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I arrived this morning in the office at 8:50 a.m. to find Glenda, my office manager, buried in charts.  She had been there since 6:30, simultaneously arranging referrals that had been requested the day before, making sure that we had properly completed the detailed forms required by the Child Health and Disability Prevention Program that helps pay for the preventive care provided to some of our poorer patients, and listening to the voice mail from pharmacies to get the medication refill requests in order for me before the day begins in earnest.

This essay supporting single payer transformation of the health care system weaves anecdotes from clinical practice with hard policy analysis. A nearly identical version has been published already at TPM cafe where it was well received and became the number one reader recommended posting. In the interest of providing it to a wider audience it is being cross-posted here along with a poll.

Glenda is a great asset to the practice.  An extraordinarily hardworking mother of two, four days a week she commutes with her husband from an outlying suburb to the office, arriving early to avoid the rush hour gridlock and get some of her work done before the phones start ringing. Having been with me for about ten years, she knows the ins and outs of dealing with all the health plans-- which ones require paper referrals, which use the Internet, which force her to hang on the phone waiting for an okay.  Only Medicare is easy; all we have to do is provide a patient with the name and phone number of the consultant.  MediCal, the California Medicaid program for certain categories of poor people, works the same way in our county but it is a bit more complicated.  Not all the consultants we regularly use accept MediCal referrals so the list of available consultants is limited. Glenda is playing what I think of as a game of "keep away" we play in our office.  The providers, knowing medicine but not the details of each health plan, send administrative work to the staff; Glenda and the rest put their stamp on the process and return the charts back to the doctors.  Eventually the game pauses, but right now Glenda is "losing" with over fifty charts on her desk.

My office, a small practice which I own and staff, has grown over the nearly 20 years I’ve been practicing family medicine in the San Francisco suburb of Burlingame.  At first I worked alone, delivering babies, assisting at surgery, rounding on my hospitalized patients, but always spending most of my time seeing patients in my office across the street from the hospitalOver time, in order to make sure that I could take vacation and to spread the overhead, the practice has grown and now we are a group of five part time physicians and two nurse practitioners supported by seven full and part time staff.  I am in the office four days a week but have managed to work it out so that I am in by nine and out by three or four most days.  The other providers work a similar amount or less.  Some have other jobs which fill out their schedule.  All but two of us have children and share parenting responsibilities with our spouses.  Except for me all the providers are women.  Family medicine, in our community at least, has been moving in that direction.  Women still tend to be the second earner in many families and so more seem to be willing to accept the relatively low salaries family medicine offers and are interested in flexible hours so they can spend more time with their families.

Shortly after I arrive and begin to call back patients who’ve left messages overnight Glenda comes by with a small stack of charts that have been giving her trouble.  A couple require a short letter from me changing the "diagnosis code" I used when completing a lab order form.  Some insurance companies, it turns out, do not pay for preventive screening tests, so when I ordered a cholesterol or a prostate cancer screening test at the time of a physical, the test would not be covered under a patient’s insurance policy.  Fortunately, the lab often catches these slips and notifies us so I can correct the "error".  For better or worse, the two patients’ whose charts she brings today have elevated cholesterol levels, so I feel honest indicating that fact in the letter, knowing that the insurance company will not balk at payment.

In our office we work with two outside labs which between them are contracted with nearly all the insurance companies we deal with.  The hospital-run lab is the most convenient, and we are required to use it for about half of our patients.  The other lab must be used by a small fraction of patients. Medicare patients and those with certain PPO insurances, can go to the lab of their choice but choosing one lab rather than another may result in a much larger bill for some patients.  We have a special deal with one lab where we have a list with prices far lower than they charge the insurance companies or the patients when they bill them directly.  That way, when we order a test that we know may not be covered by an insurance policy or if we have an uninsured patient, we can collect the discounted price up front and then the lab will bill us rather than the patient.

Unfortunately, one of the charts Glenda brings presents a little nightmare. Bridget Hanley (her name and the names of all patients in this essay have been changed and the details of medical conditions slightly altered to protect privacy) sent in her 21 year old daughter a few months ago for a routine physical.  During the course of the evaluation, a few tests were ordered.... a Pap smear, some S.T.D. tests, a cholesterol test, and two hormone tests.  Unfortunately, because her insurance had changed, the wrong lab was used and Ms. Hanley got a bill for over $1000.  That is a lot of money to the Hanley family and she is rightly annoyed.  I am too: at the insurance system, at the lab’s outrageous markups (if we had used our "special deal" the charges would have been only about $200), and at Ms. Hanley.  "Isn’t it her responsibility to know which lab her insurance requires her to use?" I think, upset that she was annoyed at me for this mess.  Nevertheless, I sit down and send my second email to the lab director pleading for her intervention in seeking a reduction in charges.

The private health care insurance system which we deal with every day is an insidious bureaucratic monster.  The morass of more than 1300 insurance carriers in this country introduces an administrative mess beyond belief.  In our small office of essentially two full time equivalent providers, seven full time support staff are needed to cope with the complexities introduced by this system. I am quite certain that the wasted effort this system creates is so great that if we had a unified system of health care I could see 10-20% more patients – with two fewer staff.  Looked at from another direction, at least 10-20% of my current income is wasted on insurance bureaucracy which benefits no one.  

By 9 a.m., the receptionist, Alba, has come in.  She is the newest member of our staff, brought in only last month when our primary receptionist, Evelyn, became ill,  requiring extended medical leave for breast cancer treatment at the same time as another staff member was scheduled to be out for maternity leave.  So the office is operating a bit understaffed these days.  Fortunately, Evelyn’s health insurance is through her husband’s large employer. He works as an animal care technician for a public university medical center.  As long as he works they are covered.  I try not to think what would happen should budget cutbacks lead him to lose his job.  The prospect is frightening for her, for her family of four, and for our office.  I certainly would feel obliged to add her to our office health insurance program should this occur.  But would the insurance company accept her?  What would happen to our premiums? Even assuming no rate increase, adding her to our policy would amount to about a six dollar an hour raise.  And what about coverage for her family?

The receptionist job requires her to verify each patient’s insurance status, checking lists, looking on-line, and calling for approvals as she confirms insurance eligibility and documents changes.  Missing an insurance change can have costly implications for both patients and our practice.  Between changes in jobs and employers changing insurance plans to save a few dollars in premiums, there is a surprising amount of "churn" among health insurance carriers.  For Alba, learning the details of this part of her new job has been a challenge.

Three medical assistants spend hours daily communicating with patients about medication refills and calling or faxing pharmacies.  Most insurance companies allow patients to collect only a one month supply of medication at their local pharmacies (three months if patients can figure out how to manage a mail order program).  The rule makes financial sense for insurance companies.  Why should one company pay for a year’s supply of medication if a patient may well switch insurance companies or lose their coverage after one month? Unfortunately, the rule doesn’t make sense for patients.  Studies show that compliance with chronic medications is abysmally low, in part because of rules like this.

The churn in insurance coverage as people move, change jobs, or suffer economic hardships which lead them to cut back on expenses introduces a huge set of problems for our little office, and wasteful costs for the medical system.  Easily half of the new patients we see explain their search for a new doctor (no small task in a community where primary care providers are retiring in far greater numbers than they are starting out) as the result of an insurance change.  So we often "reinvent the wheel", setting up a new chart, getting to know a patient, revising medications, reviewing old medical records, helping those with complex medical issues reestablish with new consultants.  The economic implications for the system are obvious.  

A serious related economic issue for our office sprang up this year.  My associate decided that she was feeling a bit overwhelmed by her patient load and so decided to close her practice to new patients.  This is a more complex and consequential process than it seems. Contracts with insurance providers often require an open practice or establish tiers of reimbursement based upon whether a practice is open or closed.  Further, in closing a practice, a wheel begins turning so that the closure is indicated in published listings and on line resources.  This process can be slow and then difficult to reverse.  Years ago I had closed my practice for similar reasons.  When volume dropped, I attempted to re-open.  Some insurance directories, however, lagged in updating these changes for years, leading to much frustration and some degree of financial hardship.

When my associate decided to close her practice, we settled upon closing only to those patients "provided" through our local independent provider association, an organization which manages insurance company contracts for doctors in our area and with which we have a good working relationship.  Gradually, over the course of a year her patient panel from this source dwindled from 1200 to 800 patients.  At that point, feeling the pinch of lost income to the practice, I asked her to reopen her panel.  We are largely paid by capitation, "per member per month" from these providers so this source of income had dropped by about one third.  She was shocked and appalled by the request.  Despite the closure of the practice and the substantial loss of income, her workload had declined only slightly.  How had this happened?

What we had experienced through this closure was the shock of "adverse selection".  By closing her practice to new patients, my associate lost from her capitation list those patients who bounce in and out of insurance, often healthy or more mobile people who don’t have regular need to see a doctor.  With capitation, a private insurance innovation, you payment is based upon the number of patients assigned to a doctor rather than upon the nature of the care required.  She was left with a group of patients who tended to be the ones who see her more regularly.  Hence, less income, same work.    

Of course, this process is something that private insurance companies play in reverse.  A great deal of insurance company money is spent attempting to avoid patients who could actually require medical services.  Underwriting, the process of selecting which individuals and business clients to insure and varying charges based upon assumptions of how much those clients will use their insurance is the backbone of the insurance industry.  Marketing, the process of selling insurance, has become a primary tool of this process.  Has there ever been an insurance company advertisement that encourages patients with serious chronic illnesses to sign up?  Instead, television ads depict elderly men walking on the golf course.  The idea is to create a "favorable risk selection", patients signing up for health insurance who are unlikely to use it; leaving  those who need it to some government-provided "safety net" or left to fend for themselves, uninsured.

My first patient of the morning is Uluake Tonga.  His English is not great, but we can get along.  We have known each other for nearly 20 years. Like most of my Tongan patients (there is a surprisingly large group of this nationality in this part of the San Francisco Bay Area) he comes with a family member who can help him translate.  His history is complex, as are his medical needs.  Briefly, he has diabetes and most of its complications.  Mr. Tonga has never been good at working with the medical system. A hard working airline food preparer at the San Francisco airport, he had for years denied his diabetes.  He believed in some natural medications and failed to see me very often.  I’ve long suspected that the expense of conventional medication was part of the issue.  He had insurance of the sort that required him to pay a significant deductible every year and when I took over his care from his previous doctor I noted that his chart had "sent to collections" stamped on it more than once.

Mr. Tonga first faced his diabetes in a serious manner when he was hospitalized for a vision threatening fungal infection.  Soon afterwards, because of  layoffs in the airline industry, he was without insurance and decided to return to Tonga for a few years.  Medical care in Tonga is free and while in the South Pacific he did get care for his diabetes and his blood sugar was finally controlled. Nonetheless Mr. Tonga returned with progressive disease.  Now, with kidney failure requiring dialysis, he is better about compliance with his care.  Maybe it is because the gravity of his disease is too much to ignore, but I suspect a lot has to do with the fact that his kidney failure now entitles him to Medicare benefits.

