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Stressed Out System

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.

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86 replies »

  1. Would someone please explain to me how it is that you think the current health care bill will eliminate any stress over health care costs? As I see it, it will simply spread more stress to more people by raising everyone’s premiums.

  2. And how would you deal with the vastly more prevalent situation Sharilyn is describing above?
    First by correcting here, she doesn’t have to pay full price. I have never meet a doctor that won’t give a cash discount close to equal to what insurance pays him or better.
    Next I would point out that for $10 a month or so she could buy access to those very same discounts insurance companies have.
    Next as a business owner myself I would say just becuase you want to be in business for yourself doesn’t mean your entitled to be in business for yourself. She comes off to me as downright selfish. Why should I pay for their choice to own their own business? If he is a half decent driver he could have a job with benefits in 3 ours. Hell I have 2-3 clients that would hire him if his record was half good.
    This is the problem with the left, your reform is built on lies and greed. She doesn’t have a problem with insurance she has a problem with the choices they have made and wanting someone else to subsidise them.

  3. Will Jesus the biggest practicing Doctor of broken souls support a Socialize Health Care?
    My Kingdom does not belong to this world, Jesus said many times. We are a Christian Nation that committed horrible sins against native American Indians, Immigrants, and Slavery. Now we institutionalized denying health insurance to the sick. Is this a Christian Act. Is Jesus a for profit savior. Can Christians profit on the poor the insured. Jesus is beyond being a Republican and Democrat. If the Lord wants health care for the poor, he will touch the hearts of all the Congressmen he wants, He is the king, and nothing can stop him not Rush Limbaugh,not Fox News, not Obama nor the Democratic Party, he is the almighty, the omnipotent and omnipresent Jesus Christ my dear and beloved brothers and sisters in Christ. You see Jesus doing miracle in Hospitals, You see him in your operating rooms, he is everywhere and he is with the poor just be humble and remember your Lord and General Surgeon of the world and the United States the Lord Jesus Christ

  4. Sharilyn is describing one of my biggest frustrations: I can’t charge what I want. It has to do with Medicare’s rules as well as the contracts we must sign to accept insurance, not the greediness of docs. We cannot discount patients without either breaking a contract or breaking a law. If we discount below what we charge Medicare patients, we are breaking the law.
    Gosh, what would fix that….hmm….I don’t think anyone has talked about balance billing yet. If we were freed from the stupid rules that Medicare forces us to follow:
    http://distractible.org/2008/05/29/ten-dumb-things-about-medicare/
    http://distractible.org/2007/10/30/ten-facts-you-may-not-realize-about-medicare/
    http://distractible.org/2009/02/03/dear-mr-president-medicare-stinks/

  5. Same way it deals with other people suffering from eating disorders and mental disease.
    And how would you deal with the vastly more prevalent situation Sharilyn is describing above?

  6. I have been reading up on health savings accounts (as implemented by countries such as Singapore). Seems like an idea that could work (at least it does there). But, I am not sure how well it will work in the US. Maybe it’s another alternative. Any thoughts?

  7. My major stress about healthcare is the unfairness of it all … I have been told that patients without insurance have to pay in full the doctors’ charges while insurance companies enjoy paying a much reduced rate … on the average about 30 to 40 % less. I am one of the 48 million without healthcare insurance as we are owner/operators. We just cannot afford several hundred dollars a month for poor quality catastrophic insurance with high deductibles as I have been quoted … we are in our late 50’s and no company insurance available. Repairs/maintenance on our 2000 Volvo truck cost us about $18,000 last year alone, wiping out our savings! This healthcare crisis is a major stress to me as I still have 7 years before I can even qualify for medicare. My husband at least has the VA … I have nothing!

  8. I don’t believe it’s true, Nate.
    archon, I have no problem with great disparities in wealth. I have a problem with exploitation and unbridled highway robbery. This country proved that it is possible to have a system that serves the wealthy and the citizenry well. I just don’t want to see it go away.

  9. Would you perhaps care to identify some of the countries where, by dint of “regulation,” great disparities of wealth no longer exist? Do you suppose Siemens, Roche, BP, Total etc. to be less focused on return on investment than their American counterparts?

  10. just repeating what I have seen in life. What I will say is it is enviromental and not genetic. I have seen the difference within families, kids of different age groups responding to their friends and what happens around them.
    Curious if you don’t have an answer to how to solve it or you don’t beleive it is true?

