“If you think healthcare is expensive now, wait until it is for free.” – PJ O’Rourke

On the eve of sweeping health reform legislation, it is hard not to notice the glowing skyline in Washington as policymakers ignite their torches, grab their pitch forks and race as a mob toward for-profit stakeholders who many feel have created, perpetuated and benefited from our highly uneven, inflationary and inconsistent system of healthcare in America.

Over a quarter century, I have consulted with and led employers, consumers, hospitals, physician groups, attorneys, pharmacuetical manufacturers and insurers. My personal epiphany prompting me to become more vocal about America’s need for systemic change did not spark in the middle of an inflammatory contract negotiation with a major hospital or flash during a heated employee meeting as we announced yet another deductible, co-pay and contribution increase. My burning bush occurred on a gurney in the hallway of British National Health Service (NHS) hospital where I lay for 20 hours deathly ill with pneumococcal pneumonia.

After moving to London with my young family, we decided to opt for public care. After all, I was curious to experience the NHS and with three kids under eight, we were constantly under siege with myriad colds, earaches and symptomless fevers. Best of all, it was free. Our neighborhood NHS family practice clinic was always crowded but convenient. Other than the occasional drug co-pay, we never received a bill. Yet, something was not quite right. My doctor always looked as if wild dogs or the Inland Revenue Service was pursuing him. I broke down during one examination and asked him how much he received from the National Trust for each patient to provide basic care. ” Not nearly enough, Mr. Turpin. Not nearly enough” He said absently while peering into my ear with a pen light.

In the bleak midwinter of our first English February, one of my kids came home with a nasty flu that raged through the house, flattening even my indefatigable wife who I considered indestructible. I was travelling on the Continent and needed to return early to play Florence Nightingale to the family influenza ward. As everyone slowly recovered, rising like Lazarus from the dead, I took ill and within one day, was coughing up blood and bedridden with a raging fever. After a brief visit with my GP, he called an ambulance and I was taken to casualty (Emergency) in a local NHS hospital. I was admitted and deposited on a gurney in a hallway alcove as I waited to be transferred to a hospital room. There was one problem. There were no beds available.

The ER was utter chaos with sick elderly and acute care victims in every conceivable location. The doctors were tireless and clearly dedicated but overwhelmed. Through the haze of illness, I watched the trauma triage go on for hours. My wife briefly appeared with the kids to visit.

As she surveyed the floors strewn with bloody gauze and the frenetic ballet of emergency medicine, she mouthed to me with her little finger near her chin and thumb next to her head,” I will call you later ” and fled the hospital as if it was a haunted house. In my delirium, I could have sworn a giant staph germ escorted her to the door. “Sorry you could not stay, love. I am staphoccocolus bacterius. Don’t worry he’s in good hands. Let’s do lunch.”

Doctors came and went in four-hour shifts. My principal worry was the harried Casualty staff’s inability to remember that I had a Penicillin allergy. I repeatedly mentioned my allergy to anyone who would make eye contact with me and twice awoke to catch a well-intentioned new doctor putting me on an amoxicillin drip.

In the early hours of the following morning, I was taken to a room that I shared with seven other of my new closest friends. There was a poor woman dying of stomach cancer and an attempted suicide. The bathroom smelled like Grand Central at 6pm and to my horror, there was no TV. My pulmonologist appeared followed by graduates that shuttled behind him like ducklings crossing a Kent country road. ” How is the pnuemo” he asked my Filipino nurse ” He is getting better, sir. Aren’t you?” she remarked looking at me. I wasn’t sure if this was a rhetorical question or a new affordability technique in stiff upper lip British medicine called “self fulfilled prognosis”.

I was suffering from pleurisy – the equivalent to a burning knife inserted in between your ribs each time you inhale. I was also very unhappy. I was in what felt like an overcrowded youth hostel and I wanted some bedside manner. After all, damn it, I was American. I wanted the head of pulmonology from the best London hospital to consult with me and give me his mobile and home phone number. I raised my hand to ask the doctor a question and he flashed a perfunctory smile and said, “right”. He turned and left the room.

I lay with an oxygen mask for a day drifting. I awoke and saw the face of a colleague from the office. It was as if he was a Red Cross worker checking on prisoner conditions per the Geneva Convention. He had lived in London as an ex-pat for five years and was appalled with my circumstances. ” What are you doing down here? ” He whispered. I gave him a pathetic look of incredulity and started blinking to him in Morse code “ g-e-t m-e o-u-t o-f h-e-r-e”.

He returned and was talking fast, “we have gotten you into private care and we have to transfer you.” He disappeared so quickly that I was uncertain if he had been a hallucination. I awoke again and was being moved. I expected to be shuttled into an ambulance taken across London to Great Portland Street to a private hospital where most ex-pats delivered babies and accessed private care for routine and elective procedures.

I was pushed on to an elevator by a Jamaican orderly who said in heavy Brixton accent, ” dis is yah lucky day mate.” The only luck I could fathom at this point was getting a room that did not smell. The elevator rose up just one floor and opened to a well-lit, beautifully decorated foyer where two eager nurses smiled and gathered around my gurney. “Mr. Turpin, we are so sorry about your illness and time down there“. Down there? Even the staff seemed to consider my two-day tour of duty in Casualty as tantamount to one of Dante’s levels of hell.