Medicare and its cousin, the Veterans’ Administration health system, contrast markedly with the bureaucratic inefficiency and buck passing of the private health insurance system. These systems, which share the fundamental features of centralized funding and near universal enrollment of the populations they serve, have shown that they can provide better quality care and higher satisfaction at a substantially lower cost than the private health system. Within these systems there are no resources spent on achieving a favorable risk selection, marketing, underwriting, investor relations; nor are there corporate profits.  As a health care provider, when I deal with Medicare I operate within a clear cut set of rules that applies to all my patients, making referrals, prescriptions, etc. easy to accomplish.  

When I see Mr. Tonga, or any of a multitude of other patients whose care has been compromised by the complexities, gaps in coverage, or the increasing unaffordability of private health insurance I wonder about alternatives.  Increasingly, I have discussed these alternatives with my patients.  During the course of an office visit or speaking to a patient over the phone problems which relate to the inadequacies of the health care system often arise.  In a typical day there might be four or five opportunities to discuss issues related to health care reform with my patients.  Yet despite the number of different health care financing reform proposals that are bandied about these days virtually all of my patients gravitate towards the same approach:  a simple and comprehensive health care plan paid for through taxes and provided through the network of private providers with whom they are familiar.

From my end, as a physician and small business owner, eliminating the multitudes of rules, the files of thick contracts, the variations in co-payments, deductibles, and  formularies, no longer needing to tell patients that they can’t see the provider I’d recommend because their insurance doesn’t allow it, seems like a dream come true.  I want to be confident that my employees have access to quality medical care, that I won’t have to be out shopping for a new plan next month, and that I won’t have to choose between a raise or medical benefits for my medical assistant’s newborn when she returns from maternity leave this winter.

But how do we get this done?  It doesn’t take much thinking to realize that the only proposal that makes sense to get what is needed is a single payer plan, a Medicare-For-All.  Other proposals, health savings accounts, consumer directed health care, managed competition, employer mandates, individual mandates or variations on these themes all promise benefits but suffer from failing to have the potential to achieve true universal coverage and from being hugely expensive because of their reliance upon private health insurance. While some of these variants have been subject to experimentation in the United States (the Massachusetts plan, most notably) only a single payer approach has been shown, in both the U.S. (Medicare) and abroad (throughout Europe and Canada) to actually work.  

A publicly financed decentralized system of private health care that is not tied to employment or "category" could eliminate the waste in the bureaucratic private health care system and eliminate the multitude of compartmentalized public and private systems which currently pay for segmented components of health care.  Imagine!! No need for Medicaid, MediCal, CHDP, SCHIP; a reduced scope for worker’s compensation insurance, medical liability insurance, and automobile insurance; human resource departments downsized.....the list goes on and on. Essentially an improved Medicare for all this reform would eliminate the distinction between health care for the poor and health care for the rich and reduce the confusion, waste, and annoyance which my office staff and I face in dealing with so many different health insurers.

A Strategy for Change

• Keep it simple.
• Include everyone.
• Support what you really believe in. Imagine, hope, and believe that change is possible.
• Listen to objections as expressions of fear.  Change may be possible, but it’s hard.
• Recognize and advocate for real reform from the perspective of values.  Single payer Medicare for All reflects the conservative American values of freedom of choice, inclusiveness, community-mindedness, and family.
• Emphasize the specific sources of cost savings in single payer reform, namely elimination of private bureaucracy, risk avoidance, and greed; and the reduction in other programs for providing health care benefits.  Repeatedly point to the savings that those who deal with the private health care system will achieve.
• Solicit and tell stories.
• Find a lead advocate from the worlds of business or finance to illustrate the prudent and conservative economics behind single payer.
• Enlist the support of business by funding the plan through taxes that are simple and clearly defined, and which replace other business expenses.
• Elaborate upon the difference between health care and other goods.  Health care is not something you can shop for in advance; competition in the insurance market operates in reverse, not as buyers look for product but as sellers look to select their buyers.
• Design the package of benefits so that there are no patients who are losers.
• National health insurance cannot be a second rate back-up plan.
• Private health insurance need not be outlawed, just made useless.

Something is missing in our political debate over medical care.  Over and over again I’ve heard people in power or those writing about the issue support the logic of the argument for single payer reform and then dismiss it without much consideration.  Barack Obama has supported this change in theory, but adds that we have to begin from where we are.  Jacob Hacker, the Yale and Berkeley political historian, seems resigned to the observation that fundamental change is just too hard.  His Healthcare For America proposal reaches towards a single payer system but undermines its cost-savings and universality by keeping a huge role for private insurance.  David Cutler, the Harvard professor most often linked with the Obama for President campaign, digs for hope that incremental changes in the health care delivery system will work and argues that the "Obama plan" that preserves insurance company waste and allows for continued corporate risk selection won’t require too much of a tax increase.  

A telling comment came from a member of the President’s Council on Bioethics, during their review of the ethics of health care reform proposals.  After commenting favorably on the powerful arguments with which he had been presented he demurred that these were "arguments that we are entirely incompetent to evaluate".  Another commissioner supported the notion of single payer reform but wondered, "if it’s not realistic in this country."   Even among advocates on the progressive side of the political spectrum there is a resigned assumption that single payer is somehow just too much of a change for our country to accept.

From my perspective in the trenches of primary care and small business, however, I can see no other way forward.  For my well-insured patients, a switch to single payer will hardly alter the face of the health care system they currently experience.  But it will reduce everyone’s level of economic and health insecurity.  None will need to worry if something is covered.  There will be no more holding on to unsatisfactory jobs simply to keep insured.  The process of paying for care will be simplified.

As a small business owner, I won’t have to worry either.  Some tax will be paid, a payroll tax, a value added tax, whatever .  But there will be no need to agonize over the question of which plan to choose and no more health insurance expense.  As I look at my office budget, the $36,144 that I currently spend on employee health insurance  is less than the $44,498.97 that I calculate would be owed under a tax of the magnitude contemplated by authors of single payer reforms. But when I add in reduced insurance-generated paperwork, reduced billing costs , and an increase in my own efficiency, this sounds like a reasonable deal for me as an employer – even without considering the improved care it would give to my patients and the increased mobility it would give to my employees who might seek to improve their lives by changing jobs.

From where, then, does the political and academic reluctance to embrace single payer reform derive?  There would be losers, of course, and this generates some focused opposition.  The health insurance business would be essentially eliminated, perhaps surviving as a remnant to serve as a data collection and money disbursement system.  Pharmaceutical companies and medical device manufacturers might feel the pinch of tough negotiations from a central purchasing center.  But the interests of patients and health care providers of all sorts are sufficiently aligned that having a single payer should not prevent us from getting the health care that we need.  Certainly the experience of other developed nations with national health insurance supports this conclusion.

The last great attempt at achieving a major overhaul of our national health insurance system-- the Clinton administration’s reform effort-- foundered for many reasons: It was developed among a group of interested parties, largely outside of the public eye, creating the impression that it was beholden to "special interests".  The plan was immensely complex and required the creation of new agencies to oversee the program which could be portrayed as "big brother"-like control.  This, together with provisions that employers must purchase private insurance for employees raised fears about potential costs.  Small business owners who have increasingly avoided purchasing health insurance for employees perceived themselves to be losers, while already insured employees in larger businesses feared the specter of managed competition and the reform proposal’s focus upon cost control would result in lower quality and reduced choice.

Now, circumstances are different.  The crisis has deepened, with a greater proportion of our gross domestic product going to support health care and insurance expenses, more uninsured, vastly more underinsured, patients feeling the pinch of health care plans with greater individual financial responsibilities, and providers increasingly frustrated by the complexities of dealing with the private health care system.  The reality of a Democratic administration with substantial Democratic majorities in Congress can finally provide a political environment where hope leads to action and action leads to change.

Politics, and political change, has been described as the art of the possible.  But what is possible only comes about when those who believe in the need for change act upon that belief.  Possibilities can be created.  Hope can lead to change.

A Physician’s Toolbook for Transforming Hope into Change

• Keep voter registration forms in your office.
• Ask about voter registration as part of a general history.  
• Call attention to where hassles dealing with the health care system or limitations imposed by insurance companies are caused by insurance companies’ attempts at limiting costs in a way that a universal payer would not.
• Fill the waiting room with literature describing the inadequacies of our current system, exposing alternatives, and calling for change.
• Join Physicians For A National Health Plan, educate yourself, and participate in advocacy for change.
• Don’t be afraid of partisanship.  

Originally posted to doctoraaron on Sun Dec 07, 2008 at 11:13 AM PST.

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Comment Preferences

  •  Look here for more (289+ / 0-)
    Recommended by:
    Serephin, Ed in Montana, Joe Bob, exsimo2, tmo, catdevotee, nolalily, hester, ogre, roonie, Geenius at Wrok, Gooserock, TrueBlueMajority, peglyn, lost, mem from somerville, ScientistMom in NY, janinsanfran, greenbird, JTML, LynChi, eeff, Bexley Lane, elfling, NCJim, 2lucky, grndrush, bigforkgirl, Polarmaker, rasbobbo, scribe, opinionated, EvieCZ, joynow, ReneInOregon, bronte17, JSCram3254, nyceve, Alden, CoolOnion, highacidity, Mlle Orignalmale, javelina, peraspera, oceanspray, FeastOr, dksbook, wader, Janet Strange, DustyMathom, worldwideellen, SneakySnu, MrSandman, emmasnacker, Dallasdoc, elmo, mad ramblings of a sane woman, TiaRachel, johanus, cosette, chantedor, 42, Bluehawk, lizah, Tillie630, inclusiveheart, barbwires, zett, ybruti, WV Democrat, kfred, parryander, JayDean, Daddy Bartholomew, snowbird42, Gowrie Gal, rapala, madaprn, tribalecho, historys mysteries, escapee, etocetoc, greycat, el dorado gal, UncleCharlie, PBen, offred, panicbean, dewtx, chidmf, figlet, jimreyn, GreyHawk, ladybug53, lotlizard, blue jersey mom, Cecile, Ozzie, Tunk, cerulean, TimeZoned, JanL, Ekaterin, psyched, thiroy, xaxnar, ThaliaR, Shirl In Idaho, Jennifer Clare, trashablanca, althea in il, BachFan, Icy, mjfgates, cybersaur, emeraldmaiden, Naranjadia, tonyahky, Ellicatt, compbear, Naniboujou, Alexandra Lynch, NBBooks, triv33, tecampbell, global citizen, erratic, Lashe, gooderservice, Bob Sackamento, SadieSue, imabluemerkin, FireCrow, JVolvo, happy camper, NearlyNormal, mcmom, Preston S, ER Doc, doinaheckuvanutjob, JugOPunch, profh, Persiflage, Clive all hat no horse Rodeo, va dare, kurt, MadMs, airmarc, drdana, FrankieB, Bernie68, ms badger, Leap Year, AmericanRiverCanyon, bigchin, One Pissed Off Liberal, phonegery, marykk, DorothyT, wa ma, JohnMac, dmh44, jarotra, mamabigdog, yoduuuh do or do not, FishOutofWater, LillithMc, Nespolo, kath25, Jimdotz, terabytes, joyful, drchelo, akdude6016, vbdietz, BlueInKansas, jnhobbs, electric meatball, Zydekos, willb48, roberta g, Red no more, BustaVessel, JDWolverton, ChocolateChris, Youffraita, lineatus, beltane, Haplogroup V, dewley notid, Ming Vase, ankey, home solar, mofembot, KttG, kyril, PMA, winterbanyan, AJsBodBlog, tlemon, luckylizard, mattc129, nzanne, wyldraven, MizC, dont think, Ellinorianne, Acugal, HoosierDeb, dmhlt 66, Tennessee Dave, cameoanne, SciMathGuy, Pris from LA, Menlo Park Mom, Psychotronicman, deMemedeMedia, no expert, eyry, be the change you seek, janmtairy, Eirene, WiseFerret, NYmind, Daily Activist, fokos, pnn23, allep10, I teach music, blueocean, Katie71, reesespcs, EmmaKY, Wings Like Eagles, ludlow, Emalene, Leftcandid, unfinished60sbusiness, sophistry makes me tired, Lazar, Norbrook, coppercelt, BasketCase, danbury6112, foolknot, Carrie Ann, ArtSchmart, Vacationland, wvmom, KS 65 woman, JellyBearDemMom, atxcats, Balanz, puffmeister, melpomene1, NY brit expat, tb mare, ItsSimpleSimon, aggie98, NYWheeler, cai, eyesonly, pateTX, debbieleft, OurFuturedotOrg, Betty Pinson, alethea, WedtoReason, USHomeopath, bottles, Taya Lawrence, renbear, gobears2000, Empehi1961, DParker, ginfizz, judybrown, kahunaloca, MemphisProfessor, BlueHead, skpow, Civil Writes Activist, blueinmn, A Bleeding God, 4JenTandT, Aprognosticator, giyoret, SusanL143, sjr1

