I saw a patient today and looked back at a previous note, which said the following: “stressed out due to insurance.” It didn’t surprise me, and I didn’t find it funny; I see a lot of this. Too much. This kind of thing could be written on a lot of patients’ charts. I suspect the percentage of patients who are “stressed out due to insurance” is fairly high.
My very next patient started was a gentleman who has fairly good insurance who I had not seen for a long time. He was not taking his medications as directed, and when asked why he had not come in recently he replied, “I can’t afford to see you, doc. You’re expensive.”
Expensive? A $20 copay is expensive? Yes, to people who are on multiple medications, seeing multiple doctors, struggling with work, and perhaps not managing their money well, $20 can be a barrier to care. I may complain that the patients have cable TV, smoke, or eat at Taco Bell, but adding a regular $20 charge to an already large medical bill of $100, $200/month, or more is more than some people can stomach. I see a lot of this too.
Finally, I saw a patient who told me about a prescription she had filled at one pharmacy for $6. She went to another pharmacy (for reasons of convenience) to get the medication filled, and the charge was $108. I could see the frustration and anger in her eyes. ”How do I know I am not getting the shaft on other medications?” she lamented. I told her that I see a lot of this.
Then I started considering how many doctors, nurses, and hospital administrators are “stressed out due to insurance,” and I laughed. I think the number of those not stressed out would be far easier to count. In this blog I have recounted the overall cost the insurance situation takes from my own practice, and my own psyche. I can’t do it justice in a single post, it takes a huge toll on those of us in it. The cost is high.
So what is the overall cost of a bad system? Sure, the system itself uses money poorly and dumps buckets of money on things that have no impact on the health of patients. Sure the system encourages doctors to not communicate, not spend time with patients, and to spend more time with the notes than with the patient. But what is the toll of this toll? What is the toll that simply having an insane system that demands huge sums of cash, yet does not give back a product worthy of that cost? What is the toll of people suspicious that they are being gouged at the pharmacy, hospital, or doctor’s office? What is the cost of having a healthcare workforce that goes home more consumed by frustration about the system than by the fact that people are sick and suffering?
Our system is very sick, and the fact that it is so sick makes me sick. It makes a lot of us sick.
I see a lot of that.
PREVIOUSLY by the same author on THCB:
“The Cost of Fear”
“Dear Mr. President”
ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.
Filed Under: The Insider's Guide To Health Care
Tagged: Commentology, health care cost, Insurance, Rob Lamberts Mar 10, 2010
Thanks for noting “insurance” is a valid stress issue. All too often physicians don’t ask and don’t note the possible causes of patients distress and noncompliance.
If only patients weren’t so passive about the issue. A letter to a Congressman or Senator making them aware that health care is a significant worry to them as a constituent/voter would go a long way to letting policy/decision makers know “status quo” is no longer an option.
One critical thing you convey is the fact that you as a physician have to spend time on these problems. You’re not practicing medicine here: you and your patients are worrying about business transactions.
As a physician you can and should worry about nothing more than what is best for a particular patient in a particular circumstances. Where people are otherwise healthy and your diagnosis follows standards you know and regularly follow, the time you and your patients have to spend on this is time you cannot spend on the patients who truly need more care.
And the patients who spend time worrying about these matters (where they are legitimate matters — not the $100,000 a year lawyer complaining that the co-pay is $20) have to suffer through other worries when all they should be worrying about is are the steps you’ve instructed actually working to improve their health?
When are some people in this country going to wake up and realize this isn’t how medicine should work? When we treat so much of health care as a for-profit business, what you get is a lot of time spent on for-profit thinking. As a physician, I expect you to make a very good salary, but that should just come automatically from a being part of a good, respected practice. When you and your patients spend so much time having to navigate a marketplace looking for the appropriate medical care, it’s no surprise that the market overrules medicine so much.
Dennis you apparetnly still haven’t learned what the words for profit mean. Majority of hospitals are non profit, majority of insurance is sold by non profits, and the majority of care is paid for by government, which technically is non profit. Where exactly is this evil profit you keep blaming?