But it got better. The same aloof pulmonologist who a day early had treated me like a flank steak referring to me as the ‘pnuemo’, grinned and shook my hand. Mr. Turpin, I am Dr. Godot. Let me help you to your room. “ The Jekyll and Hyde switcheroo was not lost on me. Apparently, Dr Godot hit from both sides of the plate – public and private. Personality and bedside manner came with private care. My private room had a clean bath, cable television and a phone where I could call and order food. It was like the Ritz Carlton.

The doctor sat on my bed and shared my X-rays and described in pedantic detail my serious brush with death. It was as if he had all the time in the world. “You are over the worst of it but the inflammation and scarring will last quite a while. Once you are released, you can see me Tuesday next privately or in three weeks through the NHS. “

I was released the next day and chose to see Dr Godot privately for all my follow up care. I was in constant pain from the pleurisy and the reassuring ability to access my doctor when I needed to see him was worth the significant out of pocket expense. I was paying for the fast pass privilege of his time and attention. My bill for the entire episode of private care delivery was well over $ 2000. I saw no bill for my 48 hours in Casualty.

As we watch Congress debate in the weeks and months ahead the future of our healthcare system, I worry that not enough of the 180 million privately insured Americans understand the downstream effects of some of the changes that are being proposed to our system. US healthcare is in need of a major overhaul but we need to attack the factors that are driving the cost of care higher. Malpractice, overtreatment, poor lifestyles, reimbursement policies of insurers, major differences in clinical quality of hospitals and doctors and an insatiable consumer demand for immediate and unimpeded access are bloating our system. However, swinging the pendulum too far in the opposite direction with national oversight, artificial price controls, the erosion of private insurance by expanding government sponsored plans to over 44 million uninsured without tackling the underlying causes for rising costs will bring our country to its knees.

We will in effect be trading one cat’s cradle bureaucracy for a public one with little effect on the true cost drivers. Anecdotally, we already have a glimpse into what government healthcare might look like as evidenced by the conditions that are often described in government run Veterans hospitals. It is not exactly encouraging.

Change is in the wind and we will all be required to modify our behavior. However, we should join the discussion and engage our Congressional representatives in the debate. If we are not vocal or vigilant, we may wake up one day on that gurney in a National Health Service hospital wondering what the hell happened to America’s health care system.

Mike Turpin is frequent speaker, writer and practicing benefits consultant across a 27 year career that spanned assignments in the US and in Europe.  He served as the northeast regional CEO for United Healthcare and Oxford Health from 2005-2008 and is currently Executive Vice President for Benefits for the New York based broker, USI insurance Services.

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49 Responses for “Waiting for Dr. Godot”

  1. bev M.D. says:

    Mr. Turpin;
    I hate to say it but your experience could easily be replicated in any number of American hospitals. The only thing I did not recognize was the 7 people in a room part, although when I was a medical student in the 70′s, 4 bed wards still existed at our university hospital.
    What you are describing is the experience of the uninsured patient in an inner city hospital here, too. We too have our VIP floors with carpet and private rooms. So don’t raise the frightening specter of UK care to be thrust upon us – it has already crossed the pond.

  2. ExhaustedMD says:

    Excellent commentary, sir! Thank you for writing this at a public forum debating this matter.
    Just watch for the apologists and defenders of this legislative attack. They will stop at nothing to prevent the truth and legitimate concerns from being heard and considered.
    Think about it. At least half of Americans do not want this legislation passed, and the alleged majority in Congress act like everyone who is not Republican is cheering them on. And yet only about 25% are Republicans, and about the same are Democrats. Which leads to say that about 50% of us are independent/other third party affiliation.
    I am glad you survived your experience. Unfortunately, how many will survive if this health care trend in Europe becomes the standard of care here?

  3. Greg Pawelski says:

    Bev
    You took the words right out of my mouth. Indeed, as I was reading, I was thinking of all the US hospitals that this same scenario occurs. Personally have seen it only last month. The US has crossed that pond, long already.

  4. Peter says:

    I’m not sure who Mr. Turpin is sending a warning to, those who can afford the elevator ride one floor up to the private care ward or to those already here in the U.S. still one floor down waiting for care with the masses. As Bev says, visited any U.S. inner city hospital ERs lately? Part of the NHS problem is two tierd care where those wealthy enough to get private care have no need to pity those who can’t. Next time I’d advise pinning a 100 euro bill on your shirt so the doc knows right away how far from death he is willing to let you go before treatment. Would he have looked at you faster if his time wasn’t also engaged with maybe less serious but higher paying patients on the upper floor? In 2004 the UK spent 8.3% of GDP on healthcare, while Canada spent 9.9% and the U.S. 15.3%. Would your treatment have been faster/better if the UK had spend the same GDP as Canada or maybe that of Germany’s 10.9%? Is the UK’s health service to the masses so poor because the high wage earners hold the political persuasion power of taxation? I will also say that ask any doctor here if they are paid enough and you will get the same; ” Not nearly enough, Mr. Turpin. Not nearly enough”.

