Controlling healthcare costs.

[The Great Hippo]

It can be beneficial to the insurance agencies that everyone receives regular preventative care, without being beneficial enough to actually cover the costs of preventative care for everyone.

I'm sure it varies from type to type; not all preventative treatments are made equal, after all. But is this the case with check-ups?

[Swiftwind]

It can be beneficial to the insurance agencies that everyone receives regular preventative care, without being beneficial enough to actually cover the costs of preventative care for everyone.

I'm sure it varies from type to type; not all preventative treatments are made equal, after all. But is this the case with check-ups?

I'm not sure what's considered a check-up, but typically people are allowed one "wellness" visit as preventative. Preventative care is not a very broad category - it includes things like one wellness visit a year, certain cancer screenings when you are a certain age and once every so many years, etc.

If wellness visits don't include lab tests (don't know, haven't been to one for a while), then I would say the cost will be around $100 to $200. This is obviously a big range, but different service providers charge different amounts and different insurance companies strike better deals than others for discounts.

Without having data, it's hard to say whether or not this saves the insurance company money or not. Some people will use preventative services and never would have developed anything serious. Others might have their medical issue caught sooner when it is cheaper to treat, but that reduction in cost may not be worth it since so many people are utilizing preventative care and purely costing the insurance company money.

Of course, even though preventative services don't cost a co-payment or co-insurance, the costs will still find it's way to the plan participants through premium increases. These services cost money, and even though they have to be covered by plans, the cost doesn't have to be born 100% by the insurance company - they just can't charge a co-payment or coinsurance.

[IcedT]

Sorry for the necro, but I have a question- objectively speaking, how effective has tort reform been at reigning in costs in the places it's been put into use? I've heard tort reform thrown around by an obvious solution by too many people who have no idea what the actual numbers involved are, which makes me skeptical that it's just a knee-jerk "capitalism would be working fine if lawyers weren't such assholes" kind of response. From reading this thread it seems to me that the two biggest factors in our healthcare costs are the bad incentives created by our insurance system, and the fact that we do provide some free healthcare but only to the most expensive age group. Where does tort reform fit?

[CorruptUser]

From reading this thread it seems to me that the two biggest factors in our healthcare costs are the bad incentives created by our insurance system, and the fact that we do provide some free healthcare but only to the most expensive age group. Where does tort reform fit?

And free healthcare to the poorest. And by free, not even so much as co-pay or deductible, so some people on Medicaid tend to abuse it, which raises the price everyone else has to pay to support it. Seriously, it costs $600 to $1500 for an ambulance ride; you only get an ambulance if you are dying or on medicaid. Every intern at a hospital will tell you how much they hate having their time wasted by people on medicaid coming in for non-problems. Just have a minimal deductible of some kind, and those abuses disappear.

Back to your main question, I'd prefer a loser-pays legal system, except not only has it been implemented in California, Texas and Georgia, it's actually unnecessary; if a person brings a groundless lawsuit against you, you can file a rule 11 and counter-sue their ass(ets) off, so frivolous lawsuits are rather rare. Frauds aren't as rare though.

The main issue I see is professionals do NOT get a 'jury of your peers' from malpractice cases. The average person wouldn't know an infarction from flatulence, yet they are expected to determine whether the standard of care has been administered. Juries tend to be polluted by the district they are in; a competent attorney knows which district will be most likely to give the desired ruling, which is why medical liability insurance will vary wildly by region. And by wildly, I mean by 5 times as much in some counties as others in the same state. This is because the burden of evidence is on the doctor, not the plaintiff, despite what the law ostensibly says. Auditor liability is worse when it comes to defending yourself in court, because no one on the jury actually knows what an auditor is actually supposed to do, only that someone screwed up and there is this rich asshole in a suit on trial.

What is needed is, for professional liability issues, only people in that field can be on a jury. So if a doctor screws up, the jury is made up of health care professionals (RNs, EMTs, dentists, and podiatrists included). If it's an attorney, only members of the bar. If an accountant, only other CPAs.

[CorruptUser]

Sorry for the necro, but I have a question- objectively speaking, how effective has tort reform been at reigning in costs in the places it's been put into use? I've heard tort reform thrown around by an obvious solution by too many people who have no idea what the actual numbers involved are, which makes me skeptical that it's just a knee-jerk "capitalism would be working fine if lawyers weren't such assholes" kind of response. From reading this thread it seems to me that the two biggest factors in our healthcare costs are the bad incentives created by our insurance system, and the fact that we do provide some free healthcare but only to the most expensive age group. Where does tort reform fit?

And free healthcare to the poorest. And by free, not even so much as co-pay or deductible, so some people on Medicaid tend to abuse it, which raises the price everyone else has to pay to support it. Seriously, it costs $600 to $1500 for an ambulance ride; you only get an ambulance if you are dying or on medicaid. Every intern at a hospital will tell you how much they hate having their time wasted by people on medicaid coming in for non-problems. Just have a minimal deductible of some kind, and those abuses disappear.

Back to your main question, I'd prefer a loser-pays legal system, except not only has it been implemented in California, Texas and Georgia, it's actually unnecessary; if a person brings a groundless lawsuit against you, you can file a rule 11 and counter-sue their assets off, so frivolous lawsuits are rather rare. Oh sure, lots of people will go to their lawyer with a frivolous suit, but that lawyer will calmly explain why said lawyer would never take on such a stupid case.

The main issue I see is professionals do NOT get a 'jury of your peers' from malpractice cases. The average person wouldn't know an infarction from flatulence, yet they are expected to determine whether the standard of care has been administered. Juries tend to be polluted by the district they are in; a competent attorney knows which district will be most likely to give the desired ruling, which is why medical liability insurance will vary wildly by region. And by wildly, I mean by 5 times as much in some counties as others in the same state. This is because the burden of evidence is on the doctor, not the plaintiff, despite what the law ostensibly says. Auditor liability is worse when it comes to defending yourself in court, because no one on the jury actually knows what an auditor is actually supposed to do, only that someone screwed up and there is this rich asshole in a suit on trial.

