not a flaw in the system that some claimants win $10 million suits against OBs that deliver babies with CP despite standard-of-care practice (see: John Edwards), then you and I will just have to disagree.

 

[xaelia]

Clearly, the sites crowing about the emphasized portion of this article are more than a little biased, but it remains a mildly entertaining irony that someone protesting the healthcare reform is accepting donations for his healthcare bills because he was laid off and lost his insurance....

http://www.washingtonmonthly.com/archives/individual/2009_08/019423.php