Wouldn’t any logical person conclude since the vast majority of the system is non profit that there are other issues? I know they are much harder for you to grasp and take more then 30 second sound bites to learn but you need to get started.
Nate, I’m not going to waste time on your ad hominem attacks. If you want to rewrite what you wrote and direct your concerns at what I write and not who I am, I’ll pay attention.
Yes, kids, play nicely.
I would say that the “non profit” side of things (like BCBS) is a bit questionable. One would think that non profits would be significantly cheaper, as they have no shareholders to please with high margins. They seem, however, to follow the for-profits in their pricing. That is very suspicious to me – it says that they don’t have to be an efficiently run organization.
But the insurance industry and Pharma are not the root cause of the problems. The root cause is the set of laws that govern the administration of HC. A government takeover is not the only way for the government to act. It needs to focus on creating a climate for HC that encourages prevention over profit, that rewards efficiency and quality. Our system at present does nothing. Insurance and drug companies are a product of the system more than they are the cause.
Perhaps one of the resident insurance gurus would explain to us why insurers don’t simply agree with employers to pay forthwith all medical bills sent to them by employees, instead of insisting on written contracts to define and limit their obligations. I mean, that’s what Medicare does, right? Why not just commission someone to create a system where the provider has a direct connection to the check printer?
I was thinking the same thing, archon41. I wish I had a business where it cost a client $20 to get my services worth $100, and then I get paid another $80 when they show up, and then complain that my client had to pay anything at all.
Maybe that’s why a lot of doctors aren’t even trying to collect the $20 copay. That way, more clients show up and I still make $80.
Rob,
You’ve described the system that exists in certain European countries. Everyone is covered, plans are private and regulated.
I just question what are the “set of laws that govern the administration of HC” that you refer to. Can you cite examples?
I am talking about the very basic level of laws. Why is the insurance situation the way it is? Much of it revolves around how Medicare is structured (such as an over-emphasis on charting, coding, and procedures). The insurance companies follow Medicare’s lead. The HMO act by Nixon was a big thing that pushed the situation toward more insurance co intervention – making them less insurance companies and more “disease management” companies. That, by the way, creates an immediate conflict of interest on their part as they are able to alter what they pay for based on their own interpretation. They are no longer risk-pools, they are money managers – deciding how it will get doled out. When they have a vested interest in not paying (to increase profits), they are difficult to trust with the money.
I really don’t get how you can say “The insurance companies follow Medicare’s lead.” What would you contract your statement “over-emphasis on charting, coding, and procedures?” I agree with you that “When they have a vested interest in not paying (to increase profits), they are difficult to trust with the money,” but I don’t know what sort of alternative you are suggesting would work better. (Me? I prefer single payer — but that won’t happen).
Just imagine: In my simplicity, I had supposed that employers and individuals could not afford, or were unwilling to pay for, insurance policies which covered every medical contingency with no procedural fuss. It comes as a great revelation that they are guided, not by the express language of their policies, but by their understanding of what Medicare does. I had also supposed that some policies afforded broader coverage than Medicare or other policies. Otherwise, the term “Cadillac Plans” wouldn’t seem to make much sense. And what are we to make of all these Human Resources Managers who devote so much time trying to figure out the most cost-effective of competing insurance proposals?
But I will agree with Dr. Rob on one thing: making the government the sole paymaster for medical professionals would certainly tend to make some aspects of care less complicated.
> Why not just commission someone to create a system
> where the provider has a direct connection to the
> check printer?
That’s the way Medicare worked from `64 to `84. Read Paul Starr’s book “The Social Transformation of American Medicine” to understand the history. You can get a used copy through abebooks.com for $10, shipping included. Less than a $20 copay! Such a deal!
> When [classical disease management HMOs] have a
> vested interest in not paying (to increase profits),
> they are difficult to trust with the money.
And when you have a vested interest in consuming “because I already paid in” and a doc has a vested interest in pandering to that, YOU are very difficult to trust with the [risk pool's] money. And do not think for an instant that your single-payer will not try to do exactly what HMOs did — the motivation will be slightly (but only slightly) different, but the result at best will be the same.