What is needed is, for professional liability issues, only people in that field can be on a jury. So if a doctor screws up, the jury is made up of health care professionals (RNs, EMTs, dentists, and podiatrists included). If it's an attorney, only members of the bar. If an accountant, only other CPAs.

[IcedT]

The main issue I see is professionals do NOT get a 'jury of your peers' from malpractice cases. The average person wouldn't know an infarction from flatulence, yet they are expected to determine whether the standard of care has been administered. Juries tend to be polluted by the district they are in; a competent attorney knows which district will be most likely to give the desired ruling, which is why medical liability insurance will vary wildly by region. And by wildly, I mean by 5 times as much in some counties as others in the same state. This is because the burden of evidence is on the doctor, not the plaintiff, despite what the law ostensibly says. Auditor liability is worse when it comes to defending yourself in court, because no one on the jury actually knows what an auditor is actually supposed to do, only that someone screwed up and there is this rich asshole in a suit on trial.

What is needed is, for professional liability issues, only people in that field can be on a jury. So if a doctor screws up, the jury is made up of health care professionals (RNs, EMTs, dentists, and podiatrists included). If it's an attorney, only members of the bar. If an accountant, only other CPAs.

It seems like this is something that should be reformed on principle, regardless of its impact of cost, but I doubt that it's the silver bullet that it's been presented as (not by anyone in this thread, but by some talking heads).

[nitePhyyre]

I believe IcedT's question was "How much will the best tort reform save us?" not "what kind of tort reform do we need?"

[IcedT]

I believe IcedT's question was "How much will the best tort reform save us?" not "what kind of tort reform do we need?"

Yeah, but the post was pretty informative so I don't mind.

[stevenf]

Last week's British Medical Journal contained this little gem:

US healthcare executives hit pay jackpot
BMJ 2011; 343 doi: 10.1136/bmj.d8330 (Published 29 December 2011)
Cite this as: BMJ 2011;343:d8330

Healthcare and pharmaceutical executives were four of the top 10 best paid executives in the United States in 2010, according to a report by GMI, an independent research firm that surveyed more than 2600 companies.

Pay for chief executives increased by 27% in 2010, the firm said. No bankers were on the top 10 list. Take home pay, the amount executives pay tax on, included annual compensation, increases in pension plans, profits from exercising stock options, and some other benefits, GMI said.

Several of the executives retired during 2010. Despite their high pay, in several cases the share prices of these chief executives’ companies declined during their time in office.

John Hammergren, chief executive of the drug distributor McKesson Corp, was the top earner, with total remuneration of $145 266 971 (£94 340 000; €112 730 000). According to GMI, he exercised 3.3 million stock options for a profit of $112m. In addition his retirement benefits grew by $13.5m. His also received $1.6m in salary. If he were to be fired, he would receive $469m in severance pay.

Second highest in pay was Joel Gemunder, chief executive of Omnicare, a geriatric pharmaceutical care company that serves nearly half a million residents in more than 5500 long term care facilities in 37 states. He earned $98 283 242 when he retired in 2010. That sum included cash severance pay of $16m.

Fifth highest paid boss was Thomas Ryan, head of the CVS Caremark pharmacy chain. He received $68 079 823, which included a $28m profit on his options.

Ninth in pay was Ronald Williams, chief executive of the Aetna health insurance firm, who retired with a final pay cheque of $57 787 786. That included a $50.4m profit on his stock options.

By comparison, the pay of top hospital executives seems small. Herbert Pardes, who is retiring as head of New York-Presbyterian Hospital, the city’s largest hospital, earned $1.7m in salary, plus a $1.9m bonus and $648 686 in other compensation. Other New York hospital executives also received substantial pay, according to the New York Post. Linda Brady of Kingsbrook Jewish Medical Center received $736 481 in salary, a $241 090 bonus, and $3.2m in retirement benefits; Kenneth Davis of Mount Sinai Medical Center received a $1.2m bonus. Dean Harrison, chief executive of the Northwestern Memorial Healthcare System in Chicago, received $10.2m in 2010, including a $7.5m retirement fund payment. The national average payment for hospital chief executives is $630 000.

In 2010 the median US household income was $49 445, a 2.3% decline from 2009. The nation’s poverty rate was 15.1%, the third consecutive annual increase in the poverty rate. The number of people without health insurance increased from 49 million to 49.9 million.



I know where I would start with controlling healthcare costs in the US - a federal single payer system giving universal coverage, free at the point of use, paid for from general taxation and of tighly defined scope.

[Vaniver]

I know where I would start with controlling healthcare costs in the US - a federal single payer system giving universal coverage, free at the point of use, paid for from general taxation and of tighly defined scope.

Great! By cutting Hammergren's pay to $243,000, the highest amount a civil servant can be paid, and passing the costs on to customers, you reduced the cost of McKesson Corp's product's by .13%.

Hm. How is that going to stop the accelerating growth in healthcare costs?

[Webzter]

It seems like this is something that should be reformed on principle, regardless of its impact of cost, but I doubt that it's the silver bullet that it's been presented as (not by anyone in this thread, but by some talking heads).

So, if we assume doctors overprescribe tests because they don't want to face lawsuits for a missed diagnosis, how likely are they to now stop recommending additional tests because their risk exposure has dropped from, say, $5mm to $2mm. Looking at it this way, I'd say tort reform, while needed, isn't a magic bullet.

Still, I know insurance premiums vary widely by states and have been blamed for the severe shortage of some specialties in some states. The most famous example I can think of off the top of my head is the dearth of ob-gyn docs in Nevada.

[elasto]

And free healthcare to the poorest. And by free, not even so much as co-pay or deductible, so some people on Medicaid tend to abuse it, which raises the price everyone else has to pay to support it. Seriously, it costs $600 to $1500 for an ambulance ride; you only get an ambulance if you are dying or on medicaid.

