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1. Everyone,

   Some very interesting posts and great comments regarding preventative health and various insurance and health care systems. However, one of the most important issues in the prevention of illness is simple the patient taking responsibility for their own health. With that said, the nation and world is facing a new epidemic, cardiovascular disease.

   In June of this year, the World Health Organization (WHO) released the “Top 10 Causes of Death” for the world. According to the report, an estimated 57 million people died. The number one cause of death throughout the world was cardiovascular disease, with 7.3 million dying of ischemic heart disease and another 6.2 million dying of stroke or other cerebrovascular diseases (WHO, 2011). During the 2011 United Nations (UN) General Assembly Global Agenda for non-communicable diseases, ““it was the second time ever that a health related topic was discussed for a UN high level meeting””, raising cardiovascular disease as one of the key topics in global health (WHO, 2011).

   We know that America is facing the worst health crisis on record, obesity and diabetes is occurring at the highest rate in history among children aged eight to eighteen (CDC, 2011). Going back to the original article about disease management (DM), we as a nation or world need to take action in the prevention of these diseases. Regardless, of the involvement of insurers or HSA’s, the individual (potential patient) needs to take responsibility for their own heath. The challenges facing this approach are two-fold, 1) most individuals and society only see’s the short term opportunities and fails to plan or look toward long-term gains, in this case prevention of disease and illness. The second 2) is the knowledge base of the general individual regarding actual prevention strategies, not just general statements, such as “exercise” and “eating right”.

   It has been my experience that these two obstacles greatly impact the failure of many to reduce their weight due to a lack of knowledge of what to eat and how to eat. This along with the importance of the individual’s self realization that health and disease prevention depends on their immediate perception (risk acceptance) and the actions they need to take now for those long-term health gains. As healthcare providers, researchers and public health professional need to continuously educate the population about correct dietary choices, importance of exercise daily and efforts to reduce obesity through these measures. Otherwise, not only will we continue to see cardiovascular disease in “now” epidemic proportions, we may not have a healthy population to support those who are ill?

   References:

   Centers for Disease Control and Prevention (2011). Overweight and Obesity, U.S. Department of Health and Human Services. Retrieved from http://cdc.gov/obesity/defining.html

   Office of the Surgeon General. (2007) The Surgeon General’s call to action to prevent and decrease overweight and obesity. U.S. Department of Health and Human Services, retrieved from http//www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm

   UN Report (2010). The Millennium Development Goals Report 2010. United Nations, New York. Retrieved from: http://www.un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdf

   WHO (2011). Fact Sheet No.310: The Top 10 causes of death. World Health Organization, Geneva, Switzerland. Retrieved from; http://www.who.int/mediacentre/factsheets/fs310/en/

2. Eligibility companies are companies that are on-site at hospitals which screen self-pay patients to see if they qualify for Medicaid. If the patients do qualify, these companies help them wind their way through the bureaucracy get signed up for Medicaid coverage. Then, when the claims on services rendered are paid, the Eligibility company takes 10-15% of the Medicaid Payment as a service fee. I would go into more detail, particularly where I came up with the 20% number, but I don’t want to get in trouble at work.
   And I did work for a billing company that took about 25% of all the money the medical group received from all payers. In exchange they did everything, including provider enrollment, claims submission, patient statement management, denial and appeal management, posting, etc. So, it was more comprehensive service than “billing company” implies, but 25% is still a ton of money to be losing for it.
   Getting patients to require fewer services would obviously help quite a bit, but the policy changes needed to bring that about are way more difficult than working with things as they are and trying to come up with a model that fits reality. That’s why I say that for a person to say “if only people lived healthier lives, the whole problem would be solved” is essentially throwing your hands up.

3. spike says:
   > Billing companies charging 25% of receipts to
   > get claims paid, Eligibility companies charging
   > 15-20% of Medicaid payments to help people become
   > eligible for Medicaid.
   It is sometimes estimated that the TOTAL cost of our reimbursement system comes to about 25% of total spending, but that includes everything from charge-capture in the hospital or doctors’ office, to the marketing activities of insurance companies. Moving to a single-payer sort of system would probably save between half and two-thirds of this amount. No billing company gets anything like 25% of “receipts”. I am not quite sure what he means by “Eligibility companies”. I have heard of “eligibility lawyers”, but their fees don’t come to a hill of beans.
   Dr. Novak’s main point is that inefficiencies matter less when we consume less of the inefficiently-delivered services. He does not suggest that every problem is solved by individuals taking better care of themselves.