  11. archon, I have no desire to see a postcorporate America, whatever that may be. I hope corporations live long and multiply and all their owners and executives and shareholders become as rich as they desire. I just want their activities regulated so the rest of America, which supplies the means by which they get rich, also benefits from this prosperity. Call it responsible capitalism, if you wish.
    Nate, I guess you are pretty much politely rephrasing what South Carolina’s Lt. Governor, Andre Bauer had to say:
    “My grandmother was not a highly educated woman, but she told me as a small child to quit feeding stray animals. You know why? Because they breed. You’re facilitating the problem if you give an animal or a person ample food supply. They will reproduce, especially ones that don’t think too much further than that. And so what you’ve got to do is you’ve got to curtail that type of behavior. They don’t know any better.”
    I have no answer to that.

  12. besides reading the glossary did you read the rest of the bill? Nothing in there actually does anything, it talks about fraud and the need to do something and studying it but it doesn’t actually DO anything.
    For example Medicare and Medicaid lose about 10% to fraud and waste, if goverment is spending 1 trillion now of the 2.5 trillon annually that means they lose 100 billion to fraud. They propose spending 100 million. That is .0001 of total spening, that is a joke of an effort. They aren’t service about fraud they are giving it lip service.
    “I don’t think it inhibits insurance companies from steering people to less costly choices.”
    Steer them how? Asking nicely? Whats left if you can’t penalize or reward them?
    “Both public and private insurers could communicate information about utilization vs. others in the population of comparable age and health status.”
    We do this now for groups that are that aggresive in cost containment. We’ll do employee meetings and tell them their generic utilization is low or ER visits are high then discuss alternative options with them, this is usually in conjunction with a change in plan to “reinforce” the change, i.e. higher co-pays or cost sharing, unfortunetly the needed utilizers are penalized with the wasteful spenders.
    “This is not a small problem to be resolved by a bunch of community clinics.”
    Exactly right it can only be solved by people not having kids they can’t afford. The way you do that is stop with all the handouts and working the parent’s F’n asses off so everyone that knows them says G D I ain’t havin no kids till I can afford them cause it sucks working two jobs to pay mandatory support for my kids. With all the liberal charity and handouts you can live a very easy life with next to no works just by having a couple kids.
    Well said Barry

  13. Perhaps Margalit will some day reveal to us her vision of postcorporate America, and how, in the “transformational” era, incomes are to be determined.

  14. Margalit – We could probably go around and around on this for a long time. Poverty statistics are, presumably, based on IRS data. As Nate says and as I and others have said before, the underground economy is all around us. I see it everywhere from the employees of the landscaping service that takes care of my yard to the waiters and waitresses in the restaurants I patronize, to contractors that occasionally do work on my house to maids and nannies, personal trainers, doctors, lawyers, and many others. Before welfare reform in 1995, everyone knew that lots of welfare recipients were working off the books while collecting benefits. Now, in the midst of the worst economic downturn, the welfare rolls nationally are less than half of what they were just prior to reform during a much stronger economy. Yet, we don’t hear of people dying of starvation now or then though food banks are admittedly busier these days.
    As for the richest among us, much of their income comes from interest, dividends and capital gains which can be extremely volatile from one year to the next. Due to people selling businesses, farms or even expensive homes, some have extremely large incomes one year and a much more modest income in subsequent years.
    While there is no question that good paying job opportunities have declined in manufacturing and construction partly for cyclical and partly for secular reasons, the long term shift in the economy from an industrial base to a knowledge and information base means more people need a college education today to thrive in the economy that we have now.
    The bottom line is that I am deeply distrustful of IRS income distribution statistics and think it is unfortunate that they are so heavily relied on to formulate policy as it relates to poverty and other programs for which eligibility is determined by income. I’m equally distrustful of CBO scoring in the current health reform debate but for a different reason. Changes in incentives change behavior but CBO doesn’t know how to score that with any precision. So, we are left with what economists call static (as opposed to dynamic) analysis which means as we change the rules like increasing taxes or cutting the price we will pay for drugs or other healthcare services, nobody will change their behavior and we can just assume we will achieve a proportionate increase in taxes or saving in healthcare costs. On the other hand, if we reformed the tort system, nobody can estimate with any precision how many fewer suits there will be or how much less defensive medicine will be practiced. So, CBO either assumes no savings at all or very little.