    I'd also like to recommend the follow sites for further information about this issue:
    Being fair, here's the Obama website.  You may want also to comment there and provide the administration some of your thoughts.
    http://change.gov/...
    Here's the link to the Physician's for a National Health Plan site, the best overall starting place for those involved in advocating for real change.
    http://www.pnhp.org/
    Within the PNHP site there is a blog, largely made up of postings by Dr. Don McCanne, a brilliant analyst who provides a daily emailed "quote of the day" about health care financing, a must read.
    http://www.pnhp.org/...

    I'd love to see more links to sites readers think are important.

    Dr. Aaron Roland is a family physician in Burlingame, CA.

    by doctoraaron on Sun Dec 07, 2008 at 11:21:42 AM PST

      •  lots of excellent insights and a few big problems (4+ / 0-)
        Recommended by:
        wader, lotlizard, vbdietz, Balanz

        I was really enjoying this through the first 1/2 or so. doctoraaron points out many of the bureaucratic minefields that litter health care, a good chunk of them coming from the payment system.

        I do think it's important to point out a few significant problems with what he wrote:

        Capitation, as an idea, is older than health insurance itself (in the modern sense, since Bismark). Regardless of who invented it, nations with universal health care use it. The UK, for example, uses capitation for primary care in the NHS. So do you really mean to have a beef with capitation? It seems to work well in England.

        doctoraaron writes:

        only a single payer approach has been shown, in both the U.S. (Medicare) and abroad (throughout Europe and Canada) to actually work.  

        That is simply not true. The Netherlands, Germany and Switzerland have successful systems in which most or all insurance payments are from private payers ("private" here means non-governmental, it doesn't mean for-profit). They are heavily regulated non-profits, but the point is that these are not single payer systems. In addition, almost every country allows private insurers for supplemental or "premium"-level insurance. England, for example. France, for example. Most French have supplemental private insurance.

        We talk about zombie "facts" on the right that won't die no matter how many times they are refuted: Trickle-down ecoomics, tax-cuts for the rich as the solution to problems, Barack Obama is a secret Muslim, etc., etc.

        Each one of us on dKos needs to decide if we want to be part of the reality-based progressive community and call out the zombie "facts" on the left, or if we want to be one of the crowd reflexively stating the same old tired, refuted claims.

        Ein Mißverständnis ist es, und wir gehen daran zugrunde.

        by jd in nyc on Sun Dec 07, 2008 at 05:23:08 PM PST

        [ Parent ]

        •  jd in nyc, I know that you are very highly inform (13+ / 0-)

          ed on these topics, and I respect that, BUT

          When the terms of the patient/insured relationship are overwhelmingly regulated by a governing body -- as they are in the Netherlands and Switzerland -- I rate that as single payer. As I understand the law in those two countries, it is more accurate to say the terms of payment are set by the regulator rather than by the insurer OR the provider. That is the market clout of single payer. Providers cannot avoid dealing with the legally created body that sets terms of compensation for the care of nearly the whole population.

          Further, the insurer has to take me. They have to charge only a permitted premium. They have to cover a whole slew of illnesses and conditions. They can't exclude pre-existing conditions. The providers cannot charge me anything above what the regulator allows for the prescribed care.

          Okay, technically, the Swiss insurer pays the provider, not the regulator -- but that's a false distinction since the insurer did not negotiate the terms of the compensation -- the regulator did.

          Also, the Aetna and the HealthPlus people are going to fight the Swiss solution JUST as hard as the Taiwanese or Candadian solutions. So why tell Americans that the Swiss or the Dutch have a system that looks a lot like ours when they DON'T?

          •  The Swiss have a far more equitable (0+ / 0-)

            society than the US without the tens of millions of poor working people the US has.

            Poverty in the US is easy to find.

            Even the Dutch have a far fairer economic system.

          •  Not what I meant...will rephrase in the future (0+ / 0-)

            I actually didn't realize that I was coming across as saying that a successful multi-payer system would look much like ours does now.

            I had written another diary that gets into some of the differences that will have to exist here. I think you'll like the direction it takes...not that any of it was original with me. It's all pretty standard international managed care policy thinking.

            And you're right that the for-profit health plans are going to fight a system like the Dutch or Germans have. Non-profits (about 1/3 of all health plan members are in non-profits) have less reason to fight it.

            Here is what I really believe: we will not be able to make any dramatic changes to any part of our health care system in our first step at reform. By "dramatic" change I mean one that (a) totally reworks the process by which care is delivered and paid for and (b) institutes a system which is able to reduce costs (as opposed to reducing the annual growth in costs by a little).

            I think the only big splash we can make in 2009 is universal health care itself. We can't make a big reform to the system. We can make smaller, feel-good reforms like expanding HIT use. However, the creation of universal health care becomes the lever by which we can then make the other reforms to the system, one piece at a time. I'm actually working on a diary on that very topic.

            Ein Mißverständnis ist es, und wir gehen daran zugrunde.

            by jd in nyc on Mon Dec 08, 2008 at 01:04:58 PM PST

            [ Parent ]

        •  As a participant in German Health Care System (0+ / 0-)

          I can add that it works much better for all of us than the system in the US.  

          As a freelancer with better than average insurance (there are different levels) I still must pay a reasonably stiff monthly premium in comparison to my overall income.  

          Typically, employers kick in for those with regular jobs to mitigate the costs.  But regular jobs are becoming more difficult to come by.

          All in all, my costs today are half of what they were in the US in 2001.  The difference is made by the radical control of health care costs from providers and pharmaceuticals.  That must happen in the US no matter what.

          As a result of the controls, some german doctors are relocating to sweden where they make more money but most stay or go pure private if they have the reputation.  The majority complain yet have far higher than average incomes--and no med school loans to repay.

          •  Two Simple Rules (0+ / 0-)
            1. All providers must charge all recipients the exact same amount for the same services (and maybe a internet data base for those costs and services by provider).
            1. Private Insurance companies must reimburse providers for administrative costs and interest on delayed payments.

            Let's get rid of "cherry picking" and hidden or past on costs.

        •  I believe I read here on DK (0+ / 0-)

          that all the German Krankenkassen will be paid from a single source.

          The Swiss have a high-cost for Europe system to help even out risk that does much the same.

        •  True, But Largely Irrelevant (1+ / 0-)
          Recommended by:
          Chico David RN

          It is true that in many Western European nations sickness-fund payers are "private" in a formal sense, but the original poster's suggestion that these systems are in practice closer to single-payer national health insurance is far truer than the idea that these "private" payers resemble anything approaching U.S.-style private insurance. In fact, they're so different that they may as well be from a different planet.

          In Switzerland, probably the most private system in Europe, the government decides the benefit packages, sets the premiums, requires that the payers be non-profit, and mandates that risk-adjustment payments be made from one insurer to others. And its extremely hard to call these systems "successful" if you look at a cost-benefit analysis. Switzerland is second only to the U.S. in per capita spending precisely because it has a multi-payer system. The poster may not be technically correct, but he is far closer in practice to say that these systems are much closer to single-payer in that they have taken the fundamental step of regulating U.S.-style private insurance out of existence. The fact that these payers are formally "private" is largely irrelevant for the important analysis.

          •  yes, I know (0+ / 0-)

            And I'm fine with much greater controls on how insurers design products, compete, etc. I don't mean that we'll get to  successful system if all we do is emulated Massachusetts. That's not enough to streamline and safeguard the system.

            Ein Mißverständnis ist es, und wir gehen daran zugrunde.

            by jd in nyc on Mon Dec 08, 2008 at 12:51:44 PM PST

            [ Parent ]

            •  but (1+ / 0-)
              Recommended by:
              doctoraaron

              creating a whole new system which revolves around creating brand new heavily-regulated nonprofit entities that we have no experience with in our history is obviously more difficult than instituting single-payer, which involves only expanding the Medicare infrastructure we already have 40 years of know-how with. In addition, it is more wasteful and costly to have multiple payers.

              Nor do you get anything in the political realm. Private insurers are going to be no more willing to transform themselves into Swiss or German sickness fund than they are just to accept single-payer. They may as well go out of business. So this whole strain of thought that says because Europe has these patchwork systems with formally "private" insurers (none of these systems, by the way, were the product of conscious design) we should do the same thing here just makes no sense to me.

              •  just think for a minute (0+ / 0-)

                Why do most European systems have this "patchwork" quality and aren't the product of a single, overarching "conscious" design? Because it was easier that way! You tackle a couple pieces at a time in order to limit your opposition.

                And it will be easier to go that way with us, too.

                I'm sure you've read as much of the literature as I have, but I really do believe that it's nuts to think you can try a frontal assault on the richest, most bloated sector of our economy.

                It has been adding jobs even in this recession. That reveals a power in the ability of the players in this industry to demand increased revenue (or get it by hook or crook).

                When we talk about real reforms that drive our costs down (and quality up), you do realize that ultimately 80-90% of those savings are going to come out of the revenue streams of those outside insurance: hospitals, physician offices, home care, nursing homes, pharma, devices, etc. Even if the savings start from changing the payment system, this is just the mechanism by which to bring greater savings from the rest of the system. Which means jobs...by the millions....would be lost. And in many cases, hospitals could threaten to lay off workers even when they could instead stop the construction of a new wing or purchase of a new MRI....and who do you think the public will side with?

