Healthcare: What Fixes Beyond Financing?
 

I had dinner with some doctor friends. One argued that the current proposals to reform the US healthcare system focus on financing - how to pay for healthcare - rather than on the healthcare delivery system itself. He claims that without making the healthcare delivery system more efficient, reform will not be successful. We will continue spending a high, growing, and ultimately unaffordable share of GDP on healthcare.

He stated that more care should be provided by primary care physicians and less by specialists, more by clinics and less by hospitals, that certain parts of the healthcare system need to make less money, and that medical "high technology" is frequently a waste of money.

Any views on this, from our medical members?

Prevention being cheaper than cure, tackling the 30% obesity rate in this country would be a start.

I think you'll find that different specialists will tout different solutions to the question you pose. As a surgeon, I think tort reform is pretty important. Defensive medicine can be pretty costly. But so are those lawsuits (even frivolous ones, which most are) and frequently ridiculous jury awards.

I had a similar conversation with my brother-in-law last month. He's a child psychologist and his wife is a family practitioner. For him, prevention and utilizing primary care providers more were big deals.

One thing we agreed on is that the medical payer system is so poor, that it forces many healthcare providers to work on a volume over quality mentality. The medical payer system does not reward spending time with people and discussing issues. That probably leads to some degree of worse diagnostic skills, less patient compliance, and higher lawsuit rates.

Finally, I'd have to argue that we, as a society, have to change our expectations of medicine, if we wish to have a viable system of universal coverage. As on other threads in the past, we have to consider medicine like a commodity. Everything in life is a balance of risks and benefits. We have to understand that if we wish to pay for healthcare for everyone, with finite medical dollars, no matter how efficient we otherwise become, we will still have to be willing to ration medical care/technology/knowledge/etc. Just because we have it within our power to do certain things to improve patient outcomes doesn't mean we should be doing so if the gains are marginal compared to the costs. And as painful as that may be, we have to be OK with that.

True healthcare reform needs to include tort reform as well.

While we are at it, strip doctors of their licenses when they have a record of botched surgeries. You sometimes hear of doctors losing their license in one state, only needing to move to another state to continue practicing.

In Sweden, the most problematic issue is that the people that decide over the money (politicians and such) have not the first clue as what practicing medicine is all about and hence they spend it in all the wrong places.

That will be true of ANY solution that involves government. Resources are allocated based on who is most effective in bending politicians' ears, not in what would work the best or be the best use of resources.

What we need is a system with relatively little government intervention. A system where doctors are naturally attracted to areas of highest need because those areas of practice command the highest fees. Of course, a supply of more doctors in a popular area of practice will bring down the price in that area over time. It would be a self-regulating system that ensures resources are allocated to the areas with the highest demand for service. Supply and demand. Huh. What a novel idea...

From what I understand, hospitals spend a LOT of time and money (HR wise) submitting claims to insurance companies, resubmitting them, etc. And, insurance companies spend a LOT of time and money (again HR wise) denying and/or eventually processing claims. I think that improving the efficiency of submitting, making sure submissions are complete and accurate, paying, etc. could save enough to be considered a "good start".

Better access directly to providers and physicians without 15 intervening layers of bureaucracy.

Simpler, itemized, understandable billing. And estimates ahead of time.

Hate to say it, but some of those problems go all the way back to the doctor. A lot of time they write down (or they are incorrectly transcribed from the doctor's notes) the wrong ICDs and CPTs on the bills. A diagnosis not consistent with the procedures (or vice-versa) will get a bill kicked out of a lot of automated bill review systems.

Another problem, is that a lot of hospitals will send bills to the wrong insurance company. This I have dealt with first-hand. Let's say you are in a car accident and break your arm. You go to the hospital. Your auto insurance company is billed and everything is paid and everything is fine. A year later, you go back to the same hospital for surgery unrelated to your broken arm (which is now healed) or the auto accident. You give the hospital your new insurance information. The hospital staff, deciding to take a short-cut, doesn't really look over your paperwork and just bills the company that paid last time: your auto insurer. Your auto insurer rejects the bill (as they should). It takes months of phone calls on your (the patient's) part before you ever find out that the hospital is billing the wrong company. All this time, your health insurer has no idea you had surgery. This battle gets even more fun when it crosses a calendar year. Health insurance companies don't like to be told about claims after the year they occur in, and when you have MER, they like to think they get to keep the money if you didn't use it. The fact that the claim was submitted in a timely manner to the wrong insurance company (which was not your fault) doesn't seem to sway them much.