4. What I’m really saying is that there are lots of ways to encourage people to be more active participants in their healthcare, but HSAs are not the way. We probably agree on more than we disagree, but HSAs are the exact wrong way to get people more involved in their healthcare. Both because of policy reasons that have been discussed ad nauseum on this site (having to do with the pareto effect in healthcare and there being no money left over to treat the 20% of the population that is actually sic), and also because the incentives they set up for patients would probably be perverse and leave people much less healthy than they were on group coverage.
   My main beef with the healthcare system is that so much money is wasted on competition that any efficiency gains that come from that competition are eaten up. As I’ve said before… Billing companies charging 25% of receipts to get claims paid, Eligibility companies charging 15-20% of Medicaid payments to help people become eligible for Medicaid. This is a ridiculous waste of money that doesn’t have to happen if we financed our care in a reasonable manner. Saying “it would all be taken care of if people were more responsible” is ignoring the inherent inefficiencies in the healthcare industry that make true progress impossible. That was my main point.
   As an armchair sociologist, I also say that there’s something wrong with a society in which 30% of the people are obese. Blaming it on each of those people and calling them lazy does them a disservice.

5. Spike- what if the ‘policy makers’, in the ‘best interests’ of all, decide to not allow hip and knee replacements for anyone with a BMI greater than 30? This was policy just put into place in a health district in England. I am not making it up. Over half of all US adults would suddenly become ineligible for hip and knee replacements, arguably one of the best medical advances in terms of quality and extension of life of the last 40 years. What if the ‘policy makers’ decide that anyone over a certain age is no longer eligible for dialysis? (also in England, except there a private system exists in parallel to the public one).
   You extremely underestimate the level of ‘holistic’ understanding of most allopathic (MD) physicians. Doctors have been saying the things I mentioned earlier on in this discussion for years and years. And the US is getting more and more unhealthy.
   Many of the ‘holistic’ treatments that you might favor would never be allowed in a system where ‘evidence based medicine’ is the guiding principle behind all allowed medical therapies. Double-blind, randomized trials with the power to really show efficacy do not exist for most ‘standard’ treatments; ‘holistic’ treatments have far fewer still.
   In spite of our lack of agreement on policy implementation– I am surprised you are willing to give the public a pass on responsibility that incontrovertedly would achieve all of the goals you and I want to achieve. Instead, you blame doctors and pharmaceutical companies and the government.
   While I am on government– what if the ‘policy makers’ determined that foods with high fat content or saturated fats should be banned completely? or that televisions can only work 2 hours per day? or that smoking should be banned in private homes? or that only one drink of alcohol per day per adult was legal? That would surely be policies that the government could impose to promote better health. It sounds absurd, but you give individuals a pass on personal responsibility for these issues and actively advocate a government appointed group (I suppose these very smart ‘policy makers’ should be appointed, not elected) be put in control like a national parent.
   PS- how would increased mental health spending do to make people eat less, exercise more, and stop smoking?
   Abby- if more of a free market existed in the ability to set fees in medicine, I would bet some physicians would set lower fees– perhaps because they were newer out of residency or because a very high density of doctors increased competition in an area (ie. Boston) or because they might not be that good– I would almost guarantee that you might be able to achieve your cost savings when seeing certain providers.
   KIAs cost less than Porsche (though I like my Honda)
   Blockbuster ‘eliminated’ late fees in response to Netflix
   A recent graduate with an architecture degree is likely to charge less to design your home than the long-established high profile firm in town.

6. Keep in mind also that I’m doing everything I can to avoid discussion specifically of HSAs, though I feel they are very relevant to this discussion. I can’t bear another battle with Ron.

7. Eric, I don’t think you can isolate it like that and say “My goal is better health” or “my goal is more cost efficiency”. I think all of those things go hand in hand. Better health, more standardization, and better management of chronic conditions would likely be reflected on the bottom line.
   My main point in this discussion is that when over 35% of your population is making the same bad choice, the answer isn’t to blame each of them individually for their bad choice, it’s to look at the system and understand why it’s so hard to make the right choice. What are we doing wrong as a society that a third of our citizens live very unhealthy lives? Maybe the answer is more money spent on mental health services.
   Healthcare in America is a very holistic problem (no wonder people trained in America’s medical schools have difficulty seeing it that way, heh), you have to look at the whole system, not an isolated piece like “people are too lazy” or “doctors make too much money” or whatever else it is. Being that it’s such a holistic problem, I think the ideal solution lies in something very much like the Clinton plan, where policy makers are given the tools they need to create good policy. It may require compromise, people may not get everything they want, but the benefits for everybody would most likely outweigh the negatives.