There are conflicts of interest everywhere you look in this, as reading THCB for about a week will show you.
t
I am not a proponent for a single-payor system. I am simply against the chaos of our current system and I do think there are ways to simplify things.
Insurance companies audit charts more aggressively than M’care following M’care’s E/M guidelines. They use ICD coding like M’care and will reject claims or pay for them largely on the same procedures that M’care does. For example, if M’care pays for heart stenting, the insurance co’s will as well. But if M’care stops paying for that procedure, they insurers will jump off quickly. Many immunizations are not covered by private insurance until Medicare or Medicaid start paying.
Spend a week in my shoes (sandals, actually) and you will see it 1st hand. Reimbursement rates are different (thank goodness), but what is covered largely mirrors the public plans.
This is such a valuable post.
What if patients actually could know reliably and well before the moment of decision to go with a particular provider or pharmacy precisely what the service or drug would cost?
Sure, some insurance plans allow this most of the time, but….average plans have surprisingly more exceptions to this than anyone would guess expect the unfortunate.
My wife needed some physical therapy for her knee (which successfully recovered in time), and the provider made a reasonable estimate of the per visit insurance allowed amount (we have a deductible for this particular therapy).
So we thought we knew what the therapy would cost.
On that basis, we choose how many visits to make, against our medical savings, and under our careful total household budget. We paid the estimated out of pocket cost as we went along. We did about as much therapy as our budget allowed, since she still had pain.
Months(!) later, we received a bill, completely unexpected, from the physical therapist for the difference between their estimate and our actual allowed amount.
Unexpected, a little stressful. (Imagine an unexpected bill out of the blue for all of your available discretionary spending (fun stuff, restaurants, etc.) for one month.
Imagine our situation multiplied by millions and including a large portion of households with less savings or less ability to pay than we had.
That’s the reality.
If the computers owned by providers and insurers, which had all of this price information already, before the fact, were simply required by law to openly disclose accurate prices to patients….
That would be different.
This is a policy of insurance. Some things are covered and some things are not covered. These may or may not be the same things that are covered or not covered by Medicare. The things that are covered may or not be covered to the same extent as Medicare, and they may be subject to policy specific deductibles and copays. The insurer may or may not try to use Medicare reimbursement critera to define its obligations as to the amounts it offers in payment for covered services. Unless you are dealing with a contract of insurance that contains no limitations or conditions whatsoever (and I have never heard of such), the covered must be sorted from the uncovered. That requires a process. This would be so even if Medicare did not exist.
The drug cost was not an insurance situation. That was the difference between cash prices in different pharmacies, and this kind of disparity is the norm (OK, not quite so dramatic, but easily 300% difference from one to the next).
I agree with archon41 in that everything has a cost, and the very first thing must be limitation of payments. Go visit Richard Forogos’s “Covert Rationing Blog” for an excellent discussion of this (http://covertrationingblog.com/). We must contain cost and not pretend we can spend whatever we want and have it magically paid for. I do agree. I just think there are far more sensible things that can be done than we are now doing. What things? I suggest you read my blog. I’ve been writing for nearly 4 years about this kind of thing (and lots of other stuff too).
“The HMO act by Nixon”
Kennedy just rolled in his grave, The HMO Act of 1973 was one of his proudest accomplishments, until it wasn’t. He even bragged about passing it through an Administration long on rhetoric and short on action.
“I just question what are the “set of laws that govern the administration of HC” that you refer to. Can you cite examples?”
Prompt pay laws say claims must be paid in X days
If I deny a claim it must be done in a certain time frame and there is specific language I must use and I need to notify them of certain rights
Some places I need to allow any doctor willing to accept my rates into the network, even if I know they are a quack and engage in fraud
I must cover certain treatments and conditions, even if I know they are of questionable value, i.e. sleep studies
I can’t discriminate against people engaging in unhealthy activity pass a minimal level
Some places I need to allow dependents to enroll up to age 30, I can’t determine who is and who is not eligible to participate in my plan
There are just a few off the top of my head and doesn’t even get into stuff like the new Medicare Secondary payor laws and how after telling me to stop requiring SSNs now require me to go out and do it again.