It's this sort of figure that just boggles my mind. Best I can tell, ambulances cost the NHS around $100/hr to run (and they will likely do more than one ride an hour). Ok, so I don't think that includes cost of the people staffing the ambulance (although it might, actually), fuel costs or the cost of drugs dispensed during the journey, but there's still a huge discrepancy.

A few years ago my wife had to pay for NHS care due to not being a UK citizen. So everything was paid for out of pocket, not through any insurance or by government. She had a caesarean with 8 staff in the operating theatre, drugs including an epidural and a week-long stay in hospital recovering, and the total cost came to under $4k. You'd be talking $20k+ in a US hospital (maybe $30k+?)

It all just doesn't add up to me. Something is seriously broken about your system.

[CorruptUser]

And free healthcare to the poorest. And by free, not even so much as co-pay or deductible, so some people on Medicaid tend to abuse it, which raises the price everyone else has to pay to support it. Seriously, it costs $600 to $1500 for an ambulance ride; you only get an ambulance if you are dying or on medicaid.

It's this sort of figure that just boggles my mind. Best I can tell, ambulances cost the NHS around $100/hr to run (and they will likely do more than one ride an hour). Ok, so I don't think that includes cost of the people staffing the ambulance, fuel costs or the cost of drugs dispensed during the journey, but there's still a huge discrepancy.

A few years ago my wife had to pay for NHS care due to not being a UK citizen. So everything was paid for out of pocket, not through any insurance or by government. She had a caesarean with 8 staff in the operating theatre, drugs including an epidural and a week-long stay in hospital recovering, and the total cost came to under $4k. You'd be talking $20k+ in a US hospital (maybe $30k+?)

It all just doesn't add up to me. Something is seriously broken about your system.

$100/hr doesn't cover the cost of the driver and the EMTs that are on call 24/7, let alone maintenance and amortization costs. It's more like $4k+/day per ambulance. And every time you raise prices, fewer people will be able to pay, so you have to raise prices further, and turtles all the way up. Now add in that the hospital has a massive budget shortfall because Medicaid doesn't even cover the cost of providing the medicine, let alone salaries and overhead. How much do you have to charge for auxiliary services to break even?

Also, in the US, the average cost of childbirth is $10k, not $20k+. Mostly has to do with all the safety precautions that are more to ward off lawsuits than to actually enhance health.

[elasto]

$100/hr doesn't cover the cost of the driver and the EMTs that are on call 24/7, let alone maintenance and amortization costs.

Pay for EMT workers in the UK is about $40k/year and a driver earns about half that. So total pay for 3 workers per ambulance is around $100k per year.

Let's assume my $100/hr figure excludes all pay then and so we'll add $100/hr for wages on top. So that's $200/hr total cost. Where is the rest of the $600 to $1500 cost per trip coming from? Does an average ambulance trip take like 3 hours in the States?

Also, in the US, the average cost of childbirth is $10k, not $20k+. Mostly has to do with all the safety precautions that are more to ward off lawsuits than to actually enhance health.

That absolutely does not square with my investigations. Here is an article from 2008 (so costs will have gone up considerably since then):

The total cost of baby delivery typically consists of: the services of the obstetrician/gynecologist and pediatrician; services of the anesthesiologist and epidural, if used; the cost of your stay in the hospital room and board; a nursery fee; laboratory fees; and any medications or medical supplies. If you are insured, your insurance provider probably will receive the itemized bill, but you might receive separate non-itemized statements from the hospital and the different doctors.

Typical costs:
The biggest factors affecting the cost of a birth are: whether it is vaginal or Cesarean; whether there are complications; and the length of the hospital stay. Geographical location also plays a part; baby delivery is most expensive in the Northeast and on the West coast and least expensive in the south. For patients not covered by health insurance, the typical cost of a vaginal delivery without complications ranges from about $9,000 to $17,000 or more, depending on geographic location and whether there is a discount for uninsured patients. The typical cost for a C-section without complications or a vaginal delivery with complications ranges from about $14,000 to $25,000 or more.

For patients with insurance, out-of-pocket costs usually range from under $500 to $3,000 or more, depending on the plan. Out-of-pocket expenses typically include copays -- usually $15 to $30 for a doctor visit and about $200 to $500 for inpatient services for delivery. Some insurance plans only cover a percentage -- usually about 80 to 90 percent after a deductible is met, so you can easily end up reaching your yearly out-of-pocket maximum. In most plans, that ranges from about $1,500 to $3,000. According to a study by the March of Dimes Foundation, the average out-of-pocket cost for a vaginal delivery for privately insured patients was $463 and for a C-section, $523. In this forum at TheNestBaby.com, new mothers compare notes on the cost of delivery, insurance and out-of-pocket costs.

Usually, the baby receives a separate bill, which typically ranges from $1,500 to $4,000 for a healthy baby delivered at term. For a premature baby with complications who has to spend weeks in a neonatal intensive care unit, this bill can reach tens of thousands of dollars.

My $4k bill was for everything - not just for the staff, drugs, surgery and hospital stay, but also about ten visits to the ob-gyn during the pregnancy and about five visits by the midwife to our house post-pregnancy. And, as I say, none of this was subsidised this was at full cost price. It looks like my total cost would be less than many insured people in the states would have to pay just in oop/copays!!

Either the UK is doing something amazingly right or the US is doing something amazingly wrong.

[TranquilFury]

1: Malpractice reform:
Replace punitive damages with jail time. It's perfectly fine to give those injured by incompetence the compensation to overcome the injury, but punitive damages don't work and serve only to increase the cost of healthcare.

2: pharmaceutical research(patents and insurance):
Force health insurance companies to contribute a percentage of revenue (say 5%) to new pharmaceutical research, and give them control over that research, with the caveat that the results of said research must be public and patent free.