  15. How true. Karl predicted all this would come to pass, and we are paying the price for not listening to him. Now, that Hugo fellow has the right idea.
    This blog really needs a soundtrack. The East is Red, maybe.

  16. Barry,
    It’s true that $60,000 for a family of four is not considered poor in certain areas, but it is in others. The official definition of poverty is inadequate and it is masking the true magnitude of the problem. According to NCCP, almost 40% of all American children live in households below twice the poverty level and as many as 20% of younger children live below poverty levels. http://www.nccp.org/faq.html#question5
    This is not a small problem to be resolved by a bunch of community clinics. Something is fundamentally wrong when the very few rich keep getting massively richer and everybody else keeps getting poorer. It is not a sustainable model for freedom and democracy, and not even for healthy capitalism. Industrial capitalism made this country what it is because, to various degrees, everybody was moving ahead. We are now leaving most of the country behind. I think the results can be easily extrapolated from history.

  17. Margalit – In my comment referring to the poor, I was thinking primarily of the Medicaid eligible population, especially those who live in the major cities. With all due respect, I don’t consider a $60K income for a family of 4 in many parts of the country as “healthcare poor” to the extent that a $15 or $20 co-pay should be an impediment to care. As I’m sure you know, the cost of living, especially for housing, is a lot lower in St. Louis, Cincinnati and Pittsburgh and many other places than in NYC, SF or Boston. Housing costs are much lower still in most rural areas. That’s the big item in most family budgets.
    Moreover, as Nate says, in any given year, most people don’t need much care. Sure, big ticket events like heart surgery, hip replacement, cancer treatment, etc. are frightfully expensive which few people could afford without insurance. But routine primary care, well child visits, immunizations, etc. are not beyond the reach of most of the insured population even if they have to make a modest co-payment.

  18. “In the case of the poor, they probably can’t afford to pay much if anything in co-pays. Their lives are often chaotic. Some of them move frequently, many lack transportation and, for that and other reasons, often don’t or can’t keep appointments.”
    I think we are having a problem with the definition of the term “poor”.
    First of all, there are many people who are classified as lower middle class, but are really poor when it comes to health care. A family of 4 making $60,000 is health care poor, and does not fit the profile above.
    Rural poverty is different than urban poverty. Folks are anchored in their communities and often poverty is generational.
    Poverty in many cases is temporary. Young people that are poor today, may very well ascend to middle class income later in life. Middle aged people who have adequate means today, will be poor when they grow old.
    With the economy being what it is, the ranks of the health care poor will be swelling in coming years.
    If we want to provide a good solution, we must understand that fewer and fewer will be having discretionary income in the coming years. There is a bigger monster at play here and health care accessibility is being affected by it. Whatever design we come up with better be scalable to accommodate the casualties of financial capitalism (replacing industrial capitalism in this country), global economies and a general decline in standard of living.
    If the world is going to become flat then we will be lowered to the common ground as others are lifted to it.
    Of course the alternative would be to grab the bull by the horns and recognize that there is no imperative to throw away hundreds of years of hard work and sacrifice, but I’m not holding my breath.

  19. To follow up on my prior comment, I think it would be helpful if people were given health insurance cards that would allow them to track their utilization of services. Both public and private insurers could communicate information about utilization vs. others in the population of comparable age and health status. If high cost facilities like ER’s are being frequently used when urgent care centers are available, the difference in cost should be brought to the insured’s attention. The same goes for independent imaging centers vs. community or teaching hospitals and generic vs. brand name drugs. Just knowing that someone is looking at this can affect behavior in a way that cuts costs without compromising the quality of care.

  20. Nate, there are provisions for Medicaid/Medicare fraud/waste/abuse:
    “Subtitle A—Increased funding to fight waste, fraud, and abuse
    Subtitle B—Enhanced penalties for fraud and abuse
    Subtitle C—Enhanced Program and Provider Protections
    Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and Abuse”
    Here is the text of the (latest I think) bill:
    http://docs.house.gov/rules/health/111_ahcaa.pdf
    It is onerous to sift through with 2000 pages and I think Democrats could have done a much better job at condensing the bill for discussion purposes. But even though it eliminates lifetime caps I don’t think it inhibits insurance companies from steering people to less costly choices. If you can find that in the bill let me know.
    What I don’t like about the bill is it does not appear to do anything for provider cost controls although it does talk about promoting primary care and prevention and wellness.