8. Eric,
   We could also go to the docotr’s office twice as much and pay them half as much. Hmmm….

9. Official word re Pacificare/QMed is that CMS has asked the parties involved not to comment further pending notification of the people in the program starting this coming Monday. So anything else would be speculation.

10. Spike- no evidence for small group or solo practices that the costs of conversion would ever be recouped for IT investment, but that’s not the point.
    Let me pose my question/ issue to you in another way: what ‘change’ are you trying to achieve in healthcare? better health? reduced cost? more standardization? perhaps I could better respond if I knew what you are trying to achieve.

11. When you talk about how the consumer is where it should all start it reminds me of how Healthcare IT firms always blame the medical professionals for not adopting their products.
    The consumer isn’t going to start it. While in a perfect world, that is what would happen, in our world, it isn’t. So saying “It has to start with the consumer” is throwing up a smokescreen to stand in the way of change. If it were easy for consumers to know everything they need to know to be a truly meaningful participant in their healthcare, you wouldn’t have had to spend 4 years in medical school and another few in a residency. Even if they did, the benefits are so far in the future and the costs are so present that it’s not the solution.
    If you disagree, think about why your doctor friends didn’t adopt the latest IT solution that would save them thousands of dollars over the long term, but has a high up-front cost and involves a lengthy implementation process with no realized benefit for a couple of years. Everybody reasons like this. It seems patronizing for doctors to blame it all on millions of consumers individually making poor decisions instead of a society that needs better policy to encourage people to make the correct decisions in the correct way.
    Doctors and administrators, the people who are supposed to have the specialized expert knowledge, should be given more responsibility, not less.

12. Hmm…I’ll see what I can dig up about Pacificare’s problems

13. In a report available on our site, “Modifying Patients’ Behaviors to Optimize Disease Management Outcomes,” we talk about patient engagement strategies — getting patients into disease management programs and keeping them in once enrolled.
    We also explore the advantages of using an engagement model over an enrollment model. In a blog post today on our site, at http://blog.hin.com, we summarize the key findings of using an engagement model over an enrollment model.
    I am curious to learn more about the inside details on the Pacificare program. What strategies did they use to enroll members in the program? Was the failure due to the unique needs of the Medicare population?
    With an ever increasing focusing on disease management, lifestyle management and population health management, these CMS demonstration projects are demonstration projects that cannot afford to fail.

14. thank you all so much for the feedback… a little weird finding myself on Ron’s side of an issue.
    Let me try to address a couple of raised concerns:
    Abby- so many of THCB discussions are raised from a general policy point of view. An underlying theme of many of the blog participants is not necessarily that the US spends too much on healthcare (though many feel that way), but rather that the way it is spent is out of control, and that it continues to increase at rates that are unsustainable over the long term.
    Diabetes and heart disease are the largest drivers of healthcare costs in the US:
    diabetes= at least $132 BILLION in 2002
    Heart disease= $352 billion in 2003 (via American Heart Inst.)
    Obesity= greater than 90 BILLION in 1998 (2002 dollars
    This is where the money can be saved- if you are into money. This is where quality of life can be improved- if you are into quality of life. This is where small shifts in the direct and indirect costs due to a chronic disease would truly impact the whole country and economy.
    Sure, you can come up with many examples of individuals with very difficult and not self-imposed circumstances– I take care of many. The system ought to be able to help them. The current system needs help.
    But if you (and by this I mean not just you) really want to impact the system– start here, and it has to start (though not end) end with the individual.
    Matthew– I respond to you using my answer to Abby as a segue. You and I have talked and written in different ways about the 20% who are the big users of healthcare. The groups above are the big users. Do we need systemic reform– absolutely. Do I think that less government micromanagement would be better? Do I think that a private insurance system focused on the individual and not the employer is an essential step? Do I think that- as a surgeon- using the latest and greatest and, oh by the way, by most expensive implant in every situation is excessive, but currently happens all the time? Do I think that patients and doctors often spend not enough time understanding the best, least expensive way to handle some conditions? Do I think that fears of medical liability drive down access, drive up costs? Yes, Yes, Yes, Yes, and Yes.
    Do I think that the single best, cheapest, and absolutely GUARANTEED way for this country to get a handle on healthcare utilization and cost is for each person and family to spend 10 minutes to keep a personal, updated record of what medications and major medical issues and treatments they have had; for each person to realize that not smoking one pack a day would fund $1000 of an HSA each year (not to mention future savings); for each person to realize that Matthew Holt should not be responsible if I choose to sit down each day and consume enough calories to feed an entire family; for each person to ask their doctor ‘why are you giving me this drug and not an alternative that is less expensive’ and ‘one week of knee pain after playing ball may not need an MRI’ and ‘what advantage is there to coming to see you every two weeks, perhaps once a month would be ok?’; perhaps taking the stairs or walking each day from a far parking spot to the mall would be a good way to get some exercise???
    Absolutely– and it does not involve paying me (as a guilded surgeon) or you as a health IT professional anything.