[CorruptUser]

$100/hr doesn't cover the cost of the driver and the EMTs that are on call 24/7, let alone maintenance and amortization costs.

Pay for EMT workers in the UK is about $40k/year and a driver earns about half that. So total pay for 3 workers per ambulance is around $100k per year.

Except that the ambulance is in use 24 hrs a day even though the driver/EMTs work only 8 each. So you have 3 different drivers and 6-9 different EMTS per ambulance. And what EMTs and drivers make is only a fraction of what you pay them. Payroll taxes are not insignificant.

My $4k bill was for everything
...
Either the UK is doing something amazingly right or the US is doing something amazingly wrong.

Like I said, all the extra care done primarily to ward off legal issues.

Replace punitive damages with jail time.

Malpractice is a civil issue, not criminal.

[Soralin]

Like I said, all the extra care done primarily to ward off legal issues.

What extra care? From what elasto said, it seems that they got more care than what would be typical in the US, for far less money.

[TranquilFury]

Malpractice is a civil issue, not criminal.

It SHOULD be a criminal issue for two reasons:
1: Any person taking employment where the cost of incompetence is human life should be charged with manslaughter if their incompetence kills someone. The same goes for a sloppy engineer, you should be held accountable for a building collapse caused by your mistakes. If you aren't willing to take full responsibility for your mistakes, you shouldn't be given the opportunity to kill people with your mistakes. Go be a janitor instead.

2: A jury might award extra unreasonable damages because they feel sorry for the patient, regardless of whether it was actually the doctor's fault(which only serves to increase the cost of healthcare), but they aren't going to send someone to jail unless that person really harmed the patient.

[CorruptUser]

Malpractice is a civil issue, not criminal.

It SHOULD be a criminal issue for two reasons:
1: Any person taking employment where the cost of incompetence is human life should be charged with manslaughter if their incompetence kills someone. The same goes for a sloppy engineer, you should be held accountable for a building collapse caused by your mistakes. If you aren't willing to take full responsibility for your mistakes, you shouldn't be given the opportunity to kill people with your mistakes. Go be a janitor instead.

2: A jury might award extra unreasonable damages because they feel sorry for the patient, regardless of whether it was actually the doctor's fault(which only serves to increase the cost of healthcare), but they aren't going to send someone to jail unless that person really harmed the patient.

1) They ARE held accountable in criminal law if it's a case of gross negligence. But short of gross negligence, everything is a gray area. Oh, and sloppy engineers are also held accountable too for gross negligence, as are auditors. Oh, auditors...

2) Don't presume to know what juries will/won't do.

Unless you actually are involved the medical profession, please don't presume to know how the intricate details of how it should be run.

Like I said, all the extra care done primarily to ward off legal issues.

What extra care? From what elasto said, it seems that they got more care than what would be typical in the US, for far less money.

Surgery in the US is done with vastly more oversight than in the UK. You get the same product, but in the US you have a lot of redundancy. That's there because someone (yo) crunches the numbers and says that all the redundancy costs less than the extra lawsuits for not having the redundancy.

[elasto]

Except that the ambulance is in use 24 hrs a day even though the driver/EMTs work only 8 each. So you have 3 different drivers and 6-9 different EMTS per ambulance.

I quoted wage figures per hour. Wages are the same per hour whether you are talking 8 hours a day or 24 hours a day - whether the same person is working 24 hours a day or it's 3 people doing 3 different shifts. (Run through the maths if you don't quite follow).

And what EMTs and drivers make is only a fraction of what you pay them. Payroll taxes are not insignificant.

I included taxes in my figures (even though taxes are somewhat irrelevant when it's a government paying the wages.)

My $4k bill was for everything

Like I said, all the extra care done primarily to ward off legal issues.

Legal issues don't explain the 5-fold increase in cost-price though. There must be something else going on I'm not getting here.

[elasto]

Surgery in the US is done with vastly more oversight than in the UK. You get the same product, but in the US you have a lot of redundancy.

Again, I'm really not sure that's true - at least not to an extent that explains the cost differential. Our caesarean surgery had eight staff in the operating theatre. What, a US caesarean surgery has forty staff in there?

[CorruptUser]

The reason I used hourly rates is because you were talking about how much EMTs and drivers were paid annually, when in reality you have a lot more than 1 driver and 2 EMTs per ambulance (and all other costs).

Taxes can't be ignored even if they are government employees. And you have to include ALL taxes, not just income. The 40k you quoted is what the workers get before they pay personal taxes, not what their employer has to pay. Don't worry, most people tend to be in ignorance of this; that's how the US can get away with it.

Let's get some real numbers here. Average cost of childbirth in the US is $7.7k for regular birth and nearly $11k for cesarean, not the $25k someone here just made up.

Did your birth cost 4k dollar or 4k pounds? Because there's a big difference.

Another cost of childbirth is the malpractice costs itself. The insurance alone can be upwards of $200k/yr depending on region. If an OB/GYN delivers 400 babies a year (couldn't get precise statistics), each delivery has to cost $500 more just for the insurance premium alone. The med-mal company I worked for had a max policy of $1m/incident $3m aggregate (or $1.3/$3.9m for extra). Meaning, if the courts award the plaintiff $5m, you are fucked on the remaining $4m (or $3.7m). Just think about what it means when the maximum policy is only 5 times the premium. Court awards for issues with OB/GYN tend to be in that multi-million dollar range, so, yeah, those costs do have to be eaten up by the OB/GYN, and by the OB/GYN, I mean the patient.

Liability in the UK is A LOT different than in the US. Not because government is inherently better than private care, but because when you sue a doctor in the UK, you are usually suing the NHS, which is government, and you can't sue the government.

