And if we actually paid attention to the title of this thread and the b******t name given to health *insurance*, one answer would fall out almost immediately - a return to community clinics, visiting nurses, and county hospitals.

The latter exists, but these days exist only in name, as their bean counters and "owners" keep lashing them with "You're not making any money! You're (gasp, horror) COSTING the taxpayers money! And you're not GROWING! And you're not as fancy as the big cancer/heart/psychiatric center in the next state!"

And from their standpoint -

They're flooded with people who should be seeing a neighborhood clinic, except that none exist. Though I have to congratulate places like Walmart for stepping up to the plate on that one.

Or people who should be seeing a primary care physician, but no physicians will see anyone without insurance except the rare cash doctors down in the South Valley. I know why: they're afraid of not getting paid. However, will someone tell me why a doctor wouldn't find it a lot easier to take cash up front, and hence give discounts for that? Are they afraid the narcs will descend on them as they deposit the money with "Aha! Large amounts of cash! You must be a drug dealer! We can confiscate that without a trial...." (Sorry, Another rant.)

All right. They're swamped, so the person who sets foot in the emergency room is faced with a long wait, and horror stories abound in every jurisdiction.

Meanwhile the state and local governments are insisting that every cost center at least pay for itself. If it could and should, why isn't it run by a private entity for profit? Oh, because it's not making *gobs and heaps of money* ... nobody's getting wildly and insanely rich from such an enterprise.

And there are now middle-class people like one I know who has a massive tooth and jaw ache and may end up having the tooth pulled, because low-level middle class doctors no longer offer health insurance, and the cost of basic care has skyrocketed beyond what anyone without insurance can afford.

So now we will start seeing respectable middle-class and working-class people with gaping holes in their dental work just like the homeless.

Oh, and why does simple, basic care cost so much? People point to all the fancy technology and bells and whistles, which I know full well. My primary care physician and my daughter the MD are driving me into more and more tests for borderline conditions that may or may not mean anything but may also cut a few years off my life - at my age. Sheesh. But adding those on is like loading all the costs of running a bar onto the peanuts in the dish, which someone once wrote a satire on. The peanuts, I believe, ended up costing $5 in 1980s money. The hospitals do that to the aspirins without even blushing.

The answer? In today's mental climate? Get yourself a good book on folk medicine.

Originally Posted by The Rani

I don't really know what you're talking about here.
I've worked in many community clinics. Their emphasis is on serving the community. As they are funded with public dollars, there is no pressure to make profits whatsoever. There are certainly restrictions on the quality and quantity of services that these places can offer, due to limited resources, both financial and human.
Some patients make use of these resources, and others wait til the problem escalates to the point that it requires an emergency room visit. Recently, more community clinics have been adding same-day emergency services, in response to this ongoing problem.

You and I both live in Chicago which for some reason has been able to hold on to excellent free clinics that provide wonderful care. From what I've been told, there are fewer of these places in other parts of the country.

Sadly, too many people wait way too long to get proper medical care. It must be difficult for those in health care to deal with that kind of ignorance.

I haven't really been following this thread, but I do have a question concerning the healthcare system. Is there anyway to bring down the cost of healthcare? That is what I see as the core problem. Getting sufficient medical help is like a luxury only some can afford. Single pay or no the main problem is the overall costs.

Originally Posted by The Rani

Not really, for me anyway. Poor people have lots of other things to do besides go to the doctor. What's worse is when you try to get them to change diet/exercise/personal habits and they'd rather take a pill. You know it won't work, but what can you do.

My MD ex has to deal with this all the time. But we live in a society where we put doctors on a pedestal and then knock them down because they can't fix everything with a pill. It's hard for people to understand that some things are not only not curable but sometimes barely treatable. And if the patient isn't contributing? Well, not much is going to happen.

Originally Posted by pizal81

I haven't really been following this thread, but I do have a question concerning the healthcare system. Is there anyway to bring down the cost of healthcare? That is what I see as the core problem. Getting sufficient medical help is like a luxury only some can afford. Single pay or no the main problem is the overall costs.