  5. Matthew Holt says:

    Well there is a major difference between the shitty care in the NHS hospital and the same shitty care dished out in the US every day….. the NHS patient doesnt get a bill that bankrupts their family or their nation.
    But the major lie propagated by Turpin and others is that NHS style care is in the current health bill. That’s complete bollocks, as we Brits say. Instead the bill expands private insurance to lots of people who currently use US public hospitals (most of which are way worse than NHS hospitals despite their staff’s heroic efforts).
    So what Turpin is complaining about it is the opposite of what he’s warning us about.
    About the logical consitency you’s expect from a former insurance broker and plan executive!

  6. Jason says:

    The massive 10-year Obama deficit estimate was underestimated by $1.2 trillion, says CBO. The estimate now is for TRILLION DOLLAR DEFICITS as far as the eye can see, an unprecendented and shocking level of fiscal recklessness that goes beyond any prior administration.
    And Obama proposes the largest expansion in entitlements in a generation.
    We are in a huge hole and this bill digs a deeper hole.
    Thus, the biggest political problem the Dems face is the debt and deficit. The Health Bill adds to this, in that no one really believes that it will lower the debt, and most believe that it will cost a lot of extra cash. See Paul Ryan’s total demolition of the spending portions of the plan during the health care summit. (Obama just shrugged this off, but it was a torpedo below the waterline for anyone paying attention.) Older Americans will rally against the health bill itself in Nov. But for independents, it is the sinking sense of impending national bankruptcy that will do in the Democrats.
    We are not creating jobs, and will not create jobs in an environment where small business taxes go up and mandates crush businesses and self-employeds with payroll costs.
    Conclusion: The US cannot afford this bill, it will massively harm our fiscal standing. the Democrat obsession with passing this unpopular bill will seal the doom of the Democrats and the US economy if, God forbid, it passes..

  7. Yes, I was thinking the same as Bev and Greg, as I was reading the article. I also noticed that by the time the patient got to the carpeted area, he was “over the worst of it”, according to his doctor. I guess they were doing something right down in the Inferno section.
    We have been hearing these dire warnings about “government run healthcare” for quite sometime, but I think there is on word missing in this slogan. The word is “insurance”. So let’s try it again:
    “government run healthcare insurance”. Does it sound different now?
    Government has been “running” healthcare insurance for millions of people in this country and for many decades. Yet all our hospitals are still private. All our doctors are still in private practice. There are no Medicare/caid hospitals or clinics.
    There are no provisions in the current bill to take over hospitals and doctors. Even the most liberal advocates are not suggesting anything more than government becoming a single PAYER, not a single PROVIDER.
    So how on earth, and why, are we going from more stringent regulations on Private insurers, to Government PROVIDED health care?
    I don’t want to see anything like the NHS here, does that mean that I should be against restraining private insurance from predatory practice, or eliminating waste and fraud, or providing decent care to those less fortunate?
    This bill and this President and this liberal base is NOT proposing NHS any more than it is proposing death panels or throwing grandma under the bus or doing away with capitalism or instituting a Marxist economy or…. breeding squirrels in the Oval Office, or whatever irrelevant monstrosity circulated by rabid conservative media.
    So exactly why are we talking about the NHS in this particular context?
    Shouldn’t we talk about Germany or better yet Switzerland? Or is that not dramatic enough?

  8. Peter says:

    ” Not nearly enough, Mr. Turpin. Not nearly enough”.
    http://www.bmj.com/cgi/content/full/334/7587/236

  9. archon41 says:

    See, if the Brits weren’t so dumb, they would invite Wellpoint, Aetna and Cigna in, and bestow a massive grant upon them to issue policies of private insurance to those who can’t afford them. “The best of all possible worlds,” as Doctor Pangloss would say.
    Seriously, I can’t imagine what this post is doing here. Venom spitting partisan hate fests are so much more satisfying.

  10. Debbie Watson says:

    I have never been to the UK, but was raised by a mother who was and remains a British citizen, who liked the NHS system. I can speak on his comments regarding care at the VA. First of all, his comments were based solely on the “descriptions” of others regarding healthcare through the VA. I, as a spouse of a 100% disabled veteran am entitled to receive my healthcare at the VA women’s health. I took advantage of this while I had no insurance, and didn’t have any complaints other than having to wait for nonurgent care for several weeks. I subsequently obtained a private insurance policy when I returned to work, of which I had to pay $140 dollars a month towards as my obligation of the premium. I was happy to have the policy, non the less, since I felt it would be less BS. Boy was I mistaken, for this $140 per month premium, 10% hospitalization copay, 500 dollar deductible I also had the pleasure of having to fight to get them to pay on claims, had to play “mother may I” games for permission to go to specialist, and approval to obtain prescribed procedures AND STILL HAD TO WAIT for non urgent appointments. I finally got tired of the BS and tried to cancel my company plan and go back to my VA health care but because it was mid enrollment was not able to do so. So I continued to pay out of my paycheck the $140 month knowing I wouldn’t be using it, because I prefered the VA to private. At least the VA only cost me $0 dollars copay, no deductibles, no denials, no seeking permission, with no longer waiting times than going through private avenues. The thing that really angers me, is that the Public Option, is neither an example of the UK’s NHS system or the care through the VA, it is simply the government taking the place of the greedy, for profit insurance industry. I equate it with the plan I have with CHAMPVA, if I choose to get my healthcare through private health care providers. ChampVA pays 75% with a $50 yearly deductible. I carry the ChampVA supplement for an additional $40 dollars a month giving me 100% coverage with the $50 dollar deductible, and no loss of sleep from mounting health care bills, or going bankrupt. I only wish that all citizens had a PUBLIC OPTION they could buy into. With Administrative cost’s accounting for the first 30% of health care dollars spent, the government has PROVED they can do it more efficiently and cheaper than the blood sucking insurance industry. Anyone who doesn’t want the public option can stay with the PRIVATE INSURANCE industry, I am sure they would love to keep you on so you can help with those CEO bonuses and their 3 billion dollar profits each year.