“And do not think for an instant that your single-payer will not try to do exactly what HMOs did”
Congress always entended HMOs to do the rationing at their beheast. They didn’t want to take the blame for rationing care so they wanted to creat a handful of federally regualted HMOs who they could control payments to. They could increase or cut payments to the HMOs as needed then the HMOs would ration care accordingly and act as a buffer to the public.
Against my better judgment, after reading at my email site how the Democrats are almost ready to pass this bill (allegedly), I had to come to this blog and again see what crap is being sold as legitimate and wonderful in getting this legislation passed to save our country. Seeing that Dr Lamberts again made a posting, I’ll say it here and hope I can find a way to check my emails the next couple of weeks and avoid the harsh reality of this dumb ass country:
“Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it–and still less safe, if he is the sort who doesn’t” from Ayn Rand’s novel Atlas Shrugged
If you are putting your hope and faith in the hands of politicians, who to this day, per the article at Yahoo, are still making “secretive deals” behind closed doors, then you have pretty much empty hope and faith, sorry to say. Changes to rectify the atrocities of health care as it is cannot come alone through legislation by politicians who won’t even be around when it takes effect. And, responsible doctors will not participate in it. It is that simple, and all you non-providers can shout and insult us until the cows come home, but it won’t change what that quote means. And believe me, I have met those doctors who fit “if he is the sort who doesn’t”, and they will thrive in this coming environment as is being drafted.
God help us as doctors and patients if I am right.
Dr. Exhausted,
I am really and truly trying to understand your anger and I can’t figure it out, so if you wouldn’t mind would you explain to me what provisions in this bill are attempting to throttle physicians lives?
I have been reading your blog. The modest point I was trying to make is that most insurance “stress” derives from decisions made by the patient or, more likely, by his employer, long before the patient presents himself in your office. Insurers, assuming they wish to stay in business, find themselves under a great deal of pressure to come up with the “low bid.” This casts the die for what will follow. Since the choices here made by HR personnel and execs determine their own quality of care, these decisions are subject to ongoing review. The situation is not made less complicated by the usual desire of management to offer two or more plans to the workforce.
I believe you are not particularly taken with the idea of having the government dictate your income. You have also expressed the suspicion that nonprofit insurers are just as interested as for-profit insurers in having something left over after everything is paid. (Little wonder, if they wish to increase the number of clients they insure.) So, I am quite at a loss to imagine what mechanisms you believe will eliminate all the “stress” everyone is making such a fuss about.
Eliminate? Nothing can eliminate it. Reduce? I think one of the most insidious things is the fact that I must accept Medicare rates and cannot charge beyond it. The rules that are tied to me because I accept Medicare and Medicaid make my life so much harder. I would love for docs to compete based on value – so if people wanted to pay more because I offered better service and better quality of care, then they could choose to pay me extra. Having pricing that is not covert but instead transparent will do a lot to simplify things. Gamesmanship with money is at the core of our system. I game it when I do my billing – and I must. There are many examples of breathtakingly stupid rules that force me to do things a little different so I can be paid better. The docs who game the system the best are paid the most instead of those who do the best for the patients.
I would not dare say that there are simple answers for the whole problem. Egad, anything done will meet with vicious opposition from someone, but that doesn’t mean there aren’t things that can be done to improve things. I think the ability to balance bill – just given to primary care physicians – would make the quality improve significantly and quickly motivate more people to go into that area of medicine.
Thanks for reading my blog, by the way. I get frustrated on this blog when people assume you are saying all of your thoughts in a single post. I have been writing for many years and am still putting together what I really think. People attack what you write because of what you leave out, but anything written is going to be incomplete. Heck, my own thoughts need to be balanced against other ideas to get a cogent system. I just voice the view from my single perspective. I don’t pretend to know it all, but I do know what I know. I see things that others don’t because I am living it every day I go to work.