[Webzter]

Let's get some real numbers here.

http://childbirthconnection.org/pdfs/birthcharges.pdf

And, read the note... that does not include anesthesiology (among other things).

edit: Sweet, even better, they have them broken down by state here: http://transform.childbirthconnection.o ... techarges/

Not surprisingly, they are cheaper in some states than others. An uncomplicated vaginal birth in Michigan is nearly $8k while it's just over $10k in Nevada (which has a reputation for a shortage of ob-gyn docs due to malpractice insurance costs) and $18k in New Jersey (apparently, not a hot destination for medical tourism). Interestingly, New York will set you back $8500. (all numbers are 2009 numbers, costs likely higher now). And Maryland will only set you back $5500.

Of course, expect to pay more for a c-section and substantially more for a c-section with complications. My guess would be that most c-section with complications also result in the baby having to spend time in the NICU which is also not included in the numbers.

Another cost of childbirth is the malpractice costs itself. The insurance alone can be upwards of $200k/yr depending on region.

It can also be as low as $10k a year, depending on region. There's also some interesting information in the last section of that article that's probably pertinent.

[CorruptUser]

$10k/yr in Minnesota? I call bullshit.

They claim OB/GYN have the highest premiums. Absolutely not true. Neurosurgery does.

As for region, keep in mind that while it does vary wildly by region, since most people live in cities, most people are paying for city doctor's insurance.

[EMTP]

My perspective as an emergency physician:

* The US has a mediocre healthcare system in terms of outcomes. You can control for things like population risk factors (obesity, smoking, drinking) and the legal environment (torts, defensive medicine) and you are still left with a system with average to poor results.

* US healthcare is incredibly expensive. A large amount of the money spent is simply waste.

* Systems tend to work better with two actors instead of three: the patient and the insurer-provider. Examples include the VA, the Cleveland Clinic, and Kaiser Permanente in the United States, and the NHS is Britain. Why it works better is of course subject to debate, but in my opinion, it has to do with eliminating fee-for-service and consequently creating providers that make their money not by doing more stuff, but by selling insurance to people and keeping them as healthy as possible after that. These provider-insurers tend to invest more heavily in things like primary care, preventative medicine, and generic drugs, because unlike a traditional provider that makes money when you get sick, they make money when they collect your premium and you stay well.

I highly recommend this essay: "Escape Fire: Lessons for the Future of Healthcare"; www.commonwealthfund.org/usr_doc/berwic ... re_563.pdf

In a recent survey of 42 medical group practices about morale among physicians and office staff, only 15 percent of the respondents rated their work environ- ment as “good” or “excellent.” Medicare and Medicaid managed care rolls are dropping monthly. We have tens of millions of uninsured Americans, significant medication errors in seven out of every 100 inpatients, tenfold or more variation in population-based rates of impor- tant surgical procedures, 30 percent overuse of advanced antibiotics, excessive waits throughout our system of care, 50 percent or more underuse of effective and inexpensive medications for heart attacks and immunization for the elderly, and declining service ratings from patients and their families. In 1998, the American Customer Satis- faction Index rated Americans’ satisfaction with hospitals at 70 percent, just below the U.S. Postal Service (71%) and just above the Internal Revenue Service (69%). Racial gaps in health status remain enormous; a black male born in Baltimore today will, on the average, live eight years less than an average white male. All this happens with per capita health care costs 30 to 40 percent higher in the United States than in the next most expensive nation.

As well as: "Mirror, Mirror on the Wall Mirror, Mirror on the Wall" http://www.integratedcare.org/Portals/0 ... onally.pdf

Despite having the most costly health system in the world, the United States consistently under- performs on most dimensions of performance, relative to other countries. This report—an update to three earlier editions—includes data from seven countries and incorporates patients’ and physicians’ survey results on care experiences and ratings on dimensions of care. Compared with six other nations—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives.

On our "National Health Service," the VA: "VA Health Care Compared To Non-VA Settings"; http://tucsoncitizen.com/veteranveritas ... -settings/

Ten comparative studies assessing the use of preventive services, care for acute and chronic medical conditions, and changes in health status, including mortality, showed superior performance–as measured by greater adherence to accepted processes of care, better health outcomes, or improved patient ratings of care–for health care delivered in the VA compared with care delivered outside the VA.

[CorruptUser]

My perspective as an emergency physician:

<Lots of things, many good insights>

- The US doesn't have a worse outcome than most. We have 1/3 the complication rate than the next best major country, though this data tends to be polluted by the fact that so many of the procedures done were unnecessary to begin with.

- We all agree that the US is expensive and that there is a large amount of waste. I was mainly arguing that a large part of the waste was because of legal issues. Another huge part is end of life care for people whose death is inevitable (and no, not that "we are all going to die, man").

- The main problem with the health insurance industry that I saw was that the insurance companies were covering things that people don't buy insurance for. Maybe I'm wrong on this, but I buy insurance in case I get cancer or break my arm, not for the routine (and cheap) things like teeth cleanings. The result is people buy more health care than they would have otherwise, because of market forces and all that fun stuff. The reason the companies do this is so that they have more control over more parts of medicine, and can force doctors into deals and so forth.

- Racial gaps are incredibly weird, especially on the life side. A random black male born today has less chance of living to age 70 than a white male, but greater chance of living to age 100. No, I don't mean given that the black male reaches age 70, I mean from birth. Though I suspect that has more to do with how mortality is calculated than actual reality. Back on topic, the gaps are nothing that can't probably be explained by poverty.

- Keep in mind when comparing the whole US to other countries, you are comparing the WHOLE US. That includes the shithole that is Mississippi with the paragon that is Connecticut. If you were to make comparisons to, say, Europe, and include Eastern/Southern Europe in there... Not that the US is a paragon of health, but keep in mind how much things vary across the country.

[EMTP]

- The US doesn't have a worse outcome than most. We have 1/3 the complication rate than the next best major country, though this data tends to be polluted by the fact that so many of the procedures done were unnecessary to begin with.

Could you expand on that a little bit? What kind of complications -- post-surgical, iatrogenic infections, prescription errors?