  11. From the Author of the blog: It’s interesting to read the various perspective here. I am married to a Brit who was delivered through the NHS and loves it. This is not an attack on the NHS as one poster pointed out, most Brits find it perfectly acceptable and have adjusted to understanding that a system that has infinite demand and finite resources can’t survive. Having been on various sides of the private US system, I am of the opinion we desperately need reforms ( you can read my article http://usturpin.wordpress.com/confessions-of-a-blue-dog-insurance-gunfighter/ )
    However, reforms that preserve quality care, reward docs, restore primary care, reduce malpractice and redirect dollars spent on waste, fraud and overtreatment, Advocate personal responsibility and waive co-pays and costs for chronic illness medications that can keep the chronically ill stable. I think any compassionate person would want to see health reform happen – however, the issue is whether you chuck the private system and expand Medicare to essentially cover everyone or whether you surgically intervene into private insurance and regulate a more solid public /private solution. The current reforms do not achieve affordability, only access so costs will keep going up. If you want a complete public system more power to you. My belief is you can fix the system but it is too politically radioactive to really drive affordability. Eliminate every for profit insurer and you save $ 40B on a $2.2B system. That’s a start but there is $ 100B of fraud each year in Medicaid and Medicare. Insurers need to be more tightly regulated in the individual and small group market but this is only a fraction of the problem. 60M Americans with BMIs over 30. Too many hospitals, too much self diagnosis, too little oversight, upside down reimbursement that pays to treat chronic illness instead of preventing it. The purpose of the article which was offered another on the Blair House Summit, was to share a real life experience. If one has trouble understanding the “position” I am trying to take, that is good -because it is hardly black and white. My UK based relatives believe the NHS works for them and therefore it does. The question is: Does the spoiled, self diagnosing, must have it today, anyone who gets in the way of what I want is a bad actor insured American health consumer ready for the austerity and change that is required to get health care under control? My own experience was I was not ready for what I experienced but I now understand the price of a basic level of care for all at a lower GDP. One reader correctly pointed out that by the time I got to private care I was over the worst of it. They actually got me better in public care. I was just not ready for what had happened as a spoiled American. Another few years in the UK and I probably would have dropped private insurance and been called a communist by my friends. Read Shannon Brownlee’s “Overtreated”if you do not believe we have a waste and overtreatment problem in the US. Or just read the New Yorker article on the tale of two Texas cities and Medicare. There are no ” right ” answers here, folks – only points of view on the best way to allocate and manage $ 2.2T of spend.

  12. MG says:

    “After moving to London with my young family, we decided to opt for public care”
    That is all you need to know about this post. He took a gamble to save a couple of bucks and then rants/raves nearly as much about the aesthetic qualities of the care as much as the actual quality of the care care itself.
    “I was in what felt like an overcrowded youth hostel and I wanted some bedside manner. After all, damn it, I was American.”
    It is not America. I hate to travel with people overseas who gripe about something and say “it is not American.”

  13. MG, I can’t resist….Most of the columns and articles I write are tinged with sarcasm. Dr Godot was intentionally unmasking my American provincialism. Glad you caught it. Having spent several years working across 30 countries in Europe and the Middle East – gaining a deep understanding of their public and yes ( gasp) private health systems, cultures , politics and social views helped me understand many things. I left the US like a child who thought its parents were always right and could do no wrong. I returned to the US seeing my nation like an adult sees his parents – still loving them but recognizing their imperfections and understanding that I could choose to disagree respectfully with their point of view – a view that was shaped by their own self interest and life experiences. Please read my column at http://usturpin.wordpress.com/the-united-states-of-europe/ I attempt to convince my readers why the US could stand to learn a few things from Europe.
    When you first “move ” to a foreign country , it is impossible not to compare things to how you had them at home. It’s called culture shock. When you are lying on a gurney in a foreign hospital – scared and out of your element, it becomes culture trauma. Traveling across Europe on business or with a backpack after college is very different than living and working with Europeans every day. What works in Norway, may not work in the UK.
    As for my healthcare, I did not have to take any gambles – you pay council tax in the UK, you get public care automatically. You also get private care from your employer. I voluntarily chose to access what I needed through the NHS- it was easier and it was a sort of social experiment. Given that I was married to a Brit who felt very comfortable with it, we used it.
    And I am sorry you hate traveling with people who gripe. I find anyone’s first adventure into a foreign country a tad overwhelming. Americans just lack the finesse to keep it to themselves. Indeed, these countries are not American. And after the first year of judging everything as worse just because it is different, you discover some political systems, entitlements, social mores etc work better than in the US. Ultimately, you come to the conclusion as with many things in life, including most people, it is neither better or worse. Just different. Vive le difference! Michael