The most obvious, simple, and .. dare I say?.. fair thing to do is simply to remove the restrictions on the supply of medical care professionals. Where trained doctors are common, and training is available to any who are able and willing to do the job, options are widely-available for those seeking care. And those options -- even at the top of the cost-scale -- tend to cost orders of magnitude less than what seems to be taken as 'normal' under the american system. The solution is more provision of health care; the first-order path to that is the demolition of the warren of restrictions keeping would-be providers from providing.

Originally Posted by radind

There is no point in looking for perfection. I am still not clear on how Medicare for All does anything to control the costs from the health care providers.

The same way Walmart controls costs from their suppliers. If you want to do business with Walmart (you you will lose most of your business if you don't) you have to meet their price expectations.

Same things with Medicare for all. If you want to do business with Medicare you have to meet their price. If you don't you can always try to treat only those rich enough to pay out of pocket for your services, but there simply are not that many rich people, and a lot of providers.

The very best providers will obtain wealthy clients, but most will not, and so if they want an income they will have to deal with Medicare.

This is how it works for drugs. We sell Lipitor to the Japanese and Europeans for lots less than Americans. Why? Because their national programs want a low price or they won't buy Lipitor, they will get their statins from a competitor.Americans don't mind paying through the nose for their drugs and so we cheerfully oblige and make it very expensive.

The same thing is true for other health care providers. France has more doctors per capital than the US and they get way less for their procedures than American docs do. Why, because the national program only pays so much and they have the take it or leave it. Now they could leave it and serve wealthy private-pay clients exclusively (if they can find them). They could come to American and make three times more. But they don't, because coming to America would mean having to deal with those insurance companies instead of practice medicine.

So they grumble, but they also have a union who negotiates with national system to boost payments. The national system, like Walmart, tries to get the lowest cost it can. Usually the two sides work it out and the price the doctors charge rises modestly over time. When they don't the docs go on strike.

For office procedures the patient pays this negotiated price (our of pocket) in full on the day of service. About a week later they will get reimbursed for most of the the cost, but they are expected to pay unless they are indigent (like qualifying for Medicaid in the States) in which case the fee is waived and the insurance automatically pays the doctor instead of the patient. There is no paperwork, its all handled automatically using the data on your health card, which the doc swipes in the office. The card also contains access to your medical records which the doc updates. Thus docs don't keep records on their patients, its all automatically stored along with the billing info. They can see not only what they have done but what all the other docs have done in the past. This and the transparent, automatic handling of the bills makes the lower compensation from French medicine acceptable to French docs. This is why you don't seen an huge influx of French docs coming here to practice medicine. Or Japanese or Germans or English docs for that matte, despite the fact they they make much less than American docs.

Originally Posted by Justin '77

The most obvious, simple, and .. dare I say?.. fair thing to do is simply to remove the restrictions on the supply of medical care professionals.

You'd think that. It was tried in the eighties, but costs accelerated. More providers meant fewer patients per provider so fees went up to maintain provider income.

This strategy only works when the providee's have negotiating power. Have you any. In this country you can rarely find what a procedure will cost the actual payers in advance. They might quote you a ridiculously inflated price, much higher than what they routinely take from the insurance companies. Similarly your insurance company won't tell you what they will cover unless it in in plan.

Hence medical care is strictly rationed, you can only use those providers who are in plan, or roll the dice and go with someone outside of plan. You will be be charged a big fee, and you insurance company will cover the stipulated portion of what they determine to be reasonable and customary, and you are left with a big portion of a huge inflated bill. Of course they won't tell you in advance what reasonable and customary is because what they pay will end up depending on how hard you fight them after you get the bill.

Originally Posted by annla899

My MD ex has to deal with this all the time. But we live in a society where we put doctors on a pedestal and then knock them down because they can't fix everything with a pill. It's hard for people to understand that some things are not only not curable but sometimes barely treatable. And if the patient isn't contributing? Well, not much is going to happen.

The issue isn't how to pay for things that are not treatable. The issue is how to pay for things that are treatable but are too expensive for those w/o insurance. Say you get sick with a treatable, debilitating illness that results in your being unable to work. When you lose your job, you lose your insurance, so you cannot afford the treatment. About 22000 Americans die each year from treatable illness because they cannot pay for it. This doesn't happen in Canada, Europe, or Japan.

In those countries it is considered unacceptable for people to die of a treatable illness simply because they cannot afford the treatment. In this country it is acceptable. I don't think this is a sentiment to be proud of, but obviously it doesn't bother me that much because I still live here.