  21. There are two distinct aspects to adequacy of coverage. One relates to scope (what’s covered and what isn’t) and one relates to the cost-effectiveness of the care provided.
    .In the case of the poor, they probably can’t afford to pay much if anything in co-pays. Their lives are often chaotic. Some of them move frequently, many lack transportation and, for that and other reasons, often don’t or can’t keep appointments. Therefore, the medical home concept probably won’t work as well as it would for the average middle class person. I think community health centers could work reasonably well for this population and would certainly be a better and more cost-effective alternative to the ER for routine care. If they just showed up when they needed care, they would likely have to wait, but I don’t think that’s too much to ask within reason. I access urgent care centers from time to time myself. If they’re not busy, the wait is short. If they are, it can be quite long. It’s not the end of the world.
    Regarding cost-effectiveness, I think referring doctors can do a better job here. If a generic drug is available, don’t prescribe a brand unless the patient, for some reason, cannot tolerate the generic. If imaging is required, send him to an independent imaging center, not the local community hospital that insurers often have to pay twice as much for. Even Medicare and Medicaid pay higher rates to teaching hospitals to compensate them for their teaching function, research activities, etc. Avoid them if you can but use them for the complex care that they are best at.
    For those in the workforce, I think employers and unions could do a much better job of engaging employees to get them to care about what services cost even when insurers are paying. Rapidly rising medical costs mean less ability to raise wages. Clearly communicate how much the employer is paying on the employees’ behalf for health insurance. These are simple steps and they don’t require legislation. Employers and unions need to step up to help bend the medical cost growth curve. I urge them to do so and soon.

  22. Peter the problem is most people don’t have hospital surgeon care and the current bill does NOTHING to get people to start going to Wal Mart, Urgent Care, or OP centers. In fact as I have said numerous times this bill actually does the opposite, by capping out of pocket and removing lifetime maximums this bill actually reduces the incentive to control cost. Why drive the extra mile when you already hit your OOP max and the insurance carrier is paying 100% of the tab? This is why reform always makes things worse, its written by people with no idea what the actual problem is and how to fix them.
    Why does reform ignore tort reform, Medicare Fraud, and wasteful spending in private insurance? Obama complains about cost but does nothing but make it worse
    Margalit I know my way around the Ozarks and all the boats aren’t reserved for the lakes, its not nearly as poor of a region and the government reports

  23. “we’re paying too much for ‘adequate.'” Chew on that for a while, Dr. Rob. You’re the one in the “transformational change” crosshairs.

  24. “It is rediculous to think driving a block further down the street to get the generic for $4 instead of $28 at CVS is praticle. It is Rediculous to think going to the urgent care center instead of the ER for your cold would save money. It is Rediculous to think getting your knee scoped at a free standing suregry center instead of Clevland Clinic will save money.”
    Nate, you misinterpret (exaggerate) my comment, of course the examples you give are good and necessary cost savers, but I was referring to hospital/surgeon care and the expensive stuff where you can’t “shop” or don’t know what you’re shopping for.

  25. “What is wrong with adequately funded community health centers,”
    I don’t think anything is wrong with them, but I’ve never heard of one that’s “adequately funded”. Talk to the states and ask them if even Medicaid is adequately funded. Clinics are ok for simple stuff, and probably could be for cronic disease management, but when someone needs a hospital where do you propose we send “clinic people”? But I don’t wish to fund clinics or the rest of the system with it’s present understanding of “adequate”, because that’s what’s causing costs to rise so quickly, we’re paying too much for “adequate”.

  26. “Ever been to the Ozarks? Poorest part of America…why does everyone own a fishing boat and have a realitvly new pick up?”
    Nate, I live in St. Louis, so yes. You are confusing the Ozarks with the resort named Lake of the Ozarks. The poor folks in the Ozarks don’t have fishing boats or new trucks. The area is sheer misery and 1/3 of the hungry are children. You can help here:
    http://www.ozarksfoodharvest.org/hunger.html

  27. As a payor I would love to do away with assignment of benefits. Also slash CPTs in half, number of them. Let the patient and doctor decide what his service is worth. I’ll pay a flat $x per office visit and don’t care where you go, who you see, or what you pay him. I’ll insure them against an event or illness happening, how they choose to treat it is none of my business.