Exhausted: I am confused too. Whose article in Yahoo are you talking about? I am not sure in your comment if you agree with me or disagree. My post is a lament about the toll a lousy system takes on me and my patients. The point is that the cost of a bad system is more than just the cost of the system itself, it is also the cost that the stress that system brings on those who have to deal with its stupidity. I am not proposing an alternative, but simply lamenting – as (it seems) are you.
I’m with you on “balance billing.” It’s getting too difficult to find doctors still willing to accept new Medicare patients. It’s going to get real interesting when Medicare insureds are forced to compete against an additional 30 million people who have publicly funded private insurance. Maybe a case of Chateau Latour at Christmas time will be in order.
“I think the ability to balance bill – just given to primary care physicians – would make the quality improve significantly and quickly motivate more people to go into that area of medicine.”
And what do you think it will do to your patient who finds that “$20 can be a barrier to care”?
It’s a zero sum game, doc.
“And what do you think it will do to your patient who finds that “$20 can be a barrier to care”?
It’s a zero sum game, doc.”
Margalit – While Dr. Lamberts can, of course, speak for himself, I think the right to balance bill also presumably includes the right to WAIVE the balance of the bill that Medicare or other insurance disallows. As I think you know, back in the pre-Medicare days, primary care doctors would routinely bill their wealthier patients two or three times what they would try to collect from patients of modest means. Some were billed nothing at all and paid with a bushel of tomatoes or whatever they could. Doctors called it the sliding scale approach.
Personally, I’m not a fan of balance billing for primary care doctors or anyone else. I would support, however, patients voluntarily agreeing the pay more than the Medicare or other insurance allows if doctors would otherwise be unwilling to take them on as new patients because insurance payments are inadequate. In exchange, I would expect complete price and quality transparency so prices were known before services are rendered and quality could be evaluated to the extent that the state of the art allows.
Well put, Barry. The fact that I am actually breaking a law when I decide to not charge people is an insanity of the system.
The key here is transparent pricing. I think people need to know how the money is being spent. It’s the fact that HC is a big black box from a money standpoint that makes it easy for costs to get out of hand. The thing that will open this up and make patients value prevention more is giving them more control over how their money is spent and the ability to spend it wisely.
I sympathize with my patients who are reticent to pay $20, but I do still charge them. It’s not my fault that their Rx cost is so high. It’s not my responsibility to compensate for faults in the other parts of the system. If I do it, I do it because I want to. Still, I don’t think I am expensive – not compared to the rest of the system. A patient can spend in a day at the hospital more than I will charge them throughout their entire life having them as my patient. Spending money to see me should be a “stitch in time.”
Barry,
Balance billing, any way you structure it, creates a charity based system, with the wealthy able to get care easily and the poor depending on the doctor’s good will.
While I am certain that Dr. Lamberts is a very good person and will provide charitable care to many, I’m not so sure about trying to base yet another system on goodness of the heart.
The bartering days are gone. Dr. Welby is dead. SuperCare Health Systems, Inc. does not accept tomatoes.
The world is full of people who would rather be beat with a chain than go to a doctor. They dread being told something is wrong with them. It does no good at all to try to “reason” with them. When pressed on why they delayed seeking treatment for so long, they are unlikely to be entirely candid in their responses.
Margalit: That is precisely why I limited balance-billing to primary care. The cost is relatively low and so balance billing would not be too much to ask. Here are what I see as the positives:
1. All doctors could once again afford to accept Medicare
2. Prices could be posted, so transparency of cost would be achieved
3. Doctors could then compete for patients based on cost and quality of the care they give. They could charge more if they wanted, but would risk losing patients. As it stands, the current system encourages worse service, not better. Wouldn’t it be better if doctors actually had to try to be on time and would be motivated to actually listen better?
I think this outweighs any negatives. You can’t do balance billing with the higher-cost items. The cost cutting on that front would be through better use of primary care and increased availability of primary care (which has been linked to lower cost).
“…. increased availability of primary care (which has been linked to lower cost).”
