I've said it before: Eliminate insurance.

1. Drives people to docs with good outcomes, and good outcomes/dollar spent.

2. Significantly alters patient's and family's thinking about end of life issues and beginning of life issues. (Although Moses mentions costs close to death, a huge amount of money is also spent on premies which often are significantly ill/continue to rack up bills or delayed, and may not have been premies with proper prenatal care. Note average cost for all premies 47K vs 2.8K full term, and "Of the tiniest babies, one-third die, one-third live with serious problems such as blindness and cerebral palsy, and the rest are relatively unaffected, he said. Hospitalization costs alone for one of these infants can easily top $1 million - March of Dimes)

3. Eliminates a huge amount of unnecessary layers and profit taking from insurance companies, various bureaucracies etc. An exquisite example are all the little oversight committees that are popping up. There is a committee for every mode of testing that requires yearly fees and continuing education to maintain certification, all in attempt to have only "accredited labs" be paid by insurers.

4. Consumer-patients might finally get that dietary and lifestyle changes mean less out of their pockets.

5. Get people to save money for a "rainy day" rather than spend it all (this might be considered a disadvantage from the business/economy outlook)

6. Less government involvement in healthcare (or any part of our lives).

7. Eliminate overutilizers who go to the MD only to decline all the approp therapies. They wouldn't get the doc visit for free (or $10).

8. Make MD life a lot more bareable, by allowing to charge for afterhours phone calls (and hence reduce the volume of such calls), or email, or anything else that takes time, like 5 page disability forms.

YMMV

PS Chris, MD's don't write CPT/ICD codes most places, although sometimes I have been asked to clarify the diagnosis (not the coding). The billing is done by the hospital. A great deal of time is spent having the insurance companies deny coverage because X wasn't documented or something else silly. The money eventually comes in. Just takes nagging. Aetna just lost a large lawsuit by MD's for categorically delaying payments. Also, making the most of modifiers to "get" the full payment occupies a great deal of time.

So what are you suggesting?
This is a pretty slippery slope you are entering

Steve

I agree with much of artplumber. #3 hits especially close to home as the nuclear medicine lab that I run had to undergo accreditation in order for health insurance companies to continue to reimburse for studies performed at the lab. Who came up the idea of needing to be accredited? Insurance companies of course, and they are on the recieving end of some of the accreditation money. Silly.
Did my lab improve because of the process? Not really, but it did need about 60 man hours to complete and an application fee that was just under 5K. Another layer of BS that somebody is making money from and the benefit to the facility is nil.
Soylent green scenario is on the way if healthcare is rationed by the govt.

I'm noticing that most of the doctors and other medical professionals who are posting are arguing for limiting or controlling how much medical care is provided in various cases. I.e. Noah, Moses, and art (livi didn't, but he works in a different healthcare system).

Yet I suspect the term "rationing healthcare" is quite controversial for the electorate at large.

Peter I also have questions about #3. I thought those areas were where a lot of progress was being made, especially preemies.

Yes rationing healthcare is not what the general electorate thinks of when "free healthcare" (i know its not free, but some will label it that) I believe the massed expect all the treatments, all the time, and with no limit.
Not gonna do it.

Caring for premature infants is very expensive. Fortunately, the vast majority of newborns are healthy and full-term. The global cost of caring for premature infants is not a huge factor.

Unlike the relatively rare premature birth, we will all die someday. Unless you die suddenly and unexpectedly, the last 6 months of your life will cost more than $500,000.00.

I understand that to some the costs outweigh the life, but I do not think the costs are that high.

My son was in ICN for 70 days and the bill was 175K. Most of the children were in and out in just a couple of weeks.

How many countries even attempt to save the tiniest of the preemies (<1500g)?

If healthcare is to be "rationed", what is the best way to do it?

I can think of a few possibilities:

1. Explicit dollar cap on payment of healthcare costs, either by time period (e.g. $X per year) or by person ($Y per lifetime). A lifetime cap might be difficult to administer as people switch plans.

2. Identify the situations which typically lead to excessive healthcare costs, and restrict treatments or limit payments in those specific situations. Who does that analysis and makes those rules?

3. Create financial incentives for patient and/or his healthcare provider to restrain healthcare costs. For example, high deductibles, sliding scale deductibles (e.g. rises with more treatment), flat fee to provider per patient, etc. I think Art's suggestion of eliminating healthcare insurance altogether falls in this category. Some of these schemes sound complicated, how handle coordination between multiple providers treating same patient?

4. Segregate population, provide very limited healthcare to one group and more-or-less unlimited healthcare to the other group. I think this is essentially how we do it today.

Any thoughts? Other, better approaches I didn't list?

OK, I'm not sure what slippery slope you are suggesting. If you are concerned about those with no money, physicians and hospitals have been doing free work for years before there was medicare or medicaid. The folks with Medicaid are still "free" work now since the payment received is less than the overhead and other headache associated with treating most of those folk. Even Medicare is approaching no profitability for some specialties.

The benefit to patients is that you won't have somebody get shafted for having some assets and no insurance, since insurance plans can dictate what they will pay for something. Example, patient gets procedure x, hospital bills $22K, insurance agrees to $16K and medicare pays $13K. If you're someone with some money and no insurance, you will end up paying $22K. Sucks don't it?

My point about no insurance is that receiving med care would become self rationing and rational. People won't be willing to pay huge sums of money to get little benefit, and researchers/developers won't develop things with tiny incremental gains and high costs.

And I disagree w/Moses on the premie thing. There are substantial dollars spent in this country on premies (premies are more than just pre 28wkers). That is one of the reasons why the country always gets bad marks for infant health/mortality.

EDIT: $175K is a whole bunch of prenatal care for several hundred people I'd guess. 175K being considered cheap is the mentality that needs to be changed. I'm not saying it wasn't worth it to you, but at a societal level it is not something that is easily afforded (my most PC).