15. Eric, name one nation that got its healthcare costs under control by increasing its level of cost-sharing. What I don’t think you realize is that other developed nations use a modest amount of cost sharing, but also need to do other things in order to insure everyone and keep costs under control without sacrificing quality, measured by outcomes.
    I would like to submit that the discussion so far hasn’t been very clear. It isn’t that FFS medicine all by itself forces an inefficient, bloated healthcare system. Rather, our problem has three parts: FFS medicine + an insurance system that insulates individuals from costs + a lack of serious government cost controls.
    If you were to change any ONE of these three parts, you would be able (with a lot of work) to create a healthcare system in the US that produces far more value than ours does (by “value” I mean quality as a function of cost, or bang for the buck).
    However, if the only part you change is to increase cost sharing, then you’ll get aggregate spending under control but there is no reason at all to expect everyone to have access to adequate healthcare. Again, name one developed nation that has done this.
    I know you’re all smart people, but we need to remember that it is easy to say dumb things when we forget what other nations do and how they make their health system performance so much better than ours. And the truth is that they do it in different ways. They all start with universal healthcare. They also pay their providers less than we do here. A lot less. We will never get our healthcare costs in line with other nations unless we pay our providers less.
    But paying less doesn’t necessarily mean leaving FFS. Some nations do FFS with strong price and utilization controls from government (isn’t this the British model?). Others use capitation or salaries for physicians. If we don’t have a strong government involvement in price controls, then I do agree with Matthew that we need to turn to salaries and/or capitation and use integrated delivery systems such as Kaiser.

16. To imagine that more personal responsibility is the answer to our healthcare woes is to imagine that Americans believe less in personal responsibility than the rest of the developed world or that healthcare systems with demostrably lower cost and better outcomes are worse than the US system. I don’t think either of thos propositions are true. We already have a system that imposes more personal responsibility than any other and it is one of the most dysfunctional in the world.

17. Why, yes I can indeed boldly link to other websites: the preview feature works, and so does the finished product. I shall try not to abuse it…

18. Without someone clearly responsible for outcomes, I fear any scheme will be gamed.
    So, if comments can have HTML coding, let’s see whether I can boldly link to other websites

19. I always get riled up when everything that is wrong with health care in the US gets boiled down to personal responsibility. If the health care system was appropriately designed and rewarded, helping people to do the right thing would be valued and well-paid. That is not the case. If you read the NY Times article on “Good Medicine, Bad Business” that would be abundantly clear. Individuals who inherited the predisposition to get bad things when they gain weight (e.g., metabolic syndrome and diabetes)find it difficult to do what they should (as would you) if you were poor, didn’t really understand the link between poor nutrition and disease, worked one or two jobs and live in neighborhoods where it is dangerous to exercise and and cheaper to eat fast foods than healthy ones. We can debate personal responsibility until the cows come home, meanwhile, we are in the midst of an epidemic of obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease (all with related, by the way), that is going to sink us both in terms of increased healthcare costs, lost productivity, and increased burden of folks disabled from the disease and unable to work. We need comprehensive social policies in this country to address these issues (remember health is not synonomous with healthcare). Blaming individuals who eat poorly, get fat, and make comments that sound like they don’t care, is not productive. (Whew!)

20. Tom. If you have a fee schedule, especially one essentially set by the government or any other payer, it will inevitably get gamed. I await to see if the “reverse gaming” of P4P works, and with our current system it’s the best option, but I’m not too optimistic.
    I think giving the system a chunk of money — whether on the canadian/Brit global budget style, or some version of the Enthoven/German/Dutch pooled pre-payment, and letting the providers sort out how they share it out to the best effect is where you have to end up. After all in practical terms that’s how most business work. (Who does rigorous FFS piece billing other than docs and lawyers?)
    Otherwise open wallet FFS in medicine with its imbalance of information and (rationally) self-interested providers is purely inflationary — as we’ve seen from 1945 onwards! But telling the consumers they have to behave is only about 4% of the problem.
    PS I wish my comments had spellchek, but they do now have html coding so you can link to other websites

21. > I am an advocated, if anything, of
    > universal insurance with a managed
    > competition system a la Enthoven
    Ooooops! I actually knew that! Mea Culpa.
    > FFS which rewards highly invasive procedures
    > which are discrete and easy to sell over
    > difficult to manage long term chronic care
    > interventions
    I might’ve said “are discrete and urgently required” but that’s a little beside the point. Not that I’m defending FFS, but don’t you think your qualifier about relative reimbursements is much more important that the FFS structure itself?