  14. Xavier Simon says:

    The real issue is rationing: by whom and how. The market or Washington? Healthcare represents one-sixth of the economy, in the UK only one-tenth. How did it get there?
    In the UK government rations medicine. The NHS decides how much care patients get. That was Michael Turpin’s dilemma. There the government decided that one-tenth of the economy is right. There is no magic to it. More hospital rooms would hold fewer patients and more doctors could dedicate more time to each patient. Both require a larger budget.
    Some prefer a mixed private-public system, like in the US. The market regulates medicine. There is a catch, however. The more government encroaches, the more its rules dominate. The more Medicare grows the more its prices dominate. But it has a fixed budget so it cuts prices and services become scarcer. Today, for instance, there are fewer general practitioners.
    The government faces a Catch 22. Patients keep voting a larger share of their personal budgets for healthcare. The government can’t. Already Medicare is “going bankrupt.” And the more government grows its share, the bigger will be the squeeze on its budget.
    Solution? Regulate the system and ration services. When the government decides for patients it can squeeze and fit more into the budget. It can “bend the cost curve.” It can reduce overall spending from one-sixth of the economy to something less.
    The alternative? A real market system where each patient decides how much to spend. To work it needs a combination of individual health savings accounts for routine needs; catastrophic insurance for cases like Turpin’s pleurisy; government subsidized programs for pre-existing conditions; real insurance competition; and malpractice reform.
    Neither system is perfect but when government rations a few thousand technocrats decide what is best for everyone. In the market millions constantly look for better solutions. Some regulation will always be needed; so are policemen. Somebody has to control extreme behaviors. But patients and doctors call the shots, not government or an NHS.

  15. Peter says:

    ” The NHS decides how much care patients get.”
    No it turned out money that Mr. Turpin was able to pay determined his care.
    “Some prefer a mixed private-public system, like in the US. The market regulates medicine.”
    Actually it’s medicine that regulates the market.
    “The alternative? A real market system where each patient decides how much to spend. To work it needs a combination of individual health savings accounts for routine needs; catastrophic insurance for cases like Turpin’s pleurisy; government subsidized programs for pre-existing conditions; real insurance competition; and malpractice reform.”
    It’s all so clear now, why we could do it over a beer during the weekend on three pages.
    “But patients and doctors call the shots, not government or an NHS.”
    Actually government determines the budget and care is determined by doctors and patients within that budget. If taxpayers feel they arn’t getting good value for the budget they can opt for more tax dollars to healthcare.

  16. “The question is: Does the spoiled, self diagnosing, must have it today, anyone who gets in the way of what I want is a bad actor insured American health consumer ready for the austerity and change that is required to get health care under control?”
    I’m starting to see an emerging theme here. The reason for our health care problems, and in a thread below, the economic crisis, is greedy consumers who will not be denied their cheap mortgages and expensive treatments, thus spending us all into oblivion.
    This is very interesting because if I learned one thing from working for corporate America, it is that the more people that can be made responsible for something, the less likely it is that anyone will be accountable for anything.
    So if we insist that 300 million people are responsible, then no one person at either Wellpoint, Anthem, Goldman Sachs, AIG or any given Hospital conglomerate is accountable, and no one corporation is accountable either.
    So we will spread the “austerity” evenly and equitably across the culpable 300 million, give or take a few thousand corporate executives, financiers and their outfits here and there. Good plan.

  17. archon41 says:

    Friends, I come to inform you of the recent deliberations of the Central Committee. We have reached a consensus that far too much laxity in message discipline has been permitted. Uncoordinated and unapproved individualism has been most embarrassing. No sooner does someone present a wonderfully agonizing narrative of a victim of selective underwriting, than along comes Peter, blabbing that, since we are already paying for the care required by the uninsured, we can do so more economically through “universal single payer.” We must be more artful in firewalling incompatible talking points.
    It is evident that some of you did not receive the memo advising that we are breaking off the assault against the insurers. You must surely appreciate the difficulty in presenting the funding of private insurance for the uninsured as leading huddled masses to joy and light, while some of you continue to flog the insurers as extortionate, egg-sucking ogres, wantonly denying claims left and right. Knock it off. We will deal with these bloodsuckers in due course.
    You are further instructed to desist from referring to HCR as a “small, but useful step” towards a profit negative economy. You are alienating those depending on their 401K’s to cushion themselves against a hardscrabble old age. Rest assured, we have plans for these antisocial hoardings of dead labor.
    You are to redouble your efforts to deny that these issues admit of principled difference of opinion. We are not targeting the “independent thinker,” but the bubbleheads who were for us before they were against us. In other word, “Keep it simple, Stupid.”
    That is all.