I could go on again about colonoscopy screening for colon cancer too. Or mammograms. Or HIV research/therapy. All "hot button" issues. All debatable at some level. (and no I'm not advocating no Rx for HIV, just that there is a disproportionate share of $ spent on a disease that is pretty minor in terms of death rates in the US).

My concerns where I though you might be suggesting which some premies might be worth spending money on and some might not. It appears you where not suggesting that.

Steve

I had a "choich" 2 months ago. Continue with a full health care plan that was $800/mth or go with a basic plan for $200/mth. The $200 plan has a prescription drug discount and access to the discounts from Blue Cross get for the doctors. But, we have a family deductible of $5K. After $5K, they pay 80% of everything.

$800-$200 = $600

$600 * 12 = $7200! But the full plan has a $1000 deductible and $30 co-pay for each Dr. visit. I would be out $2200 more, for sure. And more likely than not, I will not use $5K in health care. And the $5K can be in a health savings account...

This was a no-brainer. I will gladly pay cash for what I need.

That's another piece of the puzzle. I frequently (at least once per week) have a patient come in that is convinced he/she needs an MRI. For what, I ask? Getting a test just because it's expensive and fancy-sounding doesn't make sense if you don't know what you're looking for. I wonder if people would be so insistent on obtaining not-entirely-indicated tests and such if they actually had to pay for this stuff, themselves. But, hey, the expectation is that we have the technology, so let's do it!

true my doctor won't even touch my shoulder, but yet will send me to a specialist, then x-rays, then the specialist, then MRI, then specialist again. it's tough to do especially when it's missed up and you want it fixxed a sap.

I like artplumber's idea and would like to go further:

Everyone, and I mean everyone, pays into a non-government run health insurance plan.
This would cover basic and preventive heatlth care, dentistry, mental health, wellness clinic and follow ups. This would include family panning, AAA and drug treatment, but not self inflicted emergency treatment, for that patient (or for kids, parents) pay.

Everyone gets a plastic card: no card, no treatment under the insurance: patient pays.

Do drugs or alcohol: patient pays.

Elective or plastic surgery: patient pays.

Managed by medical practicioners who are FULLY accountable for their decisions.
Financial decisons managed by medical and financial managers.
All management sign a 10 year contract to give continuity. Absoloutely no "golden parachutes".

No restrictions on anyone paying for private insurance to have more coverage.

Payments come out of pre-tax earnings.
Those on welfare, benefits or similar make a token payment to receive card.

Free gifts to doctors won't do anything as drug companies products will be looked at by commitee with actual power.

Everyone will be expected to have yearly check-up.
Etc, etc...

This is not an issue and not related to the the subject at hand.
yup, we need to let drug addict diabetics go ahead and kill themsevlves too


Chris, the expense of submitting and resubmitting claims is largely driven by 3rd party payors trying to delay or deny payment, not by errors in the bill originally submitted. Their job is not to pay, it is to find a way not to pay. This is not where the big money is spent, so it would give limited return if addressed.

John, we are rationing care now, if we socialize medicine, we just change the means we use to do so and add another layer of beaurocracy and expense.

As it is now, many people pay nothing when they go to the doctor or hospital. If something costs you nothing, you will not value it, and use it in a profligate manner. This is illustrated by people asking for an $1000 MRI because I tell them the $25 x ray was negative, and the tendonitis they have is a soft tissue problem not well visualized by radiographs. The huge amounts of dough spent on end of life care is a good example of this too. People that are 90 with failing hearts, kidneys or whatever, are going to die soon. Just because their family is wailing about doing whatever it takes to "save" their mom/dad/granny/gramps, does not make it a good idea. People need to be financially invested in their own care; ie, their bad decisions must cost them something more than the price of a pack of smokes, a big mac or a crack rock.

The high perceived cost of specialist care is because they are generally procedure driven, procedures are expensive, not just because of surgeon's fees. OR time is very expensive. Some procedures are very cost effective though, and this can be tracked. The reason a lot of primary care docs don't treat before referring is because they are paid by number of patient contacts in many cases, not by what they actually do. I practice stupidly myself, I spend an hour with my new patients, spend a lot of time to educate my diabetics, tell them the consequences. Works out to me getting less an hour than you pay to get your Porsche worked on, so it makes sense for me to work on my own car. How is that for rationalization:p

It should be very expensive to be obese, there should be a tax on high BMI's and smoking(or higher on smoking) We should drug test everybody getting any public assistance. Needs to be a financial penalty for bad health decisions, but how are you going to get anything out of a 500 lb disabled guy?

We wanted the HMO model because it was marketed as "cheaper" and forgot that you get what you pay for.

Funny how the people who pay least often seem to be the most demanding (and litigious).


As an aside: This sentiment is entirely correct. However, it is rare that doctors can do this type of thing (anymore, at least). If there is some sort of action taken on your license in one state, then you are required to report it to all other states in which you hold other medical licenses. Realistically, if you lose your license in one state, you're going to lose your license in all other states, too. States' medical boards do communicate with each other. Better than the DMVs do, too. Most state medical boards print quarterly newsletters. They are mailed to all the licensed physicians in that state. There is a section which lists all the disciplinary action taken by the Board. There are always a few physicians listed that are from out of state. Presumably, they had some sort of disciplinary action taken on them in another state where they are currently practicing, and whatever sentence was handed down was then extended to their California license by the California Board of Medicine, despite the fact that they're not practicing in California. Heck, get a DUI while off duty on personal time, and the medical board will still take action against you (not that I have any personal problem with that as I'm adamantly anti-DUI. But in how many other professions do you risk the permanent loss of current livelihood for stuff that's done on personal time?).