I guess my point is that the communication between providers and insurers is usually pretty efficient, but every human who touches a bill between (and including) the doctor and the person who pays the claim can make a mistake, and that is where most of the problems occur.

Something like 50% of your lifetime medical costs will be spent in the last 6 months of your life. We spend obscene amounts of money treating terminal disease. We perform hopeless surgeries, endless expensive treatments with no real chance for improvement. Until palliative care and hospice are MANDATORY for terminal disease, we will never get a handle on runaway medical costs.

I don't know if the topic of healthcare administration costs goes under "financing" or "delivery system", so I might be off-topic to my own thread.

I found a 2003 study published in the New England Journal of Medicine that states US healthcare administration costs in 1999 were $395BN or 31% of total healthcare spending in the US at that time. Bring forward to 2007 at 3%/yr inflation and that that would be $500BN. http://content.nejm.org/cgi/content/short/349/8/768

An opinion article in the NYT also refers to a McKinsey study which concluded the "excess" administration cost in US healthcare was $100BN in 2003. No, I don't know how they defined "excess". Bring forward to 2007 at 3%/yr inflation and that would be $113BN. http://economix.blogs.nytimes.com/2008/11/21/why-does-us-health-care-cost-so-much-part-ii-indefensible-administrative-costs/

I know the total operating expense of the US publicly traded healthcare insurers and managed care companies was $350BN in 2007. Presumably not all of this is administration costs, though you could argue that would be true for the insurers. This wouldn't include what providers (hospitals, clinics, doctors offices) spent on claims processing, and wouldn't include private (not publicly traded) companies.

To put in context, the US reportedly spent $2400BN on healthcare in 2007.

When HMO's really got going in the 90's, they sold themselves to employers saying that they would reduce healthcare costs by closely monitoring billing. They sold themselves to investors by saying they would "squeeze the inneficiency out of the healthcare system" (and take a small cut in the process).

What they did was to introduce another layer into the system. This additional layer has made the overall healthcare system less efficient. Some doctors now spend large amounts of time "unbundling" procedures and doing other things like that now that their fees are more or less mandated by law in many places. In other words, HMO's spend a lot of effort trying to "catch" doctors billing improperly, and doctors spend a lot of effort trying to figure out how to get around a draconian reimbursement system. If doctors could just bill whatever they felt like for their time, there'd be no point in these games and people could chose to go to and "expensive" or "cheap" doctor.

I look at various pharma/biotech companies, and see lots of very expensive drugs with what seem to me like limited benefits to terminally ill patients, or even large benefits to a very limited number of patients.

Typical would be a cancer drug that costs $60K for typical patient and will extends the typical patient's survival by a couple months. Also drugs for orphan diseases that do make a big improvement in the lives of a few thousand patients (often children born w/ rare and debilitating genetic diseases), but will cost $100K-200K/yr for the patient's lifetime.

I wonder what mechanism we have to judge the cost-effectiveness of these treatments. It would be a hard-hearted thing to do, but everything has trade-offs.

John, you are correct. So is Moses.

We have learned how to extend human life by a few hours, weeks, or months at a tremendous cost and with little benefit for the patient or their family. When my grandmother had cancer, doctors kept he alive two more weeks with technology. She was still unconscious for those two weeks. Had she not been unconscious, she would have been in tremendous pain.

+1. I'm not a doctor, and I don't play one on TV, but even can see this.

How will the average consumer judge what a doctor's services are worth, whether a charge is "expensive" or "cheap"?

If I choose the most expensive doctor who gives me every possible high-tech test, does the payor (insurance company) have anything to say about it?

If not, why wouldn't everyone choose the most expensive doctor?

Go after the consumption of alcoholic beverages the way we're attacking smoking. Make it difficult, expensive and socially unacceptable. The medical cost of alcohol use (and abuse) is enormous.

So is eating Big Macs. Let's queue going after fast-food first. There's way more obese Americans than there are alcoholics.

Then we can move on to ice-skating. I'm tellin' you, that really needs to go. Those folks have *BLADES* strapped to their feet,. And not a single government employee is in sight to direct the flow of traffic around the ring.

We gotta stop hang-gliding, bungee jumping and snow skiing should be a felony. YOU DON'T WANNA KNOW THE INJURY RATES FOR SKATEBOARDS!!!! :D:D:D