It's part of the American character, what makes us Americans as opposed to Canadians or Europeans--sort of like the death penalty.

Originally Posted by Mikebert

The same way Walmart controls costs from their suppliers. If you want to do business with Walmart (you you will lose most of your business if you don't) you have to meet their price expectations. Same things with Medicare for all. If you want to do business with Medicare you have to meet their price. If you don't you can always try to treat only those rich enough to pay out of pocket for your services, but there simply are not that many rich people, and a lot of providers....




...For office procedures the patient pays this negotiated price (our of pocket) in full on the day of service. About a week later they will get reimbursed for most of the the cost, but they are expected to pay unless they are indigent (like qualifying for Medicaid in the States) in which case the fee is waived and the insurance automatically pays the doctor instead of the patient. There is no paperwork, its all handled automatically using the data on your health card, which the doc swipes in the office. The card also contains access to your medical records which the doc updates. Thus docs don't keep records on their patients, its all automatically stored along with the billing info. They can see not only what they have done but what all the other docs have done in the past. This and the transparent, automatic handling of the bills makes the lower compensation from French medicine acceptable to French docs. This is why you don't seen an huge influx of French docs coming here to practice medicine. Or Japanese or Germans or English docs for that matte, despite the fact they they make much less than American docs.

Thanks. I think I understand how Walmart enforces cost control for suppliers. However, I haven't seen effective results from the current Medicare program. I do see doctors starting to bail out of the Medicare program and there is probably some cost shifting going on by the hospitals and doctors.
Are you saying that if Medicare were the only insurance game in town that Medicare would then force the health insurance providers would come around and reduce costs & bills?

I like the idea of an integrated, streamlined billing process. It is clear that we could save a lot of overhead( estimates from 20 to 30%). Something like this should be done as part of the solution, but I am still concerned about the control of costs from the health care providers.

Originally Posted by The Rani

I don't really know what you're talking about here.
I've worked in many community clinics. Their emphasis is on serving the community. As they are funded with public dollars, there is no pressure to make profits whatsoever.

I don't know what you are talking about. There are no county hospitals here. The poor go to private hospitals and use their Medicaid insurance.

Besides, where would "public dollars" that would fund such a place come from, more taxes? Yeah right.

Sure in some places, public facilities still exist, a holdover from another time. When I was a kid the County health department vaccinated schoolchildren, had school nurses in every grade school, I went to a Catholic school but we had a school nurse, a county employee. But then we had a socialist mayor when I was born. All but two years of the 1916-1960 period saw mayors in Milwaukee who were explicitly members of the Socialist party. Can you imagine that today? A world in which socialists get elected is a world where community clinics and county hospitals are normal things. Today they are relics of the past.

Originally Posted by radind

Thanks. I think I understand how Walmart enforces cost control for suppliers. However, I haven't seen effective results from the current Medicare program.

Well sure. Medicare only covers a fraction of the total bill, providers have the option of only serving clients who have private insurance.

I do see doctors starting to bail out of the Medicare program

Yes, these docs are exercising their option.

Are you saying that if Medicare were the only insurance game in town that Medicare would then force the health insurance providers would come around and reduce costs & bills?

Medicare already demands lower prices, this is why the docs who referred to bail. Medicaid demands even lower prices and lot more doctors won't take medicaid patients. If Medicare were the only source of patients, how would providers earn an income without treating Medicare patients?

Originally Posted by Mikebert

The issue isn't how to pay for things that are not treatable. The issue is how to pay for things that are treatable but are too expensive for those w/o insurance. Say you get sick with a treatable, debilitating illness that results in your being unable to work. When you lose your job, you lose your insurance, so you cannot afford the treatment. About 22000 Americans die each year from treatable illness because they cannot pay for it. This doesn't happen in Canada, Europe, or Japan.

In those countries it is considered unacceptable for people to die of a treatable illness simply because they cannot afford the treatment. In this country it is acceptable. I don't think this is a sentiment to be proud of, but obviously it doesn't bother me that much because I still live here.

It's part of the American character, what makes us Americans as opposed to Canadians or Europeans--sort of like the death penalty.