- We all agree that the US is expensive and that there is a large amount of waste. I was mainly arguing that a large part of the waste was because of legal issues. Another huge part is end of life care for people whose death is inevitable (and no, not that "we are all going to die, man").

People disagree about how much legal costs contribute to medical costs. About 2% is the best estimate I've seen (http://health.usnews.com/health-news/ma ... year-in-us).

Another good discussion:

Q.But critics of the current system say that 10 to 15 percent of medical costs are due to medical malpractice.

A.That’s wildly exaggerated. According to the actuarial consulting firm Towers Perrin, medical malpractice tort costs were $30.4 billion in 2007, the last year for which data are available. We have a more than a $2 trillion health care system. That puts litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs. That’s a rounding error. Liability isn’t even the tail on the cost dog. It’s the hair on the end of the tail.

Q.You said the number of claims is relatively small. Is there a way to demonstrate that?

A.We have approximately the same number of claims today as in the late 1980s. Think about that. The cost of health care has doubled since then. The number of medical encounters between doctors and patients has gone up — and research shows a more or less constant rate of errors per hospitalizations. That means we have a declining rate of lawsuits relative to numbers of injuries.

http://prescriptions.blogs.nytimes.com/ ... are-costs/

The malpractice system is badly broken and should be fixed for the sake of all involved. It is a long, expensive, inconsistent process that hurts physicians, and even more importantly, hurts patients, who in many case do not have the knowledge of when they should sue, or the resource to sue and wait years for a verdict.

But the broken malpractice system does not seem to be a major driver of healthcare costs, as my sources reflect. It needs reform, but reform seems unlikely to do much about the cost problem. End of life care is another story, that's a big piece of the puzzle, I think.

- The main problem with the health insurance industry that I saw was that the insurance companies were covering things that people don't buy insurance for. Maybe I'm wrong on this, but I buy insurance in case I get cancer or break my arm, not for the routine (and cheap) things like teeth cleanings.

The problem is this. Some people are not responsible enough to pay for their routine healthcare. When their minor health problems suddenly become major catastrophes, the cost is socialized. As long as anyone in status asthmaticus can get intubated and admitted to the MICU (cost: high five figures to low six figures), it makes no sense to charge people money for inhalers. And the same goes for heart attacks vs aspirin and statins, or stroke care and coumadin.

So the markets for catastrophic coverage and minor expenses are linked, and the only way to definitively separate them would be to deny emergency care to people who were irresponsible with routine care. And that's something that, as a society, we have so far declined to do.

- Keep in mind when comparing the whole US to other countries, you are comparing the WHOLE US. That includes the shithole that is Mississippi with the paragon that is Connecticut. If you were to make comparisons to, say, Europe, and include Eastern/Southern Europe in there... Not that the US is a paragon of health, but keep in mind how much things vary across the country.

We're an extremely rich country, on average, and we're spending more than anyone else. You can certainly make the argument that the health of our population is compromised by huge inequalities and a crappy social safety net, but that is not an argument most of the defenders of our healthcare system are inclined to make.

Even if you look only at the rich and the white, though, the outcomes are still pretty mediocre. And that's while spending >70% more per capita than the average OCED nation.

The hard truth, in my opinion, is that while many of the people in the system are great, and lot of the technology and treatments are great, the system overall just isn't impressive on any meaningful metric. It hurts our national pride to say it, no doubt, but we don't provide the best healthcare any more than we make the best cars. That doesn't imply any particular solution, but the existing system does not work very well. Just my 2 cents.

[CorruptUser]

- The US doesn't have a worse outcome than most. We have 1/3 the complication rate than the next best major country, though this data tends to be polluted by the fact that so many of the procedures done were unnecessary to begin with.

Could you expand on that a little bit? What kind of complications -- post-surgical, iatrogenic infections, prescription errors?

Just total complication rate per procedure, whether it's prescription errors or surgical issues. But, like I said, we do far more procedures that are unnecessary, and the unnecessary ones tend to be both useless and more importantly for this discussion, simple, so the data is biased.

Another good discussion:

Q.But critics of the current system say that 10 to 15 percent of medical costs are due to medical malpractice.

A.That’s wildly exaggerated. According to the actuarial consulting firm Towers Perrin, medical malpractice tort costs were $30.4 billion in 2007, the last year for which data are available. We have a more than a $2 trillion health care system. That puts litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs. That’s a rounding error. Liability isn’t even the tail on the cost dog. It’s the hair on the end of the tail.

Q.You said the number of claims is relatively small. Is there a way to demonstrate that?

A.We have approximately the same number of claims today as in the late 1980s. Think about that. The cost of health care has doubled since then. The number of medical encounters between doctors and patients has gone up — and research shows a more or less constant rate of errors per hospitalizations. That means we have a declining rate of lawsuits relative to numbers of injuries.

http://prescriptions.blogs.nytimes.com/ ... are-costs/

I think you mean Towers Watson now. I've had some issues with them. Anyway...

That's direct costs, the indemnities and expenses for malpractice insurance. I spent a few months dealing with those, having worked for a Med-Lia company. It's the indirect costs which are harder to detect. For example, when an OB/GYN performs an unnecessary Cesarean because it's easier than dealing with John Edwards claiming the doctor caused the baby to be born with Cerebral Palsy without real evidence. It's giving a chest x-ray because it's cheaper than dealing with the potential lawsuit for not detecting lung cancer. It's all the extra care rendered, the extra paperwork, all the extra stuff done primarily to avoid the lawsuits rather than primarily to provide the patient with the quality of care required.


I'm not arguing that Med-Mal is the only reason the US has problems with health care. Just that I've held a hammer and that looks like a nail.

[CorruptUser]

Also, does the cost of US healthcare include the nursing homes? Because fuck those.

[EMTP]

Re: malpractice costs. If you look at the first link, it estimates total malpractice costs (including defensive medicine) at about two and a half times the direct costs, or about 2.4% of total costs. Some think it's more than that, or less, but I haven't seen any good evidence for that.