  28. “The problem with your approach is that people cannot “shop” for healthcare.”
    Where did this myth come from? 80% of my population doesn’t have anything more involved them some office visits, Rx, and some test or x-rays. All of which can be shopped. Any given year 80% minimum of patients could act like consumers.
    Of the remaining 20% a good portion of that is also shopable. People already shop, they just case their decisions on the wrong parameters. As I sit here watching the Cavs game 3-4 times Cleveland has told me everyone deserves world class care, this is BS and an example of what the problem is. Everyone doesn’t deserve world class cuisine, or automobiles, or housing, etc. People have this perception they should be treated by the top doctor in the top facility while someone else pays the bill. This doesn’t work and can never be sustainable.
    “The money is in Botox, so that’s where the market moves.”
    This is what happens when the government regulates markets. It use to be easy to find a PCP even in small towns, government “fixed” the healthcare problem and now look where we are.
    “This notion that somehow price shopping will lower our costs is rediculous.”
    It is rediculous to think driving a block further down the street to get the generic for $4 instead of $28 at CVS is praticle. It is Rediculous to think going to the urgent care center instead of the ER for your cold would save money. It is Rediculous to think getting your knee scoped at a free standing suregry center instead of Clevland Clinic will save money. Shoping is so rediculous it could never work.
    “A program specific to the poor, quickly becomes a poor program.”
    Doesn’t seem to bother you when the left passes and funds public housing, welfare, education, etc etc etc. Or is healthcare just first up then your going to throw me out of my house and move in a poor family in the name of equality? Next time I hit the strip for a 5 star meal will I be served McDonalds and pay for the 5 star mean that is given to the poor person at McDonalds? If programs for the poor create poor programs I agree lets scrap them all. With all the money we save we could hire the poor to actually do something productive.
    “but lots of “poor” people are hard working, proud Americans,”
    Lots also aren’t nearly as poor as you think they are. Ever been to the Ozarks? Poorest part of America…why does everyone own a fishing boat and have a realitvly new pick up? Just because they tell the tax man they are poor doesn’t mean they really are poor.

  29. So we’re going to make them feel “equal” by giving them a product they can’t afford to use?
    I went to a community center many years ago, for an ailment I would prefer not to mention. I didn’t feel at all “demeaned.” This discourse is being driven by partisan ideology, not reason.

  30. “What is wrong with adequately funded community health centers…”
    The same thing that is wrong with Medicaid. A program specific to the poor, quickly becomes a poor program.
    Also, community centers are basically charity centers, and while it would make the well heeled feel good about themselves, it is demeaning to those forced to use them. The “health care poor” today include a very large portion of what is usually considered middle class.
    It may be very hard for you to understand, but lots of “poor” people are hard working, proud Americans, like the pickup driving constituency that you seem to identify with, but not really know very well.

  31. Equivocate all you like, but it is a simple fact that there exist different qualities of care within the range of “the adequate.” Who, for instance, would not prefer a plan which allows one to select one’s own providers to a region specific, network bound HMO? And what sense does it make to lavish on “the poor” private insurance policies with deductibles and copays? What is wrong with adequately funded community health centers, other than grating on your egalitarian sensitivities?

  32. 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.

  33. 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!

  34. 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?

  35. 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.

  36. “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.

  37. 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.

  38. “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.

  39. 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”.

  40. “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?

  41. 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.

  42. 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).

  43. 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.

  44. 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.

  45. 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.

  46. 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.

  47. 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.

  48. 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.

  49. “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???

  50. 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?

  51. 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.

  52. “…. 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?

  53. 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).

  54. 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.

  55. 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.

  56. 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.”

  57. “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.

  58. “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.

  59. 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.

  60. 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.

  61. 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.

  62. 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.

  63. 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?

  64. 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.

  65. “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.

  66. 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).

  67. 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.

  68. 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.

  69. 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.

  70. > 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

  71. 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.

  72. 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).

  73. 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.

  74. 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?

  75. 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.

  76. 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?

  77. 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.

  78. 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.

  79. 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.

  80. 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.

  81. 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.

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