I completely agree. Most of the MDs I know support single payer. Maybe I hang around with the fringe. My feeling (not based on facts) is that with a more European/Canadian health care system people might be a bit more compliant. And maybe we wouldn't have such huge expectations of medical science.

I live here because my work is here and I couldn't get my job elsewhere. My family and friends are here and I'm part of the community. But it's true, unless we in the US as a whole decide it's unacceptable, it's going to remain this way. Health insurance reform was the tiniest, most lackluster step we've gotten so far. Although it is important that we stop believing that we can live in perfect health forever, or get a pill to "fix" the problem, the fact that 22,000 people die of treatable illnesses a year (and those are the ones reported) because of lack of money is unconscionable. And that we tie health care to work is bizarre and doesn't much work for employers, either.

Originally Posted by Mikebert

The same way Walmart controls costs from their suppliers. If you want to do business with Walmart (you you will lose most of your business if you don't) you have to meet their price expectations..

You hit the nail on the head. That was an awesome explanation!

My wife had a kidney stone on the evening of March 23. The pain was so bad that we had to take her into the local ER. (We pretty much knew it was a kidney stone, as she had one in 2003 with identical symptoms.)

In a little over three hours, they gave her some IV fluids (including anti-inflammatory steroids and pain killer), took a CAT scan, ran some routine blood work and the doctor said yeah, there's a 4 mm stone lodged in there. He sent us home three hours later with six Vicodin and that was that.

Our bill? $2,100. We're on an HSA and we can afford to pay this given how much we've saved on premiums with it (and the employer match into our HSA each year), but still -- when a three hour visit (most of it waiting in an exam room) costs $2,100 there is a big problem. The good news is that we've satisfied our entire insurance deductible for 2011 now.

Originally Posted by The Rani

I don't really know what you're talking about here.
I've worked in many community clinics. Their emphasis is on serving the community. As they are funded with public dollars, there is no pressure to make profits whatsoever. There are certainly restrictions on the quality and quantity of services that these places can offer, due to limited resources, both financial and human.
Some patients make use of these resources, and others wait til the problem escalates to the point that it requires an emergency room visit. Recently, more community clinics have been adding same-day emergency services, in response to this ongoing problem.

Where are you located? Because as far as I can tell, in New Mexico they are so few and far between, it gets in the newspaper from time to time when there is one. If I am mistaken., I will shut up, but --

Okay. Here's the data. I note that there are 115 health care centers of all sorts in the state.

I have a fully employed friend who had to go to an annual free dental clinic - a volunteer affair organized by dentists and dental students - for a serious problem. There were people there with problems worse than hers.

Health Care for the Homeless merely pulls the teeth, because a rotten tooth is life-threatening.

Originally Posted by The Rani

Try doing some research then. You can start here, if you like:
Harris County Hospital District




Last time I looked, Texas was not a socialist state.

Okay - how much does it cost to simply walk into the ER and walk out again? At UNMH it costs $80. This from someone who gave up in disgust and then received the bill.

Originally Posted by The Rani

Try doing some research then. You can start here, if you like:
Harris County Hospital District

Last time I looked, Texas was not a socialist state.

Texas may not be, but apparently Harris county is

Originally Posted by The Rani

Socialist Republicans?:

In this particular way, yes. Another example, lots of tea party people, who tend to be very conservative support Medicare. Medicare is a single payer program, you can't get much more socialist than that--except of course for the VA--and I'll bet lots of conservatives sort that program too.

Originally Posted by ziggyX65

My wife had a kidney stone on the evening of March 23. The pain was so bad that we had to take her into the local ER. (We pretty much knew it was a kidney stone, as she had one in 2003 with identical symptoms.)

In a little over three hours, they gave her some IV fluids (including anti-inflammatory steroids and pain killer), took a CAT scan, ran some routine blood work and the doctor said yeah, there's a 4 mm stone lodged in there. He sent us home three hours later with six Vicodin and that was that.

Our bill? $2,100. We're on an HSA and we can afford to pay this given how much we've saved on premiums with it (and the employer match into our HSA each year), but still -- when a three hour visit (most of it waiting in an exam room) costs $2,100 there is a big problem. The good news is that we've satisfied our entire insurance deductible for 2011 now.