UPDATE: Since a lot of states have instituted malpractice caps, I thought I would go looking for evidence that this has restrained growth in healthcare costs. I found this interesting report: www.rwjf.org/pr/synthesis/reports_and.. ... ybrief.pdf.

Damage caps have been associated with a reduction in the rate of growth of malpractice premiums by 6 to 13 percent. Since those premiums are already a tiny slice of the healthcare budget, the overall impact on direct costs is negligible. If the ratio of indirect saving to direct savings is similar to the ratio between direct costs and indirect costs (about 1.5 to 1) the total savings would be very small.

Re: nursing homes. I don't like them either, and I've probably spent a lot more time in them than you have. However, what is the alternative for people who can't care for themselves, whose families can no longer care for them? I had a patient the other day (a head bleed) who had been repeatedly hospitalized over the past two years with multiple falls, pneumonia, and heart failure, whose wife was in end-stage renal failure and had been refusing to start dialysis because she had to watch him 24 hours a day. Families do a lot more than people think, but there comes a time.

Re: operative complications; did I miss the link to that study? I'd like to look at it.

[CorruptUser]

The 3x statistic is what I got from doctors I spoke to. But like I said, even if it's true it's not a good metric because of all the unnecessary procedures performed which bloat the numbers.

As for nursing homes, the biggest issue I see is that Medicare/Medicaid doesn't even come close to reimbursing them for the services rendered. Not that the US even could afford to begin properly funding nursing care. So, poor funding means shortcuts, which means accidents and other issues, which means it becomes even more expensive, which means more shortcuts, and turtles all the way down. The main issue we should work on as a nation is nutrition, health, etc, so people don't need to go into a nursing home so soon for so long. I also suggest robot-assistants (give it a decade or two) that could be used as in-home care long before the person is too senile/disabled to need to be institutionalized.

[EMTP]

The 3x statistic is what I got from doctors I spoke to. But like I said, even if it's true it's not a good metric because of all the unnecessary procedures performed which bloat the numbers.

So in terms of quality, where do you think we are, relative to other wealthy nations?

As for nursing homes, the biggest issue I see is that Medicare/Medicaid doesn't even come close to reimbursing them for the services rendered. Not that the US even could afford to begin properly funding nursing care. So, poor funding means shortcuts, which means accidents and other issues, which means it becomes even more expensive, which means more shortcuts, and turtles all the way down. The main issue we should work on as a nation is nutrition, health, etc, so people don't need to go into a nursing home so soon for so long. I also suggest robot-assistants (give it a decade or two) that could be used as in-home care long before the person is too senile/disabled to need to be institutionalized.

Even if we could keep people healthier and independent longer (which is a great goal) we would still be dealing with decades' worth of traditional old people in the pipeline. If I were tasked with keeping those people out of nursing homes as long as possible, I'd want them all to have regular visits to primary care, and have that primary care optimized for geriatric care, which involves things like knowing when to start and stop different kinds of preventative and chronic care (i.e., people who are falling shouldn't be on blood thinners; people with 2-3 years to live shouldn't be getting mammograms; everybody over 65 should be getting vaccinated for pneumoccocal pneumonia; no one should be getting PSAs), limiting polypharmacy (the dangerous state of affairs in which medications are added one by one and rarely discontinued, leaving you with a elderly person with marginal kidney function and borderline cognitive limitation at baseline dealing with the side effects, toxic buildup, and interactions of ten, twenty, even thirty different prescription medicines,) screening for depression and dementia and educating patients and families (signs of heart attacks and strokes, etc.)

I would also want more home visits, home safety evals, hot meals, housework, shopping, bathing -- whether or not you do it with robots or semi-skilled labor, of which we have no shortage in the US right now.

I know I threw up a lot of links all at once, but I really, really recommend "Escape Fire," by Dr Donald Berwick, who headed the Center for Healthcare Improvement before he was tapped to oversee Medicare and Medicaid. What he says about waste in hospitals can also be applied to care for the elderly and many other aspects of the system:

One after another, caregivers told us of their own distress. The occupational therapist apologized for cutting back Ann’s treatment, explaining that 17 OTs had been laid off the week before. The doctors told us about insurance forms and fights for needed hospital days. The nurses complained that the transport service never came.
And the bills were astounding. They have been covered by our insurance, for which we are immensely grateful. But I cannot reconcile what happened with the fees. Pharmacy charges of $30 for a single pill. Remember the Colace that was discontinued but brought anyway? Well, there it is: Pill by pill charges for all the days on which the nurse opened the unneeded packet and threw it in the garbage. Radiology charges of $155 per film for second readings of 14 films transferred from one hospital to another. MRI scans over and over again for $1,700, $2,000, $2,200 per procedure. Ann’s care has been billed at perhaps $150,000 so far, at a minimum, and the bare fact is that, of all that enormous investment, a remarkably small percentage—half at best, probably much less— stood any chance at all of helping her. The rest has been pure waste. Even while simpler needs, for a question answered, information explained, a word of encouragement, or just good and nourishing food, have gone unmet.

[CorruptUser]

The 3x statistic is what I got from doctors I spoke to. But like I said, even if it's true it's not a good metric because of all the unnecessary procedures performed which bloat the numbers.

So in terms of quality, where do you think we are, relative to other wealthy nations?

If you can afford it, best in the world. If you can really afford it, you can even skip the waiting list for organs. If you have only semi-decent insurance, you have some issues; nothing like arguing with an insurance adjuster what is and is not necessary care. For those that can't afford it at all, well, there's the emergency room, but pray to whatever gods ye have if you aren't completely broke. Seriously, this country doesn't hate the poor so much as the poor who dare not to be poor.