                I don't think you've seen what a fight against the provider lobby looks like. Try a frontal assault on it right up front, and you'll be slaughtered. So will healthcare reform.

                Ein Mißverständnis ist es, und wir gehen daran zugrunde.

                by jd in nyc on Mon Dec 08, 2008 at 05:48:39 PM PST

                [ Parent ]

                •  Wrong! (0+ / 0-)

                  You will rarely get what you need if you don't articulate what you need.  (My wife has told me this many times!) We should not throw up our hands before the battle has even been waged.

                  The fight, furthermore, is not against the provider lobby.  I am a provider, the hospitals are providers, the nurses are providers. Providers are stalwarts of the fight for single payer: http://www.pnhp.org/,http://nursingworld.org/...   The fight is against the insurers.  The insurers are middlemen who take our premium dollars and then keep a prodigious chunk in their efforts to minimize the amount they have to pay providers who actually care for patients.

                  The Obama team has asked us to-
                  http://change.gov/...

                  Sign up to host a health care community discussion over the holidays

                  Health care is a top priority for President-elect Obama, and he wants your help in reforming the system to provide quality, affordable health care for all Americans. That's why this holiday season, we're asking you to give us the gift of your ideas and input.

                  Sign up to host a Health Care Community Discussion anytime from December 15th to 31st.

                  We'll provide all our hosts with special moderator kits that will give you everything you need to get the discussion going. And Senator Tom Daschle, the leader of the Transition's Health Policy Team, will even choose one discussion to attend in person.

                  I say we take them seriously.  

                  I am going to plan a meeting with my patients and colleagues where I hope we will discuss problems and will dream, not about which plan we would like to see enacted but about how we would like to see our lives within the health care system.  I imagine that will lead us towards a proposed solution.  We shall see.

                  Dr. Aaron Roland is a family physician in Burlingame, CA.

                  by doctoraaron on Tue Dec 09, 2008 at 05:15:55 AM PST

                  [ Parent ]

                  •  that was deeply delusional response (0+ / 0-)

                    You will see how delusional when the fight over real reform happens.

                    If you think the AMA or AHA or any major healthcare lobby except the nurses unions wants single-payer, then, well, I give up. You will see.

                    And don't forget: 90% of the savings will come from those who supply the care, drugs and equipment, not from insurers. You seem to believe this is an opinion. It is not.

                    Ein Mißverständnis ist es, und wir gehen daran zugrunde.

                    by jd in nyc on Tue Dec 09, 2008 at 10:43:43 AM PST

                    [ Parent ]

                    •  The American College of Physicians (0+ / 0-)

                      which is the second largest physician organization after the AMA has already endorsed single payer.
                      And again, you are wrong about the source of savings.  At least in the initial years of reform, 100% of the savings will be from reduction in the administrative costs (profits, underwriting, marketing, product development, utilization controls, etc.) at the level of the insurers or from that imposed upon providers by insurers.  How's this for a fact:  Mass. General hospital has over 300 staff working on billing.  Toronto General, a hospital of equal size which operates in an environment of global budgeting and is thus relieved of the billing requirements which American hospitals face, has just two billing staff.... both involved in billing Americans who happen to end up in their hospital!

                      Dr. Aaron Roland is a family physician in Burlingame, CA.

                      by doctoraaron on Wed Dec 10, 2008 at 06:15:32 AM PST

                      [ Parent ]

              •  should have mentioned (0+ / 0-)

                I don't really think we should go the german route, since as you say there is an articificial element in fitting our insurers onto their system. Switzerland is closer, Holland in some ways is also closer (and better). But I do think we'll go our own way. I hope we borrow some of the better ideas from the Dutch.

                Ein Mißverständnis ist es, und wir gehen daran zugrunde.

                by jd in nyc on Mon Dec 08, 2008 at 05:50:40 PM PST

                [ Parent ]

                •  even a cursory glance at the european systems (0+ / 0-)

                  should prove that their patchwork nature wasn't in order to "limit their opposition." It was the product of the various historical circumstances that gave rise to them, from the guilds in Germany to the war in England. It had nothing to do with (perceived) political expedience.

                  What is obvious is that going "a couple pieces at a time" is absolutely useless as a reform strategy. Since 1970, Hawaii, Oregon, California, Minnesota, Illinois, Utah, Vermont, Massachusetts (twice!), Tennessee, and Maine have been among the states that have tried the "piecemeal" approach to universal coverage. All have failed miserably, because anything short of elimination of U.S.-style private insurance (which ALL eruopean nations have done) will be insufficient to provide any solutions, making real reform harder to get. Experience shows us that incrementalism just doesn't work.

                  As far as the futility of launching a "frontal assault," I remind you that the same things were said about the abolition of human slavery, the enfranchisement of women, civil rights, social security, minimum wage, etc. History teaches us that what's "impossible" today can change very quickly.

                  I also strongly disagree that reorganizing a for-profit dialysis center to give transplants to those who actually need it or to reorganize the health system to focus on primary and preventive care rather than on expensive interventions of dubious value is not a good reorganization of human labor. These savings are of the type that can easily translate into an economic stimulus that produces enhanced health outcomes rather than profits.

                  •  "historical circumstances" (0+ / 0-)

                    No nation that achieved universal health care had as large and entrenched a private insurance system as the US does. This is one of our unique "historical circumstances" that will be considered as we develop our way. But don't listen to me, listen to Daschle, Baucus, Obama, Clinton, Kennedy and everyone else who is pushing health care reform forward now. No one is working on single payer. It isn't going to happen.

                    State-based efforts failed for several reasons. As a rule, they don't even provide universal coverage, and states don't have the power to really reform the system because half of commercial insurance is governed at the Federal rather than the state level. I could go on.

                    As you must know, most European nations did cobble together their systems over time, with subsequent waves of reform. Their reforms were absolutely "piecemeal."

                    Ein Mißverständnis ist es, und wir gehen daran zugrunde.

                    by jd in nyc on Tue Dec 09, 2008 at 11:00:24 AM PST

                    [ Parent ]

                    •  The problem (0+ / 0-)

                      is that Obama, Daschle, Baucus (the king of corporate payoffs), etc. AREN'T pushing health care reform forward. They're pushing subsides to the insurance industry - certain failure - forward. And they're not even doing that very well.

                      If we measured social movements by what a bunch of senators think is possible, we would have missed abolition, civil rights, women's enfranchisement and a host of other social advances. Single-payer is being worked on by 90 Representatives, hundreds of unions, the national council of Mayors, and thousands of grassroots activists. On the contrary, no one is working on the ridiculous Obama / Baucus plans, other than a bunch of foundtations and imaginary coalitions with no real base (e.g. HCAN).

                      State efforts BY DEFINITION failed to provide universal coverage because incremental reforms BY DEFINITION fail to provide it. Its not any more complicated than that. It doesn't make any difference at what level health insurance is regulated, any of these states could have passed single-payer if "piecemeal" reforms were worth anything. They haven't because "piecemeal" reforms are useless.

                      •  time will tell (0+ / 0-)

                        Well, we'll see whether my approach works out or whether yours does....it may take us 20 years, but the truth will out.

                        I do have to say that I find something you said ludicrous, though:

                        State efforts BY DEFINITION failed to provide universal coverage because incremental reforms BY DEFINITION fail to provide it. Its not any more complicated than that.

                        In point of fact I know that Germany, Switzerland and the Netherlands for a long time had a mostly-universal system and gradually filled in the remaining gaps so that now they are 100%. So that is definitive contradiction of your definition.

                        More generally, what you said is literally non-sensical. It's not even clear what you are trying to say, or what reasons there could be for saying it. Is it impossible to get universal sufferage incrementally? (We did.) Is it impossible to protect the environment incrementally? (How could we do otherwise?)

                        And how could it possibly be a matter of definition? If it is, then what do the key terms mean to you, such that there is no logical possibility for a reform which is incremental and provides universal coverage (as putting in the keystone completes an archway).

                        Ein Mißverständnis ist es, und wir gehen daran zugrunde.

                        by jd in nyc on Tue Dec 09, 2008 at 03:36:34 PM PST

                        [ Parent ]

                        •  we've already had 20 years (0+ / 0-)

                          to see whether your piecemeal approach would work. Hawaii claimed to have instituted universal coverage in the 70s.

                          And as I've already said repeatedly, the countries you mention already took the fundamental step of eliminating U.S.-style private insurance, which is the critical difference between your plan and single-payer / Europe...the very reason I said the difference between single-payer and those systems was irrelevant in the first place. I don't know how many other ways I can explain it to you without drawing you a diagram. Europe / Single-Payer = No US-Style Insurance. Want to eliminate private insurers? Fine. That's good incremental. But you might as well go to single-payer while you're doing it, because the German/Swiss/Dutch system is no more politically feasible and costs more. I'm out of ways to explain this concept to you. No reform that preserves private insurance will provide universal coverage. The wealth of experience, both domestic and international, confirms this.

        •  I think you are right on (0+ / 0-)

          I was wrong to say only a single payer plan has been shown to work.  The tight regulation in Germany, Switzerland, and the Netherlands has resulted in functional systems with near universal coverage.  Perhaps something like this might work in our country, but I suspect Medicare For All would have greater appeal and be less subject to debasement during times of political change.  The simplicity of Medicare for All has "legs" while tight regulation is even less likely to gain political traction than a more comprehensive overhaul.

          Dr. Aaron Roland is a family physician in Burlingame, CA.

          by doctoraaron on Mon Dec 08, 2008 at 10:00:26 PM PST

          [ Parent ]

    •  Excellent. Thank you for explaining (17+ / 0-)

      what happens behind the scenes in our family doctor's office, which is very similar to your situation.

      I think, therefore I am. I think.

      by mcmom on Sun Dec 07, 2008 at 02:06:10 PM PST

      [ Parent ]

      •  When I was growing up, (4+ / 0-)

        our family pediatrician's office had 2-3 doctors, 1 nurse, and one front office manager, who handled reception, scheduling, and billing.

        The family practice doc I see now? His office has 1 doctor, 1 nurse, and FOUR front office ladies, most of whose time is spent handling insurance. I really don't know how AHIP and these other insurance-industry interests can even pretend that the current system is in any way efficient. Such a colossal waste of time and money - dealing with literally hundreds of different insurers and plans.

        We know why Republicans don't ever want universal coverage to pass. Once Americans get a taste of what other civilzed countries have, we will never give up affordable coverage and the almost complete absence of haggling/paperwork/preapprovals/etc. (Note: I have lived in 2 countries with universal care.) If Democrats pass this, I have a feeling the GOP will go even further down the tubes.

    •  Thanks, Doc (16+ / 0-)

      I've been wanting a single-payer system for a long time.  I think health care should be paid by all of us, collectively, as we pay for any publicly owned utility.

      When I go on vacation or lose my job, it should be there, just like water from the tap.

      When I travel, I don't have to ask, "Can I get water in your city?"  So, I shouldn't have to ask, "Does your city have a doctor on my plan, just in case I need one?"

      Health care should be there for everybody, no upfront cost, because we all pay for it together (either that, or pay for it out of the defense budget by not authorizing any more purchases for planes the Pentagon doesn't even want, like that $63 million dollar plane that doesn't fly.