  18. Aaron Cole says:

    I think we need to get everybody under the tent, and then figure out how to reduce cost later. What is obvious to me is that if the financial incentive for the care providers is to provide more individual services, tasks and tests and not the improve the health of their patients, then more tests, visits, interventions and consultations will be ordered. What if doctors got an annual budget to take care of the patients under their care, and the amount was adjusted for known pre-existing conditions in the group as well as for ethnic or age variations that contribute to higher or lower costs as demonstrated in studies. If a doctors’ group was able to keep their costs down while maintaining high quality health in their patient group, they would get a percentage of the savings in bonuses over time. (Perhaps patients should also participate in bonuses for maintaining their health as well.)
    Insurance as a concept doesn’t work for people the insurance companies, PPOs or HMOs know are going to draw care. Think about how insurance works. In exchange for a premium, they take a risk that you as a patient won’t use more care than the premium will pay for. For a patient currently receiving expensive care, why would they take $1000 as a premium against an guaranteed payout of services of $10,000. In a free-market system, they will never do this. For the normal patient insurance is a bet is that your expense will be more than the premium. In our free-market system a patient also has another choice, one that is being chosen by increasing numbers of people. That choice is not to pay the premium, essentially risking that his cost will be less than the premium. If the cost is not less than the premium, ie, he has sickness/injury and cannot pay for it, he is not denied care, because the system does not allow people to be denied health care for acute sickness/injury. This is his ace-in-the-hole. In the current economy, many young and/or healthy people are choosing to risk that they will not get sick, and therefore the health insurance premium is a cost they do not choose to pay. That means less money to feed the medical sector of the economy, and more cost to be spread among the those who feel the need to be covered due to pre-existing conditions or age/health related underlying factors.
    In general, I am not in favor of government intervention in the economy, however, in this system people can opt out of paying health premiums but they cannot opt out of getting health care services and incurring expenses on the system, whether or not they can pay. Because of this problem of people incurring costs without contributing, we need a mandate that everyone pay in to the system.

  19. Peter says:

    “since we are already paying for the care required by the uninsured, we can do so more economically through “universal single payer.”
    We are paying TOO much for the care required by the uninsured and by the insured, private or public. archon fails to grasp that this is healthcare where no one can choose less expensive care, only less premiums for less coverage. He still fails to articulate what kind of care he would advocate we give those who can’t afford the admission ticket sold from the insurance industry booth? One of his solutions appears to be that taxpayers buy that ticket no matter the cost, but then complains we are spending ourselves into financial annihilation. Or maybe his solution is to just step higher over the healthcare wounded and killed laying in the street while extra perfume masks the smell.

  20. Xavier Simon says:

    Aaron writes “I think we need to get everybody under the tent, and then figure out how to reduce cost later.” That is precisely what Obama wants to do but note that it is under a centralized system that includes at least some element of rationing. Go back to my entry yesterday about rationing.
    The real challenge is to keep a well balanced system, one in which you continue to have substantial individual initiative balanced with at least some centralized rules. Note that the latter tends to take away a lot of flexibility, individual initiative, and therefore opportunities for innovation. Instead of many tens of thousands of small units seeking new solutions across the nation, you run the danger of having just a few thousand technocrats and bureaucrats running the whole system.
    In the end it is about how you balance both extremes. And that is really what the current debate between the “left” and the “right” is all about. Ultimately you want to come up with a compromise that achieves a good balance. That is what America has always been about, and that too is why it has been so successful. Today, however, and unfortunately, you are not seeing any of that compromising and balancing taking place, at least not in Washington.
    That is why I personally prefer “A real market system where each patient decides how much to spend. To work it needs a combination of individual health savings accounts for routine needs; catastrophic insurance for cases like Turpin’s pleurisy; government subsidized programs for pre-existing conditions; real insurance competition; and malpractice reform.”
    In such a system you have both sets of players working together: small individual units throughout the country—patients, doctors, insurance companies—innovating, and these are hopefully in balance with an active but less intrusive government that still does take care of extreme cases.

  21. Nate says:

    bev M.D. under NHS majority of people are subject to that care, in the US a very small minority are. Why should the majority of us with great employer sponsored coverage give that up for NHS quality?
    “the NHS patient doesnt get a bill that bankrupts their family or their nation.”
    Of all people Matt you should know the financial postition of the trust, half of them are bankrupt. FYI the Medicaid, un-insured population, illegals, and uninsured don’t get a bill that matters anyways, not like they pay it or it effects their life, it just gets added to all the other unpaid bills.
    This type of better Matt?
    http://www.dailymail.co.uk/news/article-1255858/Neglected-lazy-nurses-Kane-Gorny-22-dying-thirst-rang-police-beg-water.html
    notice you did say public hospitals, seems we have a history of failure in public health, why expand upon it?
    “Yet all our hospitals are still private. All our doctors are still in private practice.”
    What country are you talking about Margalit? Most of our hospitals are public, VA, ever hear of that? We have tons of public health clinics.
    “it is simply the government taking the place of the greedy, for profit insurance industry.”
    Debbie you might like to know over half of our insurance system is non profit so your rant about greedy for profit industry is baseless.
    “With Administrative cost’s accounting for the first 30% of health care dollars spent,”
    Wow Debbie you can’t get anything right, with all the factual errors your opinion is pretty worthless.

  22. Nate says:

    notice in the article you never once hear mention of the mother suing. I tried to look up malpratice attorneys in England and can’t seem to find any. If Tort reform is so worthless why is it not a problem in the UK were the NHS is deplorable?