And this is exactly why I don’t understand how charging patients more than they pay now for primary care is a good thing.
I do agree that Medicare in particular should pay more for Primary Care and I think there is incremental effort in the current bill. Even without the bill, there will have to be some sort of fix for the measly E&M codes, or better yet the entire logic of the system.
However, balance billing opens an entire can of worms. It will be abused, just because it can be abused. If it is indeed abused in a regional fashion, lots of people will lose access to care. It will exacerbate existing disparities, because you will end up with doctors for the rich, operating on high margins, and doctors exclusively for the poor, who will still operate on volume. Not sure that quality of anything except superficial amenities will be a factor. So basically we are institutionalizing different tiers of available quality based on ability to pay.
If anything, shouldn’t it be the other way around, like Barry often proposed?
It is not necessarily charging people more. Balance billing increases availability of primary care because all of the doctors who choose not to see Medicare patients (Medicaid even more so) will have no reason not to see them. It will once again make primary care a viable choice without putting an increased burden of cost. It will essentially create a free market. This doesn’t work with hospitals and specialists as well because they are fewer in number. What kind of abuse would happen with primary care?? How much do you think PCP’s charge? If someone overcharged, they would simply not get business.
If Medicare continues the way it is, the care gap will increase. In our town, there are very few doctors accepting Medicaid at all, and Medicare is steadily dropping as well. At this point there is no access to a lot of patients aside from ER’s and public clinics. This is a two-tiered system.
The system you fear with rich getting lots of time and poor being volume driven is already happening. It’s called boutique or concierge medicine. It’s growing rapidly because Medicare is not a good part of a viable business plan. Making docs compete based on service and quality (I repeat) is actually good. I want quality to improve.
I’m afraid I may be misunderstanding what you are trying to say.
First this: “It is not necessarily charging people more.”
Then this: “It will once again make primary care a viable choice without putting an increased burden of cost.”
I thought by balance billing you meant that you would be at liberty to charge the patient beyond what Medicare reimburses you and beyond the copay amount.
If that’s what you mean by balance billing, then you will be charging people more and you will be creating an increased burden of cost for the patient.
As you said in the original article, even a $10 increase is burdensome to patients. And I do know that an average 99213 can be reimbursed by Medicare at less than $50.
Wouldn’t a better solution be to have Medicare/caid increase rates for PCPs, while decreasing the amount they pay for certain procedures and/or increasing the copays for those procedures?
BTW, what do you think would be a reasonable reimbursement (or a reasonable range) for an average visit? Do you think it should be a function of time spent, or complexity, or both?
“I am not a proponent for a single-payor system. I am simply against the chaos of our current system and I do think there are ways to simplify things.”
But what are you FOR???
One potential benefit of balance billing not mentioned so far is that primary care doctors would be able to charge by the hour like lawyers do. Imagine if there were a sign that said our hourly rate is $300 with a minimum charge of $50 even if your visit lasts less than 10 minutes. It doesn’t matter if you need a sonogram, an x-ray or just a consult. The rate is still the same. Prescription drugs are extra as are labs and procedures that need to be referred out to a specialized facility but there should be price transparency for those too. Bills can still be submitted to insurance using CPT-4 codes as they require, but the patient will be responsible for the hourly rate and whatever insurance pays, it pays. I recognize that this won’t work well for the low income population but it should work for at least the upper 50-60% of the income distribution for primary care.
Hospital charges, surgeons’ fees and procedures done by specialists will not lend themselves to this approach but, again, price and quality transparency should be available. If doctors cannot quickly determine your medical problem, especially in the case of a hospitalized patient, price transparency is not practical because it can’t be determined how much work and how many tests will be necessary to figure out the problem. Even here, though, if hospital charges, excluding surgeries, were based on a per diem amount, the patient would have a good idea of the likely cost.
I think a two tier system is inevitable. The wealthy will always be able to buy up whether it’s a private room in a hospital, access to the most famous doctors and medical centers, or concierge primary care. Even in Germany, the top 10% of the income distribution is allowed to opt out of the public system if they want to. If the quality of healthcare available to the poor is sufficient to either keep them reasonably healthy or address their issues on a competent and timely basis when they occur, that should be good enough no matter what amenities rich people are able and willing to buy with their own money.