      In TX-32, track the voting record of Pete Sessions at SessionsWatch.

      by CoolOnion on Sun Dec 07, 2008 at 02:11:57 PM PST

      [ Parent ]

      •  Health care like a public utility (0+ / 0-)

        We pay for the installation of the utilities through taxes, but we pay for our actual use of utilities. What do you think would happen to water, electricity and natural gas usage if it was not paid in proportion to your usage? How might that relate to health care?

        What mechanisms would have to be put in place to control costs?

        One of the benefits of nationalized health care is preventative care. Do you believe that people will really use preventative care?

        Most preventable diseases are caused by a bad diet and lack of exercise, how will we fix those with nationalized health care?

        Im not against it, Im just skeptical that it will really fix our overall health problems.

        •  Utilities -- not the same (2+ / 0-)
          Recommended by:
          happy camper, Leap Year
          1. you don't have to get a prescription to turn on your lights. Providers are gatekeepers to how much medical care you need or should get.
          1. Public health benefits. Access to care means longer life and better health.  Smokers who see their docs gets info about how they need to quit, encouragement, cessation prescription. Overweight people get information, encouragement to eat healthy, referrals to dieticians. It's no accidenct that highly insured people in the US are far less likely to smoke and are proportionately less overweight than the chronically underinsured.
        •  Controlling costs (2+ / 0-)
          Recommended by:
          Ozzie, happy camper

          For starters, we can slash a good 20% or more by removing insurance industry profits and overhead. This is not a secret. I suggest reading articles by Ezra Klein, or nyceve's diaries here about how much money is wasted by having for-profit middlemen control the distribution of health care. Private insurers are not more efficient; they just siphon funds from both care providers and patients.

        •  The issue of prevetive care is complex (0+ / 0-)
          and admittedly will take some work.

          It is highly likely that a "build it and they will come" approach will fail.  There are a series of steps that need to be taken for preventive approaches to alter the curve on health care expenditures.  Clearly, the first of these steps is to establish a mechanism for reimbursement of professionals who engage in a preventive approach to health care.  Without this step, others steps are likely to be meaningless.

          After we take the step of incentivizing physicians to engage the patients in preventive/wellness care, we must make it socially and financially possible for patients to engage in the behaviors that accompany prevention.  More than that, we must make it socially unacceptable to engage in behaviors that increase the risk and cost for the rest of us.  This will take a combined carrot/stick approach, and some real social change.

          Allowing patients to share in the financial benefits of preventive care will also go a long way toward incentivizing the behaviors we wish to encourage.

          Pulicizing (anonymously of course) the successes and failures of this approach will help to ensure that the public gets the message about how this directly affects their lives.

          Disincentives (such as going to the "back of the line" to get care for the illnesses that you brought on yourself) may also play a role.  These will need to be administered with great caution.

          It's too bad the school of hard knocks gives you the final exam before the first class

          by Imavehmontah on Mon Dec 08, 2008 at 07:04:54 AM PST

          [ Parent ]

    •  Thank you! (14+ / 0-)

      This took some time to write, and I just want to thank you for doing it. This is the most important issue facing us today.

      One thing I'd like to add is that lack of appropriate health care for any of us affects all of us when it comes to communicable diseases. Because many preventive measures commonly utilized by americans with insurance coverage are rendered pretty much ineffective in the presence of overwhelming infection of someone who can not afford appropriate health care.

      Currently, there are several metropolitan areas struggling with measles outbreaks-this occurs wherever those who cannot afford healthcare come into contact with immunization non-responders (5% of all who receive measles immunization do not develop immunity). If we had a universal payer system, people who are sick would seek treatment promptly, so there would most likely be fewer sick people to act as vectors for disease in the general public. In this scenario, outbreaks of serious communicable dieases would be much less likely to occur.

      It's very sad that many physicians continue to frighten patients about single payer systems "they're trying to take your freedom!" or "Canada's heathcare system is terrible! Their citizens come to the US to get decent care!" It's disgusting.

      Here's my own solution: nursing as a profession needs to take up this cause because there are many, many more nurses than doctors, and nurses spend more time with patients.

      It could be one of the most important patient education topics we ever teach.

      Thank you, thank you, thank you,

      NC Yellowdog, RN

      Tarheel born, tarheel bred! And when I die, I'll be tarheel dead.

      by NCYellowDog on Sun Dec 07, 2008 at 02:55:13 PM PST

      [ Parent ]

    •  Great job (1+ / 0-)
      Recommended by:
      happy camper

      I was a lawyer in private practice for a while, even though it is much, much less cumbersome than being a MD it was still a pain. As a Public Defender, I have an awful caseload, but can concentrate on being a lawyer.  I think most Doctors would like a similiar, though certainly not identical, system.

      (-7.0, -6.4) "I said, 'Wait a minute, Chester, you know I'm a peaceful man.'" Robbie Robertson

      by NearlyNormal on Sun Dec 07, 2008 at 04:55:25 PM PST

      [ Parent ]

    •  I had a similar experience 20 years ago (5+ / 0-)

      when I left the group that was employing me and took over their office in the small town where I'd been spending about 80% of my time. As a solo practitioner, I was working with two full-time and two part-time staff, and, due to the low reimbursement level of Medical Assistance and the efforts of the insurance companies to minimize reimbursement, everyone in the office was making more money than I was. I stuck it out for two years, surviving largely on part-time emergency department work (I'd spent five years in full-time emergency medicine after my residency before I moved closer to family in the Midwest). In part, I'm sure my problems were due to my inexperience in dealing with the bureaucracy. After I closed the office, I worked for in family practice for four more years before the group where I was working sold out to the group I'd originally left. I've been in full-time emergency medicine since.  

      -5.12, -5.23

      We are men of action; lies do not become us.

      by ER Doc on Sun Dec 07, 2008 at 05:07:12 PM PST

      [ Parent ]

  •  While you're being so thorough and forthcoming (13+ / 0-)

    Could you outline for us in rough percentages how your gross billing splits out into things like practitioner compensation, staff compensation, advertising, malpractice insurance, health insurance, general liability insurance, continuing education, supplies, uncollectable accounts, rent, profit, etc?

    I'm particularly interested in the percentage for malprac, but really all the major categories help us readers get a better understanding of a family medicine practice of your size.

    Republican politicians tell us that malprac  insurance is the big killer expense in medical practice today, but I've seen on dKos where another doc said he paid far less for that than for staff to interface with insurance companies.

    Hey, Wolf. DailyKos is the Best Political Team on the planet.

    by Alden on Sun Dec 07, 2008 at 11:29:48 AM PST

  •  Stop Dancig Around The Issue (1+ / 0-)
    Recommended by:
    ladybug53

    If doctoraaron is truly a doctor then he no doubt is closer to the issue than I am, and I thank him for his long post.  Maybe someday I can find time to pick thru the thing in order to make any sense of it.  

    There have been a number of proposals to reduce the cost of healthcare and to make it accessible to everyone, but I have noticed only two that I feel really address the true issue, the cost to the provider of giving us healthcare.  All other proposals seem to dance around the issue.  

    I did not vote or participate in his poll because it is not that simple in that there may not be a one size fits all solution for the issue.  Such thinking is typical of the Bush admin. in much of its policy, and maybe that is the best a high level office can offer.

    Reducing the cost of malpractice insurance and suits is a true reduction of the provider's cost of delivering healthcare. Gee, we cannot do that becaue then there would be high priced lawyers in the breadlines.  Those bozos make big bucks of four misery and off doctor's mistakes so we need a system that cuts them out of a piece of the pie. Buying lower cost meds from foreign suppliers also address the cost of healthcare.  Rotsa ruck on passing that one, what with the strong pharma lobbies.  All of the above are worth pursuing but has anything happened over the past 50 yaers? Isn't it time we go creative and took a new approach to the issue?

    How about lowering the cost to the provider of skilled labor, meaning doctors, PAs, Nurse Practitioners, Xray techs, Lab techs, and even administrative personnel who need special knowledge and skills to function well in the doctor's office, clinic, or hospital?

    I have some specific ideas on this approach if anyone cares to listen.  How about it? It won't fix all our ills but it might be one big step forward for a change.

    •  It is not really practical (16+ / 0-)

      to reduce the hourly cost of most individual skilled human providers. Nurses generally are not overpaid. Family doctors are rarely making out like bandits nowadays.

      One could use more nurse practioners and fewer doctors.

      One could also introduce pricing reforms such as the French conventionnel (?) system where providers  voluntarily choose to accept the government price list.

      One could require public posting of a provider selected Medicare multiple (say 1.3) so many non-Medicare sick people can price shop.

      The best way to cut costs is to simplify the administrative requirements at the office level.

      If the patient doesn't pay, the patient's Social Security account could be debited or the government could pay for the office visit.

      Drugs could be priced and paid at the national gross cost level so doctors could simply prescribe what they think is best.

      Deductibles could be largely replaced with test cost co-pays.

      •  or reduce the cost of education (3+ / 0-)

        If we want more doctors, or more of certain types of doctors (like general practitioners), reducing the cost of medical education would be a good place to start. It's commonplace for new MDs to come out of med school with over $100,000 in student loans.

        If one's doctor is carrying a $1200/month student loan payment you can be sure that cost is covered somewhere in what you are paying: either directly through your premium, or indirectly through your inability to find a primary care doctor (or get an appointment with the one you have).

        Outside of a dog, a book is man's best friend. Inside of a dog, it's too dark to read. - Groucho Marx

        by Joe Bob on Sun Dec 07, 2008 at 05:07:41 PM PST

        [ Parent ]

        •  Yes, a very important factor! (5+ / 0-)

          In most civilized countries, medical school is free if you are qualified. Thus doctors don't start practice with a giant debt.

          Also, (and I am biased because I'm an RN) nurses are a vitally important part of an effective and efficient health care system. The NIH used to give gifted nurses scholarships to graduate school, so that they could become nurse practitioners or anesthetists. Most nurses today can't afford the tuition to study for advanced degrees. Nursing salaries have not even kept up with inflation.

      •  Reducing the costs of providers (0+ / 0-)

        My proposal effectivly reduces the cost of entry level hourly workers who are taking part in a contractual agreement to work for
        their education. The technician that xrayed my shoulders is living proof that it can be done.  She was in a training program and did actual hands on work as part of her OJT.  At first her wages were low after completing the course but in time they came up very well.  

        The trick is to keep enough trainess going thru the system and doing hands on work as part of their OJT, at a lower rate than they would receive as a fully qualified provider in their own career field.  The army does it, the air force does it, the VA does it, so why can't the private sector do it?

        Given supervision, a trainee can do many things that a doctor might do in civilian life.  I had an airman trainee remove a fibric cyst from my groin under the supervision of a sergeant at sick call one morning.  He gave a local anesthetic, surgically removed the growth with a scalpel,and then sewed up the wound.  On another occasion an airman, called a corpman in the army, opened some blisters on my scrotum.  That time he had no supervision, and I am still here to tell about it.