22. And note that the Pacificare example was about putting DM into a FFS population NOT INTO A PREPAID HMO. That program is still going forward

23. Sorry guys, as usual too many assumptions about me but great discussion (with a certain exception!)
    a) I am an advocated, if anything, of universal insurance with a managed competition system a la Enthoven — not a single payer. I just think single payer would be better than the mess we have now, and would eventually be the place to get us to that system…as our 1994 attempt to get to managed competition was killed.
    b) And of course money is a motivator, but it’s more of a motivators for suppliers of services for which they get immediate rewards than for consumers who’s incentives are likely to come to them down the track. So saying that FFS, especially FFS which rewards highly invasive procedures which are discrete and easy to “sell “over difficult to manage long term chronic care interventions, is NOT the problem is just Bullshit….and 100 years of FFS under the guild model in this country shows it. Go chat with Enthoven (or read any of his stuff) or look at the national Health Expenditures and you’ll see the proof. Pre-paid organizations are able to put in the programs that just dont work in a FFS world, which is why Kaiser has had DM programs for 20 years which have had modest cost and massive quality success (as seen in Health Affairs and here)
    c) Meanwhile Eric, there is a whole movement — information therapy/DM — talking about how to best get patients to take part in this, and the answer may include some “personal responsibility” but it’s only part of it. And it’s really really hard. But it seems to be your only answer. And unless you are prepared to allow those you say “weren’t responsible” to die out on the street when they do get sick — which i know you (persaonlly and as a conscientous clinician) will not — it’s a red herring

24. Eric,
    He’s able to control his illness pretty well. It’s just that he had to take some time off from college to get his illness stabilized. When you’re not in school, most employer-based group health plans won’t cover your children over the age of 18, if they’re not in school.
    And the polypharmacy required to control schizophrenia with fewer side effects is expensive (easily more than $300 per month at retail prices). Don’t even try to suggest that the older generic drugs are an effective substitute. Tardive dyskinesia and extrapyramidal symptoms are not pretty. Plus things like Thorazine and haloperidol control the positive symptoms, things like hallucinations, well, but not the negative ones–strange affect and disorganization–the sort of thing that makes it hard to keep down a job.
    And the older drugs tended to lead to increased wait gain so that heart disease and diabetes are major concerns for schizophrenics. Nor have psychiatrists been good about coordinating with primary care doctors and other specialists to make sure that the basic medical health of their patients is looked after.
    But let’s say that he gets a job out of college that pays $35,000 per year. Do you really expect him to spend $5-6K per year on his healthcare and carry some sort of catastrophic coverage on top of that? The whole point of insurance is to distribute risk, but any insurer won’t want to underwrite him if it can possibly help it. So, he’s locked out of the individual market unless he lives in one of those states that require community rating. And we’ve all agreed that the current employer-based system is not optimal.

25. In Matthew’s defense, although he is an advocate of a single-payer, universal coverage system, he is criticizing the FFS aspect of existing system(s) that approximate this, not suggesting simply that a move to single-payer will solve the problem of human nature and have everybody immediately begin to make decisions leading to the subgame-perfect Nash equilibrium. (Sorry — I just read the WSJ article about “Deal or No Deal” and have grown misty-eyed for my Game Theory course. Professor Swinkles would be proud, I am sure.)
    But, I think he’s wrong about FFS destroying the incentives of doctors and hospitals necessarily. My dentist has his own DM program: he send me reminders a couple time a year to come in for my Preventive Maintenance, and his is purely a FFS practice. Even in a FFS world, it seems that DM programs could work to the extent allowable by human frailty if (say) a group educational session is considered a service.
    The trouble is to get patients to make appropriate use of the programs. This seems to have been the Pacificare story, as Dr. Novak points out. The Pacificare episode says even with Kaiser-style pre-payment, patients won’t show up. People undervalue risk, so you will have to pay some of them in excess of the risk to get more of them to participate, and you won’t get them all, even with wildly excessive payments.
    From a policy persepctive, the question is whether spending commensurate with the aggregate risk avoided in the absence of the program matches the cost of delivering services, including doing whatever it takes to get patients to take advantage of the propgram. Social Choice theory says it is not justifiable to spend in excess of expected benefit, but even if we did that to a great extent, some diabetics would still end up blind and without feet. Although this is a great tragedy for the individual, it seems to me this represents the intersection of personal resonsibility and public policy. People who want the information can get it, and nothing much can be done for those who don’t.
    It still seems to me rationalization of incentives is a Good Thing(tm). But how do you do that for patients who undervalue risk? There are equity and liberty issues everywhere you look in this area…