Finally, I wonder if Dr. Lamberts could offer a few examples of care that PCP’s could handle themselves if they had more time to spend with patients but refer out to specialists under the current system. It doesn’t make sense to pay them more unless they can reduce referrals to specialists and do a better job of keeping patients out of the hospital, especially those with chronic diseases like diabetes, hypertension, asthma, etc.
Please read http://distractible.org/2010/03/11/expertise/ which I wrote today regarding my thoughts on this and other debates. Let me think on all of these questions. I suspect a post will come out of it (so I won’t push it while here in the comments). I think all have valid points, but I agree most with what Barry just said. The system needs to encourage quality care and good service. What better way to do that than have docs marketing themselves to patients. Empower patients by letting them compare docs based on price and on quality. We do that in many other industries. We already have a two-tier system, so I don’t buy that as a reason to not do balance billing.
I do agree that Medicare in particular should pay more for Primary Care and I think there is incremental effort in the current bill. Even without the bill, there will have to be some sort of fix for the measly E&M codes, or better yet the entire logic of the system.
The discussion gets a bit fuzzy when the term “insurance” is used to signify both Medicare and private insurance. I assume that “balance billing” contemplates only Medicare recipients who have exhausted all other alternatives. Everyone else will want “authorization,” i.e., a guarantee of payment from the insurer, prior to treatment.
I am allowed to see most other patients and have them file their own insurance. It only applies to M/M. HMO plans are waning. This plan would cap costs for insurance, so it would undoubtedly be attractive for private payors.
Rob, The problem with your approach is that people cannot “shop” for healthcare. With very few exceptions, healthcare is not a commodity with a economic utility curve on it. Healthcare is something we have to buy to stay health, and in some cases stay alive.
If you ask people to comparison shop on the basis of price, often there simply is not enough time to do that, or the variables involved are just too obtuse understand.
When people do comparison shop, we end up with a situation where the wealthy will continuously be getting better care than the poor, and the poor will too often be shut out of the care they need. The concrete example about this that I am aware of is the case of dermatologists where it’s easier to make and get aBotix than be tested for skin cancer. The money is in Botox, so that’s where the market moves. But the poor person who cannot get a potential skin cancer addressed may suffer because of that market force.
People shop for health care where the market allows it. Lasik surgery, plastic surgeons, prompt care centers – all are “shopped” for. People don’t necessarily get good or bad care based on what the person charges – I am sure some bad docs would charge a lot – but the average patient doesn’t shop now because they cannot. If someone asked me “how much does an office visit cost?” I couldn’t answer. It varies depending on the insurance, length of visit, etc. The cost of a visit is also more expensive than I would want to charge someone without insurance – that is because of how docs set their fee schedule to get the most out of what the insurance companies pay (writing off the difference).
Wealthy people always can afford more than poor people. It’s kinda what being wealthy is all about. Now, should preventive services or access to care be available to people of all demographics? I think so. If I have a poor patient and call a dermatologist because I am worried about a skin lesion, they never refuse. That inability to get the visit due to all of the folks getting Botox, by the way, is not just for poor people. Everyone has difficulty getting in for non-cosmetic procedures (but can if the PCP calls).
Precisely. “Adequate medical care” for the poor should be the goal, Not “equal medical care.” You won’t get much agreement on that here, though.
“Lasik surgery, plastic surgeons, prompt care centers – all are “shopped” for. People don’t necessarily get good or bad care based on what the person charges – I am sure some bad docs would charge a lot – but the average patient doesn’t shop now because they cannot.
The average patient DOES shop for a physician that they can trust (or at least feel they can), especially for more complicated procedures, but not for price. But their shopping decisions are not based on reallity, just feel and recommendation. What would a lower price tell you – “I do less than average work, but you’ll save money”? What would your answer be, “That’s OK doc, my life is less than average anyway”? This notion that somehow price shopping will lower our costs is rediculous. Would people assume that really expensive cost is really good surgery, I bet they would as they assume that really expensive college is really good education. How would the average person cut through the lesser cost – equal care question? And how would docs determine where to place themselves in the “price point” market?