    •  You're indicating a common fallacy. (34+ / 0-)

      There's this notion that if we could simply reduce the cost of malpractice, or of ancillary services, or of the old straw man "waste, fraud and abuse", our cost problems would be solved.

      It just ain't so. The large majority of the rising cost of medical care is simply due to...providing more care. I'm currently treating an unfortunate fellow with advanced metastatic cancer. He's relatively young and wants everything done. Twenty years ago we couldn't have done much. But he's recieved more than a year of aggressive (i.e., expensive) chemotherapy and a range of surgical procedures to keep him going. That's surely his prerogative, and he was fortunate to be well insured. But the total cost would simply take your breath away. Likewise for all the 80+ year old patients receiving extremely expensive (like $27,000) pacemaker/defibrillators to treat ischemic cardiomyopathy. Yes, evidence suggests this will extend their life expectancy by a measurable amount. But is it a wise or cost-effective way to spend the taxpayers' money? Personally I don't believe so. For every Medicare recipient who gets a $27,000 pacer/defibrillator, there are dozens of uninsured or underinsured 40 - 50 somethings who don't recieve appropriate treatment for diabetes, hypertension or hyperlipidemia, which puts them on the fast track to...that $27,000 pacer/defibrillator when they're 66.

      In America we still routinely provide extremely expensive hemodialysis to frail 80+ year olds with limited life expectancy. Until we're ready to have an honest national conversation on this, we'll keep "rationining through being uninsured".

      •  "ischemic" (0+ / 0-)

        means not enough blood flow I believe

      •  The government could allow (0+ / 0-)

        cholesterol tests periodically above a certain age and allow the doctor to issue an open prescription for a statin.

      •  Drug stores have free machines (0+ / 0-)

        that allow one to check one's blood pressure.

        •  A two litre Pepsi is a perfect fit. (0+ / 0-)

          "Never get out of the boat."

          by tlemon on Sun Dec 07, 2008 at 12:24:06 PM PST

          [ Parent ]

        •  And it's been proven that they are ... (2+ / 0-)
          Recommended by:
          Sychotic1, inclusiveheart

          ... rarely accurate.

          "Imprisonment... is a series of cubes!" ~ Sen. Ted "Toobz" Stevens (AK-Felon)

          by The Werewolf Prophet on Sun Dec 07, 2008 at 03:26:55 PM PST

          [ Parent ]

          •  But hey, they make SingleVoter feel better (0+ / 0-)

            so let's spend hundreds of millions of dollars funding them across the country rather than freakin' treating people who are sick!  /s

            •  ::Waves to inclusiveheart:: (1+ / 0-)
              Recommended by:
              inclusiveheart

              You get the feeling that SingleVoter is an AHIP troll? Or a freeper?

              "Imprisonment... is a series of cubes!" ~ Sen. Ted "Toobz" Stevens (AK-Felon)

              by The Werewolf Prophet on Sun Dec 07, 2008 at 04:05:40 PM PST

              [ Parent ]

              •  I do get that feeling. (0+ / 0-)

                Oddest chain of comments I've ever seen.  Who needs docs when we can do it ourselves?

                America to the world: Does this make up for the last eight years?

                by althea in il on Sun Dec 07, 2008 at 04:09:39 PM PST

                [ Parent ]

                •  I do it myself (0+ / 0-)

                  as millions of Americans must.

                  •  Until there is such severe pain from an (2+ / 0-)
                    Recommended by:
                    Sychotic1, Alexandra Lynch

                    ailment that you run screaming to the nearest healthcare provider to figure out what the problem is and how to fix it.  Or you just drink or get prescription or other illegal drugs from your friends and you miss out on the potentially simple cure or management approach that someone trained could provide to you.  

                    This game of withholding the wisdom of the medical profession from those who cannot pay the highest rate is not only wasteful, but also completely self defeating for us as a nation.

                    •  The recommended treatment for (0+ / 0-)

                      appendicitis is surgery.

                      There is normally epigastric pain followed by pain in McBurney area.

                    •  Denial is a powerful part of behavior (0+ / 0-)

                      Probably the biggest contributor to complications.

                      Denial is a large part of the reason that physicians should not try to provide their own care or for those they are emotionally attached to.

                      Denial consists of fear, rationalizations, disruption of one's normal life, giving up autonomy, financial incentives.  I gladly pay a professional to help me sort through my illness because I know that I cannot overcome my own denial.  And I have years of training and practice experience.

                      What I object to is when the professional I ask to help me is perversely motivated by fear and greed (provided by insurance companies, malpractice risk, or poorly conceived regulations).  This is one of the areas where a well administered single payer system can go to great lengths to reduce perversity and improper incentives.

                      It's too bad the school of hard knocks gives you the final exam before the first class

                      by Imavehmontah on Mon Dec 08, 2008 at 07:18:05 AM PST

                      [ Parent ]

              •  SV and I have been talking all day. (2+ / 0-)
                Recommended by:
                wader, EmmaKY

                I started a thread about SP Universal HC in bonddad's diary early today and SP had a few comments.  I haven't a clue what motivates him or her to make the comments I've read.  

                My favorite comment though was something along the line of "I remember getting shots in elementary school".  In response to a discussion about preventative care as it relates to controlling communicable diseases.

                Trully profound.  lol

          •  They seem to be repeatable (0+ / 0-)

            in that I can repeat the testing and get a closely related result.

          •  They can be inaccurate (0+ / 0-)

            if the person moves or if the cuff size is wrong.

            http://www.medem.com/medlb/article_detaillb.cfm?article_ID=zzzvv6dwglc&sub_cat=74

            I disagree with the rarely bit.

            Don't confuse these machines with the finger type machines.

            The drug store machines bear instructions to not move if I remember right, so follow the instructions not to move.

            Old photographs prove human beings can hold still.

            The cuff size probably is appropriate for well over half the population.

            However, for many people who one might suspect might have high blood pressure due to fat arms etc., the cuff size may often not be right. Running multiple tests to get consistent test results would be wise for these folks.

            Blood pressure taken at home may be slightly lower than that taken in the doctor's office.

            Would you care to explain that quoted text?

          •  They are never calibrated, (2+ / 0-)
            Recommended by:
            wader, Sychotic1

            ever.

            The manometers on bp cuffs need to be recalibrated yearly.

            Tarheel born, tarheel bred! And when I die, I'll be tarheel dead.

            by NCYellowDog on Sun Dec 07, 2008 at 06:58:32 PM PST

            [ Parent ]

      •  Drug store cashiers could (1+ / 0-)
        Recommended by:
        Gravedugger

        throw in a card with a diabetes urine test strip into the plastic bags of middle-aged shoppers.

        ...if the strip turns like this, you should see a doctor...These doctors are offering a discount diabetes evaluation for only....

      •  So you'd opt for elderly people going (7+ / 0-)

        without pacemakers and potentially ending up in the emergency room numerous times instead?  Or just say, "tough - you're gonna die from SCD - could be tommorrow - could be years from now - see ya"?  Is that a way to keep people independent and productive in their later years?  And what of the advances we make in both preventative and direct care for diseases by treating patients?  I worked with brain cancer patients and docs at one time - the insurers sure as hell take your POV that six months is not enough life benefit for someone to spend the tens of thousands of dollars on those patients - and yet as time goes on - we are learning more and last chart I saw several years ago now - we have been slowly but steadily increasing the average lifespan through the trial and error of treatment.  Are we going to walk away from potentially being able to learn enough to find a cure because of the cost "benefit" mentality?

        I don't know.  I'm all for physicians being practical and prudent, but your post kind of crosses a line imo.  Maybe I'm just sensitive because I was kind of excited about the fact that we had come so far in heart disease treatment that people like my Grandaddy are less likely to drop dead of a heart attack like he did when he was 59.  That was a big loss for all of us.  I'd like to think we've gotten to a place where fewer families would endure that hardship.

        •  Love to understand your position better (16+ / 0-)

          but I'm really confused.  My position would not at all result in delays of care or rationing.  All I'm saying is get the waste out of the system, the waste that the private insurance industry creates.  We need a publicly financed system of privately delivered healthcare.

          Dr. Aaron Roland is a family physician in Burlingame, CA.

          by doctoraaron on Sun Dec 07, 2008 at 01:04:53 PM PST

          [ Parent ]

          •  This is what I am responding to: (1+ / 0-)
            Recommended by:
            hester

            Likewise for all the 80+ year old patients receiving extremely expensive (like $27,000) pacemaker/defibrillators to treat ischemic cardiomyopathy. Yes, evidence suggests this will extend their life expectancy by a measurable amount. But is it a wise or cost-effective way to spend the taxpayers' money? Personally I don't believe so.

            •  future FDA approval pacemaker price list (0+ / 0-)

              Age 65 and under, good general health $18,000
              ...
              Age 80 or greater, poor health $1,500

              •  I'll bet you're in your 20's, in ... (1+ / 0-)
                Recommended by:
                Alexandra Lynch

                ... excellent health, and really self centered, aren't you? Either that, or you're an AHIP troll.

                "Imprisonment... is a series of cubes!" ~ Sen. Ted "Toobz" Stevens (AK-Felon)

                by The Werewolf Prophet on Sun Dec 07, 2008 at 03:16:27 PM PST

                [ Parent ]

                •  The price of a pacemaker (0+ / 0-)

                  should include the maximum expected probable cost of removal and replacement.

                  A 60-year healthy person will be expected to live longer than an 80-year old sick person, so the probably of having to pay for a replacement is greater, so the price should be greater.

                  Note that I wrote "FDA approval" and not HHS approval.

                  The time for price control is at the FDA stage.

                  Once the "cat is out of the bag" with "FDA approval", there is no voluntary legal price control scheme possible with respect to the device maker.

                •  huh? how is this a reply to SingleVoter? n/t (0+ / 0-)
            •  Saving money in the wrong places can cost you (2+ / 0-)
              Recommended by:
              wader, inclusiveheart

              It may or may not be.  And there may be cheaper ways to get the same outcome.

              But tight controls have costs of their own.  They're more intrusive on doctors.  And sometimes, the doctor is right, and it turns out the non-standard treatment will turn out to be cheaper over the life of the patient.  And the same tight controls may prevent flexibility that improves outcomes, and makes the system better both for patients and practitioners.

              But the bigger problem is that you're focusing on the wrong problem.  The big costs are catastrophic care and end-of-life care.  Preventative medicine can make a huge difference in costs over the life of the patient, and globally in the whole system.  So you are putting a lot of inflexibility into the health care system without having the hope of getting great improvement out of it.

              A lot of statistics back this up, it turns out.

              "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

              by mbayrob on Sun Dec 07, 2008 at 03:09:13 PM PST

              [ Parent ]

          •  You want the multi-billion dollar insurers to.... (0+ / 0-)

            reap windfalls in the new system?  Why?  So they can take those billions and spend them on credit-default swaps and other risky investments.....and then request a bailout like AIG?