  23. Peter says:

    “I tried to look up malpratice attorneys in England and can’t seem to find any. If Tort reform is so worthless why is it not a problem in the UK were the NHS is deplorable?”
    http://www.loc.gov/law/help/medical-malpractice-liability/uk.php
    Just a few I found in 20 seconds:
    http://legal-directory.net/links/medical-negligence-uk.html
    http://www.medicalsolicitors.co.uk/

  24. Nate says:

    which would you suggest Peter? Did read somewhere while looking that they are 10 times less likly to sue in the UK then the US, from the little I read the burden of proof there is you have to actually prove they didn’t follow suggested care, unlike the US where you can sue and win if you just don’t like the outcome.

  25. bev M.D. says:

    Hey Nate;
    Somewhat off topic, but I’ve got a question and, since you are in the insurance industry, wonder if you know the answer. Nobody on the provider side seems to. Why do private insurers put up with and accept the brazen provider cost shifting to make up for below-cost (supposedly) Medicare reimbursement? In other words, everybody knows that hospitals charge more to private insurers because they lose money on Medicare admissions, and yet the private insurers go ahead and pay the higher bill. Why don’t they just say “we’ll pay what Medicare does and no more” rather than go along with this cost shifting? It seems to be a bad business decision. Is there some law about this or something?

  26. Barry Carol says:

    “Why don’t they just say “we’ll pay what Medicare does and no more” rather than go along with this cost shifting?”
    Bev – While I would like to hear Nate’s view as well, what I keep hearing is that insurers are under pressure from employers to offer plans with broad networks that must include the well known medical centers as part of the network because, supposedly, this is what employees say they want. Also, community hospitals or small groups of them that built a dominant market share in a geographic area due to consolidation now have very strong bargaining power to negotiate rates well above what Medicare pays. Both the community hospital groups and the famous medical centers take full advantage of that bargaining power as do certain very large physician groups that dominate the business in a specific geography. Conversely, small stand alone hospitals, and solo physician practitioners are sometimes paid less than Medicare rates on a take it or leave it basis.
    I keep coming back to the need to group hospitals and physicians into tiers. If it were up to me, I would copy the prescription drug approach and have a preferred tier where the coinsurance percentage is very small, a non-preferred tier where it is sufficiently higher to get the patient’s attention, and a third tier which is even higher that would be the equivalent to what’s called out of network providers today. We would need good price and quality transparency tools to help patients understand why certain providers are in the second and third tier including how much more they charge for similar work with no discernible difference in quality. Referring doctors would need to be able to easily identify which doctors and hospitals are in which tiers so they can incorporate that information into their referral decisions. Most important, the premium differential between an insurance policy with a tiered structure and one that allows members to go anywhere for a low coinsurance amount must be meaningful. If the member chooses the more cost-effective plan, he or she should capture the savings in premium for making that choice. Alternatively, the employer could pay for the more cost-effective plan on a defined contribution basis and allow the member to buy up to the more expensive plan with his or her own money.

  27. Nate says:

    Barry touched on it but it is changing, it’s actually one of my best sales tools right now.
    There are a couple classes of payors and the reason they pay what they do differs. First is BUCA, Blues-United-Cigna-Aetna, they have the size to fight but historically lose the PR game. Employees and thus employers don’t want to be told what hospitals they have to go to so they pressure the insurers. The carriers are also stuck by circumstance, they can fight to get an extra 10% off billed charges but if the hospital refuses and drops them now the insurer is paying full price for all emergency care. They have base discounts of 40-60%, to lose those over the remaining 10-20% Medicare advantage could quickly be whiped out by patients they can’t redirect.
    MMO here in Ohio just went through a blow up with a chain down south, back and forth press releases, news coverage etc etc and they finally relented. Off the top of my head I can’t remember the last time an insurance company won.
    With the big insurers as long as none of the other players have an advantage they really don’t have a motivation to fight for better discounts. They already substantially beat the little guys so they only need to stay in line with the other big boys. They don’t have much to gain by starting a fight with the hospitals. There loss ratios are public and big groups get their claims experience, if they could wring savings out of the hospitals in a couple years it would just go back to the employers. Fighting cost money while capitulation makes them money.
    Now for the little people like me, unless we can rent one of the big boy networks we are in the 10-30% discount range usually. It is very hard for us to compete on big groups becuase of the hospital discount difference, on smaller groups our more efficient administration makes up for the gap, or doing stuff under their plans so we get their discounts levels the playing field. We just dont have a choice, for a long time hospitals tried to make up both the Medicare/Medicaid and BUCA discounts by killing us. They killed off a big chunk of the small and little players aggregating business with BUCA. Finally they are starting to learn that giving us discounts within 10-15% of BUCA allows us to compete with them and thus raises their income. Sadly it took a huge chunk of private business consolidating before they learned.
    This has been a huge problem and we didn’t really have a way to combat it before. Now we have a solution though, we reimburse cost plus a fair profit margin, say 25%. Courts have found Medicare reimbursement to be arbitary so you can’t base private reimbursement on it. Cost they report to givernment plus a profit margin has stood up well. It hard to go into court and argue why your charging 400% of your cost for a service someone usually doesn’t have a choice of buying.
    This also fixes one of my big beefs, PPO access fees, they use to be 3-6 nd where fair to cover the cost of negiotating contracts and all that. Now the strong networks charge percent of savings or 20-40 for access to their discounts. Those fees are PEPM. This is extortion plan and simple. THe hospitals are basically saying you give my buddies this “access fee” or we will over charge you so bad you will be out of business. That is wasted money the hospital and the plan could split it and everyone but the PPO comes out ahead.
    I would ideally like to get rid of hospital PPOs and pay all hospitals on cost plus. If BUCA had to compete and couldn’t hide behind their discounts rates would come down drastically.
    I would also like to put it back on members to pick their providers. If members would look up the usual charges for competing facilities and take that into consideration it would make a huge difference. For some basic procedures do we really need to go to the most expensive facility in town?