Quite the opposite, archon. I wholeheartedly agree with the notion of “adequate medical care” for all, and whatever extra that people with money can buy is their business, and they can go around shopping for it all day long, and doctors can balance bill for it to their wallet’s content.
Of course, the devil is in the definition of “adequate”.
“Of course, the devil is in the definition of “adequate”.”
Margalit, I have challenged 41 to give us a definition of “adequate”, but so far he has not come through. I think for him adaquate for the “poor” (also no definition) would be their local vet, along with the euthanasia option when it got too expensive for the rest of us.
Next, y’all will be blabbing that I’m just your angry, white pickup driving male, with no egalitarian sentiments whatsoever. Nothing, of course, could be further from the truth. I’m not mad about anything.
So what happened to “equal access for all”? The earthy feeling of solidarity with the financially stressed? Or, as Wendell recently put it, “from each according to his ability, etc.” (Seems like I’ve heard that somewhere before.)
Your memory is being very selective with you, Peter. I have said on several occasions that it makes far more sense to broaden and expand the “safety net,” rather than to aim for homogenized medical care, or to fund, for “the poor” policies of insurance like those typically provided by employers to employees. There has to be some rational middle ground here. I am particularly sympathetic to the truly indigent who, for whatever reason, can’t qualify for Medicaid. But I may as well make a clean breast of it on one point: I lose little sleep over those who, having other priorities, are disinclined to spend their own money on medical care.
“broaden and expand the “safety net,” rather than to aim for homogenized medical care…”
This is not at all equal to “adequate medicare care for all”. What is adequate for you, should be medically adequate for any homeless person. Same doctors, same hospital, same equipment….
Now, if you have a propensity for MRIs every time you get a headache or if you need pay-per-view TV services in the hospital, that exceeds my definition of adequate, so you can go buy yourself a subscription to an MRI center and write a check for the hospital upgrade.
“I lose little sleep over those who, having other priorities, are disinclined to spend their own money on medical care.”
That’s admirable, considering that you end up paying for whatever care they end up getting.
The quality difference the poor and wealthy get should be environmental. It should be like hotels – both Motel 6 and the Ritz Carlton have beds and you sleep at both. The difference is in the environment. For medical care, the difference would be wait time, on-call availability, email access, and perhaps extra time spent. If people want to pay more so they can get premium service, then I am fine with that.
I do struggle with a system that does not reward hard work and excellent care. Since I spend more time and pay attention to details, I have better outcomes. My reward for this? I am paid less than the doctor who speeds through 40-50 patients per day. THIS is where me being able to compete based on my quality of care would be a positive, with two outcomes: I would be actually rewarded for doing good, not penalized; and the doc seeing 40-50 patients per day would not be able to charge as much, as he/she would lose patients. Again (for the 10th time), our system MUST stop encouraging bad care and start rewarding the right thing. Simply increasing E/M reimbursement for primary care does nothing to address this serious problem.
Yes 41, broaden and expand to where, the same hospital and doctors you use with the same treatments?
“I lose little sleep over those who, having other priorities, are disinclined to spend their own money on medical care.”
So with your 40 years in the insurance industry when did you ever pay for your own healthcare? And now, is your “retirement” also spruced up with the “forever” medical coverage package from your previous employer?
Per clip of Nancy Pelosi in the past 24 hours:
“let’s pass this bill so we can see what’s in it.”
This, is your leadership, america. Even this idiot is now admitting she has not read the 2700 pages to know what she is trying to ram down your throats.
Think of it like a suppository, in your mouth!
My, aren’t we defensive today. Actually, you are in the process of creating, for “the poor,” broader private insurance coverage than the coverage afforded under Medicare. And on their behalf will be paid full private insurance rates, making them more desirable patients. Not that I’m worried about it. I’ve got me a good curandero lined up.