          •  We are with you doc. I have had more than (2+ / 0-)
            Recommended by:
            lotlizard, Alexandra Lynch

            my share of family members treated to death and I for one would like to think that sometimes the kindest treatment is limited in nature especially for older patients.  Unfortunately family members are not always the best judge because they feel so guilty and want to much to hang on to a loved one.  We as a culture need to come to grips with our mortality and maybe accept that just because a thing can be done doesn't mean it should be done.  We put doctors in a very hard place because we refuse to deal with our own mortality.  

        •  I'm with inclusiveheart (12+ / 0-)

          It seems to me that this "cost benefit" model doesn't belong in medicine.  First of all, it's easy to wonder about a pacemaker in a 80-plus patient.  Everyone can think of the so-called "bright line" patient, where the utility of the treatment does seem to beg the question.  Unfortunately, most of life, and decisions about the quality of life, are subjective.  That young man with metastic cancer, who has good insurance, wants everything done.  Isn't he entitled? That woman with metasized breast cancer wants a few more months so she can see her son graduate from college.  Sorry, too expensive? And it seems to me insurance companies LOVE this kind of analysis.  And it is not because they are going to use the money to help someone uninsured.

          Great Britain has been struggling with this as to drugs and oncology patients, with limited success.  And, if the diarist is right, the major hassle is dealing with the insurance bureaucracy, not with giving the care.

          I am one of those people my insurance company would LOVE to see die a quick death.  I am an expensive consumer of healthcare.  But I have a good policy, one I pay a lot of money for every month.  I have kept my end of the bargain.  I expect the medical professionals to keep theirs, and not decide that someone else is more deserving. I didn't ask for the chronic conditions I have. I am more productive than a lot of people.

          We do not rent rooms to Republicans.

          by Mary Julia on Sun Dec 07, 2008 at 01:17:22 PM PST

          [ Parent ]

          •  You know, the reality is that not everybody (4+ / 0-)
            Recommended by:
            hester, elfling, Mary Julia, Naniboujou

            who is offered a pacemaker is going to take one either.  Some people do choose to opt out and take their chances.  In fact where it comes to ICDs a lot of people don't want them implanted for various reasons.  People make personal choices about their healthcare decisions.  All I ask is that they get a fair shot at making the choice.  

            In any case, I'd have to go back to an old computer and look through a stack of medical papers to confirm, but I am pretty sure that the percentage of people getting ICDs in their 80s is extremely small - miniscule.  There is a point at which the implant surgery becomes too dangerous because of aging.  If you're 80 and your body is as healthy as a 60 year old, you might get one, but not if you're too frail and the procedure could result in harm.

        •  Every industrialized nation rations care. (16+ / 0-)

          Here in America, we ration care in the most grotesque and immoral way imaginable: based on personal wealth and the capricious nature of employer-sponsored insurance. Realistically this means we are on the verge of a new wave of horrific cost-based rationing as millions of newly unemployed folks lose their insurance.

          In England, this rationing is explicit and far more ethically defensible. As in, octagenarians are generally denied hemodialysis. It's costly, it's painful, and it adds very little longevity relative to the cost. Likewise, England restricts non-emergent coronary bypass operations to patients who don't smoke. If you refuse to quit smoking, they feel it's not the taxpayers' duty to bail you out of your own folly. You can argue with this, but it's all explicit and above board.

          In Japan it's the same. Very aggressive surgical procedures and implants are generally not pushed on frail elderly patients with limited life expectancy.

          Speaking as a family doctor, here in America we frequently torment frail elderly patients by performing endless aggressive interventions when a far more rational and humane approach would be to provide palliative care and comfort measures. How much good are we doing when we perform heroic surgery on 87 year old Alzheimer's patients who no longer recognize family members? Yet we do this every day.

          •  Even so, rationing can be more or less rational (2+ / 0-)
            Recommended by:
            elfling, inclusiveheart

            The UK system is particularly aggressive in examining the system for ways to get the same outcomes for less money.  The good news is that it really does work -- they get better outcomes than we do in the US, for a fraction of the cost.  The bad news is that the system can be a pain-in-the-ass.

            It turns out, though, that even systems that are less careful about "rationing care" are cheaper than ours, and have better outcomes.  That takes some explaining.

            Doctoraaron shows some of the reasons.  The direct cost of the bureaucratic buck-passing (seven admins for five part-time providers, to start with), and the indirect costs of patients falling between the cracks and not getting good management over the course of their lives dominate the cost savings you get from rationing.  Rationing can be the right thing to do.  But the real savings come from having a healthier population.

            "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

            by mbayrob on Sun Dec 07, 2008 at 03:15:54 PM PST

            [ Parent ]

          •  My Grandmother died of congestive heart (8+ / 0-)

            failure at 89.  My Grandfather on the other side died of liver cancer a few weeks short of his 90th bithday.  In neither case, did anyone suggest that we engage in heroic measures or experiments that would never have brought them back to a healthy status at that point in their lives.  I never thought then nor do I think now that it made any sense what-so-ever to pretend that any medical responses without access to the Fountain of Youth would have worked for either of them.  We do all die at some point.  I am pretty sure that I don't want to live to 110 unless I still feel like I'm a healthy 60 year old - which I don't think is in my genetic cards - 85-90 might be though - who knows - I don't.

            The thing is though that I do believe strongly that these decisions should be taken on a case-by-case basis.  Not all 80-year olds are created equal for starters.  If you're forcing some frail elderly person to undergo a procedure that is so invasive that you are risking more than the potential gain, then I'd stop doing that.  

            In fact, my Grandmother had her first heart attack and pacemaker implant because some doctor insisted that she have knee surgery and didn't bother to do a full check on the strength of her heart.  That was ridiculous and really screwed up the last ten years of her life which she had to spend in a wheel chair.  Something she wasn't doing before that surgery.

            In any case, in my experience with ailing family members, the docs were less than forthright about what was really going on which made it even more difficult for anyone to make a rational and informed decision about their healthcare.  I had to force the damn doctor treating my Grandfather to tell him that he was dying.  The guy really didn't like having to do that and he didn't like me.  But what he was doing by trying to withhold that information was taking away my Grandfather's control of his own life.  20 minutes before the doctor gave my Grandfather the news about his medical condition, my Grandfather was writhing in his bed in pain.  When I walked in a few minutes after the doctor talked to him, he was upright, dressed and tying his shoes getting ready to leave the hospital.  I know he was still in pain, but his whole perspective on the situation had changed - he knew that whatever life he had left he had to go out and get and not wait for something that he now understood was not going to happen - there was no cure for his condidition and he wasn't going to get a transplant.

            I'm not all pollyanna about this stuff, but I do think we could do a lot better.  I also really believe that if we start care early in people's lives and control health and environmental policy appropriately, we won't see as much heart disease, cancer and other debilitating diseases.  There is a huge focus on tobacco for instance, but I don't think that is nearly as dangerous as most of the chemicals and pollution we are all exposed to daily because no one has studied them extensively.

            If we want to go down the individual "moral hazard" path, I think it is incumbent upon us to first clean up our collective act and provide a cleaner environment, better preventative care and then firgure out how to deal with the personal choices people make.  I am pretty certain that it was a particular chemical used for growing roses that produced my Grandfather's liver cancer and yet no one wanted to know - not his doctor - not the health authorities - no one wanted to challenge the chemical companies.  But if I were going to deny anyone coverage based on your meathod, I'd be going after people like my Grandfather faster than I'd go after people who smoke.  I used that stuff to try to keep some of his 300 rose bushes alive because the flowers made him so happy when he was dying.  I three up for three hours afterwards and spent an hour and a half in the shower trying to get the stuff off of me.

            •  Dear Inclusive (6+ / 0-)

              I'm so glad you made the doc tell your grandfather that he was dying. It's so important that people maintain their autonomy, especially in a situation like that.

              You simply would not believe how many 90 year olds we perform cardiopulmonary resuscitation on. It would make you ill. You can't believe how cruel it is to do that to someone. A couple of years ago I was involved in a "code" where the 94 year old patient's ribs crushed during the code from the force of compressions. And we never got her heart restarted.

              I read a journal article last year about the moral distress of medical personnel who are forced by the nature of their jobs to participate in medically futile care. For the nurses, it feels like you are trapped in the role of torturer.

              What if you were dying, unable to defend yourself and people kept sticking you with needles to draw blood and sticking needles into your groin to try to get a femoral line. What if people were hitting you in the chest just as you were dying? It's awful.

              This is why so many nurses are "DNR" on their personal medical charts. Actually, I've never cared for a nurse who wanted "everything done". They know too much about codes, that's why.

              Tarheel born, tarheel bred! And when I die, I'll be tarheel dead.

              by NCYellowDog on Sun Dec 07, 2008 at 07:26:56 PM PST

              [ Parent ]

          •  Amen (3+ / 0-)

            See my response to inclusive below about medically futile care. Of course, I can't begin to count the 90 year olds we've coded and kept alive to torture one more day. The numbers are huge and the dollars spent on futile care in the billions.

            And it makes me sick that we spend billions on this, but children go without basic medical and dental care because their parents' income falls between the cracks.

            Tarheel born, tarheel bred! And when I die, I'll be tarheel dead.

            by NCYellowDog on Sun Dec 07, 2008 at 07:31:48 PM PST

            [ Parent ]

      •  Ralphdog: How is who to be denied decided? (6+ / 0-)

        evidence suggests this will extend their life expectancy by a measurable amount. But is it a wise or cost-effective way to spend the taxpayers' money?

        This almost 80 year old is emphatic in my determination to prevent being discriminated against ,in any fashion, and particularly because of old age.

        There are a myriad of maladies that will cost a bundle to provide medical care for, for the afflicted persons life time.
        If said person is unable to contribute usefully to themselves or society do you cut them off & if so, at what age?

        "About 70 percent of Americans – twice as many as fifty years ago – say doctors should be allowed to help end an incurably ill patient's life when that request is made by the patient and the patient's family."

        Are you not being a bit draconian to suggest denying  medical care before ALL in this country have a legal approach to a dignified assisted means of induced death should they so choose?

        Lets not rush to put a cart before the horse!

        •  Rationing is central to the conflict (1+ / 0-)
          Recommended by:
          Sychotic1

          about implementing any kind of single payer system.

          Care must be rationed for any system to be workable and viable.

          For care to be rationed and people to feel that they are being respected and empowered is where trust in any government sponsored health care system breaks down.  People don't believe that a system will be able to respect and respond to their needs.  They feel that they will be disenfranchised, and although the elderly and the ill are most vulnerable. anyone can imagine that they will be held hostage to a system that is monolithic and incomprehensible.

          I believe there are two interlinked resolutions to this problem.  The first, being addressed by Obama as we speak, is to make government itself more transparent, accountable and trustworthy.  The second, is to move the administration of a single payer systems out from governmental intervention and control entirely.  More than that, a single payer system must be administered locally by a multitude of small, locally responsive agencies that can determine the needs of local communities and respond to those needs in a personalized way.  When people can know and trust the administrators in their community can know that their needs are addressed, the trust issue will dissolve.

          It's too bad the school of hard knocks gives you the final exam before the first class

          by Imavehmontah on Sun Dec 07, 2008 at 02:13:49 PM PST

          [ Parent ]

          •  No, it really isn't about rationing (5+ / 0-)

            The cost problem isn't "over consumption" -- it's the lack of focus on lowering costs over the life time of the patient.