26. Abby- as I have posted on many occassions, the system should be set up to help people. Many people do not choose their medical conditions– although the actions of people once they have a problem can (certainly there are exceptions) be the greatest determinant of complications.
    Mental illness, particularly in children, is not chosen or lifestyle related. We must account for that and have systems in place to assist. If the family can afford it, the family ought to contribute to the cost of paying for care. Obviously, as a child and as one with an illness which can have a lack of insight/ control as a fundamental feature- perhaps the personal responsibility is limited (although schizoprenia can have a range of severity). In these cases, the question that society needs to ask is related to how much society can require patients to participate in care- including taking medicines.
    The great freedom that psychiatric medications was supposed to give to the mentally ill has worked, except for those most afflicted– in whom illicit drug use, homelessness, suicide have become more prevalent. It may be that society would decide that certain people are too ill and may be better off in more structured living. Much cheaper than the costs of crime, drug use, welfare, and the human tragedy of failing to be there for a population that cannot help itself.

27. Eric,
    How does your analysis apply to other chronic conditions which strike people when they’re young. A friend of mine has a brother who was just diagnosed with schizophrenia. Do you think it’s his fault that he got it? Taking responsibility for his condition means taking expensive drugs (avoiding them would be noncompliance and would mean that he lacked insight into the nature of his illness) and seeing lots of doctors.

28. Eric is right, you are completely wrong Matthew. Consumers are king and they decide who gets the money, even the insurers’ money, sorry. We need people in DC who understand free markets and economics. Jerry Zandstra is running for US Senate from Michigan and he will debate Democrat Senator Stabenow, who is a fine girl, but not to bright on Tripod Economics. Sure Stabenow has $6.7 million but Zandstra has ideas, ethics and a PHD. Both Ted Kennedy and Stabenow are over-weight. Knowledge and ideas are more valuable than money. Less Government / More Freedom.

29. Just read the Times article- and, though when read through the eyes of a devotee of nationa, single payer, I can see that as a solution- it was not the conclusion that the author was intending, I believe.
    “After ignoring her condition for 20 years, Ms. Hammond, 63, began to ride a bicycle twice a week and mastered a special sauce”
    “Type 2 diabetes grows hand in glove with obesity, and America is becoming fatter. Undoubtedly, many of these diabetics are often their own worst enemies. Some do not exercise. Others view salad as a foreign substance and, like smokers, often see complications as a distant threat.”
    “Chronic care is simply not as profitable as acute care because insurers, and consumers, do not want to pay as much for care that is not urgent, according to Dr. Arnold Milstein, medical director of the Pacific Business Group on Health.”
    “Health economists suggest that if these preventive measures were practiced on a wide scale, complications from diabetes would be largely eliminated and the American medical system, and by extension taxpayers, could save as much as $30 billion over 10 years. The experts disagree on what such an effort would cost. (How much nutrition counseling does it take to wean the average person from French fries?)”
    I quote this long list only to illustrate the fact that complete government control over payments will do nothing to fix the problem of lack of personal drive to get better.
    “Since endocrinology is one of the lower-paying specialties, there is a national shortage of such doctors” — please tell me how complete, one payer control will solve this problem.

30. Matthew- you have got it completely backwards… you should lead with the dsicontinuation of the Pacificare program. Although I believe I sound somewhat like a broken record… nothing will work to do what really matters– improve the health and quality of life for those with chronic disease– unless the patients are completely invested in taking some responsibility.
    In our society, whether you like it or not, one of the biggest motivators is- money. The problem is not fee for service- I promise you. The problem is the lack of connection between patient-payer-physician. The problem is fear of litigation. The problem is “the treatment imperative”– that is the expectation (often demand) from patients that something be done for a problem and the feeling that doctors have of wanting to provide something for a problem.