I just had a run in with a guy who lost his job as a construction worker, but he couldn't qualify for food stamps because he made 42 cents a month too much. What the hell is wrong with this country where making $6/yr causes you to lose out over $1500 in welfare? More on topic, why should making a few extra dollars not qualify you for Medicaid? And we wonder why people on Medicaid are 'afraid' to work. I often think our safety-nets are more of a net-trap.

TL;DR, Best place for the rich, not so great for most or the poorest, but just horrible for the 'working poor'.

[EMTP]

If you can afford it, best in the world.

But why do you believe that to be the case? You gave us a statistic which is anecdotal and you yourself find unpersuasive. So why do you think we have the best healthcare in the the world for the rich? It's not as if the Japanese haven't discovered the MRI machine, or the French never got the memo on antiretroviral therapy.

I suggest to you as an alternative hypothesis that US healthcare is awful for poor people, bad for middle-class people, and average for rich people (all by comparison with their peers elsewhere). Some of the problems in the system have to do with access, but some have to do with waste, lack of communication, lack of adherence to evidence-based medicine, poor infection control, lack of coordination, and poor record-keeping. And those problems affect even the richest and best-informed consumers of healthcare.

Steve Jobs is an interesting example. He was able to jump the line for a transplant. On the other hand, in the critical moment, he didn't have a primary care doctor he trusted enough to convince him not to delay real cancer therapy for nine months in favor of herbal teas and fruit juice cleanses (http://www.psychologytoday.com/blog/foo ... steve-jobs). If we had done the simple stuff right, maybe we don't have to do the heroic stuff like organ transplantation which, as in Jobs' own case, more often than not buys time, not a cure.

If you have only semi-decent insurance, you have some issues; nothing like arguing with an insurance adjuster what is and is not necessary care.

The hell that people go through with less than stellar insurance is something I hope you never have to experience. The bills bankrupt people; the delays or outright denial of needed care can literally kill. "Just horrible for the working poor" is right, and add a big slice of the middle class to that. More people are in this position than realize it because you only experience the failure of your health insurance when you get really sick, which for most people doesn't happen before they're eligible for medicare.

[lutzj]

If you can afford it, best in the world.

But why do you believe that to be the case? You gave us a statistic which is anecdotal and you yourself find unpersuasive. So why do you think we have the best healthcare in the the world for the rich? It's not as if the Japanese haven't discovered the MRI machine, or the French never got the memo on antiretroviral therapy.

Because when rich oil princes and dictators go overseas for medical treatment, and aren't blacklisted by the CIA, they go here or someplace else in the US very much like it.

[CorruptUser]

If you can afford it, best in the world.

But why do you believe that to be the case? You gave us a statistic which is anecdotal and you yourself find unpersuasive. So why do you think we have the best healthcare in the the world for the rich? It's not as if the Japanese haven't discovered the MRI machine, or the French never got the memo on antiretroviral therapy.

Because when rich oil princes and dictators go overseas for medical treatment, and aren't blacklisted by the CIA, they go here or someplace else in the US very much like it.

Yeah, pretty much, though less Oligarchs and Dictators and more wealthy Canadians/Europeans.

I'd still argue that compared US's health care compared to the rest of the (developed) world, poor: mediocre, 'working poor': abysmal, middle: mediocre, upper-middle: superior, wealthy: supreme. I'm assuming that Medicaid coverage and emergency care is similar to what's available in Europe, though I put mediocre because it varies wildly between states. Heh, the only place that I think arguably has better health care for the rich is China, where the executions are timed to when a politician/oligarch needs a transplant. Supposedly. Can't really be sure what is rumor or truth over there.

We can both agree that the 'working poor' get screwed by the current system, and I guess I haven't irritated you to the point that you wish for me to have terrible insurance. Speaking of which, which health insurance companies tend to be the worst? Because I really want to know which ones to run away from.

[EMTP]

We can both agree that the 'working poor' get screwed by the current system, and I guess I haven't irritated you to the point that you wish for me to have terrible insurance.

You haven't irritated me at all. It's an interesting conversation.

Because when rich oil princes and dictators go overseas for medical treatment, and aren't blacklisted by the CIA, they go here or someplace else in the US very much like it.

Or they go to Britain, or France, or Israel, or Germany, or one of the other fifty countries that recognize medical tourism as an industry. Yes, people seek specialized care in the US, but they also seek it in Europe, in Japan, and elsewhere.

Nor are we giving and not receiving. According to the same source, ten Americans seek healthcare abroad for every visitor. We could of course assume that when Americans seek foreign care it is to save money, while when others seek care here it is for quality. But then we are in danger, I think, of assuming what we're trying to prove.

Suppose we accept, for the sake of argument, that wealthy people come to the US for treatment. Does that mean we give outstanding care to the rich in general? I would argue it does not. People who travel to another country to get care typically have a diagnosis, and are seeking a single instance of specialized care; a surgery, a chemo- or radiotherapy, a consult with an expert. Then they go back home. Consider the parts of the healthcare system they never experience. They never need or use primary care. They don't use or require follow-up. They weren't diagnosed here. They don't plan on using our emergency rooms for their complications. And so on.

Rich travelers are using a select portion of our healthcare system, while rich Americans are stuck with all of it. Even if we conclude that the business of the former reflects well on the quality of the services they are purchasing, that still doesn't tell us much about the overall quality of the system.

Speaking of which, which health insurance companies tend to be the worst? Because I really want to know which ones to run away from.

Kaiser is very good. In general, if an insurance company is closely associated with a system of hospitals, that's a good sign. Blue Cross/Blue Shield is usually OK. Aetna is not worth the paper they print the policy on. In general, though, it's hard to know how good or bad they are until you get sick, when it's too late to make a change. Fortunately The Affordable Care Act is curbing some of the major abuses (like cancelling people retroactively when they become sick).

[CorruptUser]

Oh yes, AETNA was the industry leader in refusing to reimburse physicians for services rendered, so I'm not surprised they would refuse just about everything else.

So, I guess, stick with the Mutuals?