Emergency room care is the most expensive care one can use. These departments have to financially support all of the medical equipment and the people to staff them for every possible true emergency on a 24/7 basis. Trauma center staff are paid higher salaries than most because they need expertise in so many areas.

Also important to understand is that the ER is too often used by people who are are unfortunate enough to not be insured. Which is another a factor in the high costs. The cost of those treatments are added as expenditures. If everyone was covered, we could cut some costs in the ERs and hospitals.

It might be tempting for some of us to condemn those who are without insurance for using the emergency departments for treatment for health concerns that have become chronic. But there's something we need to understand, the clarifications of survival needs. When those who live in poverty, or are in some of the situations that Mikebert described, like losing a job, or other devastating life situations, many of these people are in survival mode.

Millions of Americans have to choose between basic everyday needs. In many instances, living everyday in a survival mode and struggling to meet the most basic of needs like, food, shelter, and utilities, is very draining, so going to a doctor isn't even on their radar screen.

It's a misunderstanding too often in our country that all people who live in poverty are on Medicaid. The qualifications of income for a family to qualify for those meager services are rediculous.

Originally Posted by pizal81

I haven't really been following this thread, but I do have a question concerning the healthcare system. Is there anyway to bring down the cost of healthcare? That is what I see as the core problem. Getting sufficient medical help is like a luxury only some can afford. Single pay or no the main problem is the overall costs.

Yes, there are lots of ways. The starting point would be to evaluate every test that has become standard and ask, how much does the test cost, how much unnecessary and necessary treatment does it generate, and how many people does the treatment genuinely help? I also think the standards for drug approval need to be tightened. The anti-brain tumor drug Ted Kennedy took was approved after a trial showed it could prolong life for six months. It can't cure anybody. That eliminated any incentive to work for something better for quite a while.

We spend enormous amounts of money on end-of-life care which does not do anyone much good. Just educating the public better on that issue might change that significantly.

There is a whole system in place that incentivizes more care, not less, now. We have to change that.

I don't see how concierge medicine will help much. Based on what I read, it covers the sort of services provided by a primary-care doc.

The fees for these services are inexpensive, my current doc would charge about $80 for a office visit if I paid out of pocket. For example, when I was 50 my doc recommended that I get a colonoscopy at an office visit. Were I to pay for that it would have cost me $3000. It seems to me that having a concierege doc would mean I don't pay the $80 for that visit but I do pay the $3000. Unless I see the doc like 20 times, that $1500 would be way more than I would spent simply paying cash for each visit.

But then their is the question of the value of services rendered. For example, I need to see the doc to get new prescriptions each year. I have to do this because it is illegal for me to purchase a med I have been taking for years without a prescription. I get no value for what the primary doc provided.

There are things that the primary doc has done for me that have value. Probably 2-3 times a decade I come in with a specific issue which gets resolved with a single visit. $80 every few years sure beats $1500 a year.

The big problem is the $3000 charge for a 20 minute procedure, not so much the $80 charge for getting a referral.

Originally Posted by The Rani

Only 22,000? I've seen even higher numbers. But is it true? I decided to look, and found this:

The issue I raised wasn't about the risk of death from going without health insurance. The issue was whether it was acceptable for people to die from treatable illness for lack of insurance, like this woman.

Had White lived in Canada she would not have died. Only the other hand, someone else dies of a hospital acquired infection from a treatment she cannot afford. In the US she would not have gotten that treatment and not a have died. So the net effect of not paying may increase, decrease or have not effect on overall mortality.

Originally Posted by The Rani

I knew one who did years ago, but now she's so fed up with the whole system that she really doesn't care what happens ... as are the rest of the docs that I know.

As I said, I probably hang out with the weirdos. And the system is so Byzantine that docs in private practice have to have extra staff just to handle the insurance labyrinth. Hell, when my derm retired I had to go through my list to see if any of the derms he recommended were on my plan. I still haven't figured it out.

Originally Posted by Mikebert

You'd think that. It was tried in the eighties...

Bullshit. There's not once in the last century been anything even resembling an attempt to reduce the restrictions keeping the number of health care providers down. Possibly longer, but I don't really have any idea what happened back before the 1900s on that matter.

Originally Posted by annla899

As I said, I probably hang out with the weirdos..

I would guess that your doctor friends are not weirdos, just compassionate people who took the Hippocratic Oath very seriously.