  28. “Finally they are starting to learn that giving us discounts within 10-15% of BUCA allows us to compete with them and thus raises their income.”
    I don’t understand this one. How does it raise the hospital income? Would your members go elsewhere?
    Also, if the hospitals stay big and the insurers get smaller, wouldn’t they just charge even more? Is this what you are saying above?

  29. Health care is must… So start caring in the beginning…

  30. Nate says:

    exactly our big clients all left and went with BUCA becuase the disparity was so large. Hospitals thought they could wring an extra 5-10% out of us and actually cost themselves 20-30%. UMC in Las Vegas for example had some brillant administrator that cancelled all the small contracts and gave us prompt pay discounts. We moved all of our business to Sierra or SilverState, two biggest players at the time and the hospital has never broken even since. Instead of the big two controlling 50-60% of the market it shot up to 80%+. United which bought Sierra alone now has over 70% market share. People hate United but if you want the discounts you have to go with them. If UMC came back and gave me a contract 5-10% higher business would pay it just to get away from United and the hospital would make 5-10% more. Get some movement away from United then next time their contract is up they would have leverage.

  31. Barry Carol says:

    “People hate United”
    Nate – Why is this? Is it especially the case in Las Vegas or do you see the same attitude in other markets where you do business?

  32. Nate says:

    all over, United has a special way of pissing off both customers and brokers. I would say they are dispised more in Ohio then Nevada. More then the others they come off like a huge company with no two departments on the same message.

  33. bev M.D. says:

    If, as I assume, you’re speaking of United Health Care, isn’t that the company from which Bill McGuire, M.D. (he should be stripped of that title) took some 2 billion dollars??? That alone made me hate them; it doesn’t take anything else.

  34. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  35. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  36. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  37. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  38. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  39. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  40. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  41. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  42. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  43. Yuriy R says:

    This is a very heart felt article. It seems that you did indeed take the overcrowding at the hospital to heart. Having friends in USA, there are indeed similar stories there. From personal experience in Canada, we have “free” healthcare systems similar to the English ones. There are no horror stories here. The waiting times in the emergency rooms can be long, however, that is due to poor information systems and not due to not enough cash. The problems you speak of are not a necessary outcome of the health reforms you are being skeptical about. They have worked in many countries and with enough thoughtful design, they have great potential in the USA. Again, thank you for sharing that experience and exiting a dialogue.

  44. Xavier Simon says:

    Bev MD, McGuire “took” some 2 billion dollars? “Took,” really? I suppose Bill Gates and Warren Buffett are just as dastardly? Many many innovators, some more successful than others, or Obama’s Brave New World, which I suppose you would prefer? The Post Office, Amtrak, FEMA of Katrina fame, Fannie Mae, Freddie Mac? You have to be careful what you wish for. There are no perfect solutions but some are better than others.

  45. Xavier Simon says:

    Bev MD, since many will come at me for my prior entry let me provide some factual background. One of Obama’s senior advisors has been David Cutler, a Harvard Prof. of Applied Economics—see for instance http://sentineleffect.wordpress.com/2007/12/01/health-mandates-a-talk-with-obama-health-advisor-david-cutler/
    Yesterday, March 8, Prof. Cutler spoke at the NABE Economic Policy Conference in Arlington, Virginia—see http://www.nabe.com/pc10/program.html You can try to catch him on C-Span, perhaps at http://www.c-spanarchives.org/program/id/220717 Cutler envisions in ten years a healthcare system run by large corporations with small private medical groups totally displaced.
    Cutler even showed some Forbes Magazine charts showing the largest corporations and wealthy individuals, and said there were no healthcare billionaires. He further said that the new healthcare system would present opportunities for new organizational giants to emerge and become billionaires. You may want to write Cutler at Harvard about Bill McGuire; apparently Forbes and Cutler are not aware of the two billion dollars you say McGuire already has.
    That Cutler believes in large corporate solutions is not a secret. You can go, for instance, to the New England Journal of Medicine last August at http://healthcarereform.nejm.org/?p=1344
    Finally, and this is harder to reference but its there, at least the Senate bill has a number of incentives to promote large corporate solutions, i.e. more Bill McGuires, and discourage small private practices. The latter were amply discussed during the markup of the bill in the Senate Finance Committee last summer or fall. I am sure the latter can be found in the C-Span archives.

  46. I must congratulate you for this wonderful bit of information..

  47. david says:

    All the more reason why administrators governments role should be minimized in health care-they have sought to serve their own best interests to the detriment of the public good.

  48. Kamagra says:

    Excellent commentary, sir! Thank you for writing this at a public forum debating this matter.

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