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View Diary: Medical Crisis: The Shape Of Things To Come (245 comments)

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  •  This is why capitation works out so well (4+ / 0-)
    Recommended by:
    dww44, Cassandra Waites, Uncle Bob, ryan81

    in a system which emphasizes good health. Providers are rewarded for keeping people well. It also sets on its head the old system of paying premiums for surgery while noninvasive procedures don't receive more than pennies.

    To really see insanity, consider that Medicaid in many states limit the number of office visits per year with no restrictions on ER visits.

    •  Yeah (0+ / 0-)

      But in the system we now have, people are rewarded for denying coverage. Makes me sick (figuratively and for to many people literally).

    •  in what fantasy world? (1+ / 0-)
      Recommended by:

      capitation only serves to make the folks paying out the reimbursement richer, incentivizes physicians to treat only the healthiest most compliant patients... you cannot hold healthcare providers responsible for the severity of a patient's illness or whether or not they even friggin take their medicines, follow a diet, exercise, etc... that's the problem with capitation...

      I truly give a damn about my patients, and whether or not they are well... to insinuate that capitation works well is to insinuate that most providers are simply out to churn their patients... and dont care to have them healthy.

      •  So do you think it is wrong (or just insulting) (0+ / 0-)

        to try to bring more material incentives to make healthiness the great, desired endpoint of our health care system?

        The President is telling everyone he was provided with faulty intelligence. Yeah, well, DNA is a bitch. -- Will Durst.

        by ajbrown on Tue Jan 08, 2008 at 09:34:58 AM PST

        [ Parent ]

        •  no, not what i am saying (2+ / 0-)
          Recommended by:
          ladybug53, ajbrown

          It has to be done fairly... ie, decide on a fair reimbursement rate under medicare, then reward with incentives doctors who provide exceptional care (ie meet targets regularly for bp, blood sugar, etc)... only downside is that it still leaves room for discrepancies based on patient compliance.

          I think actually paying for preventative exams yearly for medicare patients would make a huge difference... currently they only pay for a "welcome to medicare" wellness visit.

          Private insurers reimburse higher for wellness, and typically do not require a copay for wellness visits... incentivizes both patient and provider to focus on wellness.  

          •  Thanks for your answer. (0+ / 0-)

            I'm interested in how we can better incentive for healthiness, especially given the ways that our society undermines our health (e.g. everything from highway commuting, to agriculture subsidies for corn syrup, to the expense of a doctor's visit).  I just don't think relying on the self-interest of patients and the heroism of caregivers is enough, and I'd love to see more thinking outside the box on the question.  And see ways that our public structures could work for public health rather than against it.

            The President is telling everyone he was provided with faulty intelligence. Yeah, well, DNA is a bitch. -- Will Durst.

            by ajbrown on Tue Jan 08, 2008 at 10:21:11 AM PST

            [ Parent ]

      •  Back in the late 80s or early 90s (0+ / 0-)

        a third party administrator, FPA, if I remember the alphabet correctly, was able to provide care to a population without slighting the individual needs of the patient.
        In order for capitation to work, each provider has to have a risk pool sufficiently large to account for any outliers, a stopgap agreement with the carrier in case of catstrophic illnesses, and a staff which is able to adequately triage patients so that they receive appropriate levels of care. The savings comes from rendering care in the clinic, not the ER and controlling pharm costs, which are two major drivers of healthcare costs. Maldistribution of resources remains an ongoing problem in this country.    

        •  agree (1+ / 0-)
          Recommended by:

          and that is the crux of the problem...

          but keep in mind, there are standards of care for labwork and visits... and most insurers including medicare wont pay for visits more frequent... so in effect there are capitations in place for illnesses already, just not in stated form.  Capitation as a policy seems to favor the insurer and not the patient or the provider.  Ie, standard of care for diabetes is every 3 month visits, with a hba1c blood draw, 6 month eye exams etc... I cant see that pt more often and get paid for it unless I really can justify that they needed it ie out of control diabetes, complications, etc.

    •  Ah yes, the joys of single payor. (0+ / 0-)

      I've been castigated for my comments before, but single payer will not solve very much.  I've seen both Medicare and Medicaid from the point of the primary provider. To be blunt, it's not health care, it's health financing. In one case, someone in the insurance industry is trying to reduce costs by denying care; in the other case its someone in the government trying to reduce costs by denying care.  Frankly, what's the f'ing difference? There is something fundamentally evil about a health system that puts health care decisions in the hands of bean-counters. Those are decisions that should be made by Doctors.

      •  not to jostle your cynicism, but (0+ / 0-)

        there is an important distinction between private companies, who are unable to prioritize the public good over profit, and the government, who can and often does prioritize the public good over cutting costs.  And it's not hard to make the case that improving public health has benefits that reverberate throughout the society -- far beyond the beans being counted in a program like Medicare.

        The President is telling everyone he was provided with faulty intelligence. Yeah, well, DNA is a bitch. -- Will Durst.

        by ajbrown on Tue Jan 08, 2008 at 09:31:53 AM PST

        [ Parent ]

        •  I prefer realist over cynic, and I agree (0+ / 0-)

          about improving public health. It's the mechanism that's needed to achieve this that has me concerned. Too many people focusing on failed methods of universal coverage without even beginning to address some of the central issues of public health. I don't know if it adds to my credibility or not (and frankly I don't care), but I taught at the Johns Hopkins School of Public Health for years. The primary care physician, the front line in any public health initiative is routinely shafted by Medicare and Medicaid.  It's hard to make a living in primary care.  However, someone coming straight out of their residency in radiology gets $450k plus profit-sharing, all of it approved by medicare. There are tremendous inequities out there with far too much emphasis on insurance and precious little on access, quality and financing.

      •  It is going to be a lot more interesting if the (0+ / 0-)

        10% Medicare cut goes through for providers; Medicare and most private carriers now peg their rates to Medicare so the reps I have talked to said that if the Medicare cuts hold, the private carriers are anticipating a windfall.

      •  Well, being public it should be explicit... (0+ / 0-)

        The elephant in the room is that regardless there will be rationing of health care.

        The current form of rationing (for non-Medicare) is via income, employment, and some hidden method used by a health insurer to deny care.

        Rationing in a public system will hopefully be explicit since being a government program the processes for making these decisions should be subject to FOIA requests.

        At least if you get everyone some form of coverage the doctor at least gets a chance to make a health care decision, and preferably make that decision at a time when it can be most effective and probably less costly.

        The issue it seems is going to hammer any universal care plan is the way we treat primary care in this country.  There will be a huge shortage of primary care physicians because it does not pay. We pay for procedural medicine in this country and shaft the primary care doctor.  Which I am sure is something Uncle Bob can attest to.

        •  So attested to higher up in this sub-thread. (0+ / 0-)

          Required universal coverage where most people will have multiple thousand dollar deductibles will not lead to improved health care or access. First of all, required insurance for the unemployed or under-employed is extremely hard to enforce.  It might reduce the frequency of medical bankruptcies. That should keep the hospitals, banks and insurance companies happy, but will do absolutely nothing for the delivery of health care.  Might make it worse for a few years while people who believe that universal health insurance will solve problems will conclude that the central issue has been resolved.

          •  I was not even thinking of deductibles... (0+ / 0-)

            Just the fact the primary care gets paid squat, so there are not enough primary care physicians.  We could have $0 deductibles and copays and there would still be the primary care problem.  My understanding is that the Medicare reimbursement cuts will make this even worse in Medicare.  It seems a primary care doctor almost has to order a couple tests per visit just to pay the bills.

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