            And as RalphDog points out, the system already rations in the states.  It's just the worse of both worlds: the "rationing" just passes costs to somebody else, and by the time the poor patient ends up in the system, the patient's problems cost that much more to treat.

            Rationing in US private health care is penny wise and pound foolish.

            "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

            by mbayrob on Sun Dec 07, 2008 at 03:18:59 PM PST

            [ Parent ]

            •  I respectfully disagree (1+ / 0-)
              Recommended by:
              Sychotic1

              The rationing process that currently exists is irrational.  It does not target procedures based on their lack of value, nor is the application of rationing done in a just or fair way.  Rationing is applied in a random, accidental way.

              In ocntrast, rationing care that is of unproven value, or very high cost and limited value is rational and of demonstrable benefit.  Redirecting resources that suppport limited benefit to high benefit areas results in tremendous savings to the system.  Those whose care is denied of course feel disenfranchised.  But if this could be done in a way that was accountable and transparent, it would have much wider acceptance.

              New medications and practices come into existence on a daily basis.  The evaluation of the effectiveness of these treatments is deeply flawed, yet the demand for the latest and the greatest never ceases.  This is particularly true for people facing significant degradation of the quality and length of their lives, and these people feel most threatened by any kind of rationing.  

              Hence my original post.  The "fear factor" used by insurance companies to steer people away from a single payer plan preys on this fear of disenfranchisement.

              I do agree that lowering costs is the essence of problem solving that a single payer plan achieves.  I was discussing the obstacles to implementation of single payer plan in my post above.

              It's too bad the school of hard knocks gives you the final exam before the first class

              by Imavehmontah on Sun Dec 07, 2008 at 04:51:19 PM PST

              [ Parent ]

        •  See my post above; we already ration brutally. (12+ / 0-)

          I just want an open and honest discussion of what we as a society consider people to be entitled to in the realm of health care. I'm perfectly happy to provide aggressive care to active and functional 80 year old patients. Unfortunately we are currently providing insanely aggressive care to thousands of terribly debilitated elderly patients (because they have Medicare) even as we deny the most basic and inexpensive care to millions of children and young adults, who simply have the misfortune to be members of the working poor.

          This is a moral atrocity.

          •  Kind of reminds me of this poster (0+ / 0-)

            http://img.photobucket.com/...

            Why should the elderly get any treatment at all? What a drag upon the young these human beings, heh?

            Why should the elderly pay for your child's education when they have no children or grandchildren or great grandchildren in the system?  Why should the elderly fragile and sick in need of treatment pay for your roads, which they no longer travel upon?  Grow up for crying out loud and get some humanity into your system. You are talking about human beings, you know, the things we call HUMANS, not cardboard copies of human beings ready to be tossed aside into the waste bin, as garbage not worth the money, while your children deserve all the the health we can afford, even if they are also doomed with a fatal diagnosis ?!

            •  I think he means... (4+ / 0-)

              having read his previous posts, that if people got better care when they were younger, covered by a Medicare-type plan, many of them wouldn't need these expensive treatments when they are older.

            •  I think you're misreading his intent (6+ / 0-)

              He's not saying that it's bad to give care to the elderly, but he is saying that a system that overall makes it easy to give expensive medical treatment to people who are 80+ and denies it to people in their 20's is (a) rationing and (b) especially stupid rationing.

              Next time someone tells you about long waiting periods in Canada, remind them that in the US, for many people and situations, they have to wait until they're 65 for treatment. That's a long waiting period.

              Fry, don't be a hero! It's not covered by our health plan!

              by elfling on Sun Dec 07, 2008 at 04:57:41 PM PST

              [ Parent ]

            •  Rationing of some kind needs to happen. (2+ / 0-)
              Recommended by:
              Tennessee Dave, fokos

              Currently if your family has insurance you can get hundreds of thousands of dollars of care even if it only adds a couple of years to your life span while if you don't have insurance you can't get the couple of thousands of dollars of care that can extend you life decades. We need a system that has room for common sense, but no country is able to every conceivable benefit to all citizens, choices have to be made.

          •  Most conservatives I know agree exactly with this (0+ / 0-)

            The issue isnt that conservatives disagree with nationalized healthcare, it is that they realize that government mandated rationing is the only solution. There are two main issues for conservatives

            1. Government employees provide the worst customer service because they typically cant be fired except under extreme circumstances
            1. without rationing, the government will have to raise taxes to an untenable level. Health care has the potential to suck the country dry. However with rationing the system is viable, Im just not sure most progressives realize that government controlled rationing is mandatory.

            To avoid fraud the providers will not be able to make decisions except with a very narrow latitude.

            However the current system is so broken for so many people I think the pain of the current system is enough to overcome the fear of a badly run government system.

            •  Whoa! (4+ / 0-)
              Recommended by:
              RAST, lotlizard, Leap Year, gobears2000

              Government employees provide the worst customer service ...

              Apparently you've never dealt with a cell phone company!

              BTW -- did you complain about how nice the firemen were the last time they rushed to your house without asking if you were insured?  Come to think of it, the cops who have responded to my household alarm have ALWAYS been really nice about it -- but the dept. store clerk I talked to about the blender that didn't work was kinda mean -- so it seems to me public employees are often more reliable and are obligated to maintain transparency in their decisions because they're answerable to an elected authority, who is answerable to me.

            •  Your points (0+ / 0-)
              1. I know very few people who would rate customer service provided by their private insurers as good, or even decent. The beauty of the best universal care systems is that while the government sets some policies, patients themselves do not have to deal with any government bureaucrats. Doctors and patients make decisions together, which is as it should be.
              1. You should stop thinking only about "taxes", and instead consider the wallet as a whole. Taxes may be raised, but we will no longer be paying (either alone, or in conjunction with employers) outrageous premiums and deductibles. Costs to cover just myself and my husband are roughly $900 monthly (split between me and my employer). Raise my taxes to institute universal care, and I would probably still be saving money. I will have out-of-pocket savings, and my employer can pass at least some of its savings on to me in the form of salary. Furthermore, to people who have gone into bankruptcy; lost their homes; etc. due to medical bills (and note: many of these people HAD INSURANCE), it's well worth paying a little extra in taxes to avoid this kind of increasingly common disaster. It's also worth it, to me, to not see my fellow citizens, children and adults, literally dying due to lack of access to health care.

              I'm not sure what you mean by this:

              To avoid fraud the providers will not be able to make decisions except with a very narrow latitude.

              You seem to buy the Republican scare stories that government workers will insert themselves in every medical decision affecting you. Read up on existing universal care systems, and you will see that this is just not the case.

      •  you are right (4+ / 0-)
        Recommended by:
        zett, Alexandra Lynch, mcmom, Ann T Bush
        and I am one of them.

        I am five months off meds for hypertension.  I have been on meds for hypertension for more than 20 years.  My 'doctor' (clinic)has turned over four times in the last few years.  I really do not like the folks who took over the practice.  I have a thousand dollar deductible through Blue Cross, so it is all on my dime. I have to have the time and the money to see an MD, and pay hundreds of dollars for a 4 dollar a month prescription.

        I make too much money for free care.

        If anyone has any suggestions for a likable physician with reasonable prices near North Dallas, I am open to suggestion.  Otherwise I will take my chances on not strroking out until I get the time and the money to see some doc somewhere.

        I'm insured, yet rationed, via deductibles and time.

        •  Here's the one I went to (1+ / 0-)
          Recommended by:
          miss SPED

          I'm young and don't make a habit of seeing doctors, so it was a major pain in the ass to have to go find one when I needed a lump on my shoulder checked out.  I picked this one randomly out of the BCBS provider list:  http://www.baylorrichardsondoctors.com/ , and saw this doctor:  http://www.baylorrichardsondoctors.c...

          It was a very good experience overall, I went at about 4 in the afternoon and had a very short wait, the doc was very kind and friendly but also very efficient and to-the-point, and less than 15 minutes after I got there the scalpel was out and she was going to work.  I was out of there and lump-free in less than an hour, not bad for the first time I'd been to any doctor in years, I thought.  

          I don't know what their prices are like, but if you're worried about a time suck, this place seems to be pretty good about cutting to the chase.  :)

          Good luck!

      •  Ohhhh - so Ralphdog, you don't believe in it, eh? (7+ / 0-)

        Well let me introduce you to someone who DOES!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

        I am 56, my husband is 82.  We have been married for 22 years. Twenty four years ago he had 30 cardiac arrests in 24 hrs.  It is a miracle that he is still here today.

        Two years ago I had 5 paramedics in my bedroom keeping him alive when his heart rate went to 200.  He left the house in an ambulance and had a defibrillator put in on Christmas Eve.

        Are these last two years I've had with him worth it?  GODDAMN right they are!  ASK ANY OF OUR TAX PAYING FRIENDS!!!!!!!!!!!!!!

        So Ralphie, just because you don't know or value those 80 yr olds doesn't mean the rest of us share your views.

        •  I found Ralphdog's remark incredible for (1+ / 0-)
          Recommended by:
          mamabigdog

          any human being and mind-numbing for a doctor to make.

          "I like paying taxes. With them I buy civilization." Justice Oliver Wendell Holmes

          by hester on Sun Dec 07, 2008 at 02:02:44 PM PST

          [ Parent ]

        •  Not to mention how many citizens of other (6+ / 0-)

          countries would we have to stop shooting at in order for us to afford medical care and additional years of life for our valued and loved citizens.

          Two birds with one stone.  Stop killing people in other coutries who didn't attack us and prolong the lives and quality of life for our citizens.

          This will never work.  It's just too smart and decent.

        •  At the same time (1+ / 0-)
          Recommended by:
          Sychotic1

          my sister, making minimum wage in her twenties could not afford to get good care after her miscarriages. Now in her thirties she is having trouble conceiving. There's no guarantee she could have ever had children but all the care in the world now that she is covered will not fix the lack of cheap and basic care earlier. We need a rational system that makes sure every one get the easy stuff

      •  I disagree (3+ / 0-)
        Recommended by:
        inclusiveheart, Leap Year, cameoanne

        There are a lot of examples of waste and excessive use in the system.  How else would it be possible for the US to spend a larger percentage of GNP  for healthcare than any other industrialized country (not to mention a larger amount per capital for health care than any other industrialized country) and still have worse outcomes?  Common sense tells you that something doesn't smell right here.

        What is the low hanging fruit?

        Well, unreasonable administrative costs for one.  The money that health insurance consumes is highest on the list.  At the same time, providers incur high expenses for completing the paperwork to get paid.  This doesn't begin to account for the countless hours patients spend trying to figure out their bills.

        Excessive malpractice costs cause two problems - the cost of premiums and the cost of excessive and unnecessary tests.

        Treatments, procedures, and medications that are of marginal or unproven benefits are a third area of waste.   We don't really document the effectiveness of a large number of things that are done to people.

        Lack of reimbursement for preventive care, and lack of resources to make preventive care effective is a huge opportunity to lower the cost of health care.

        This list just scratches the surface.  If you like, I can document several episodes of care I have had in the past 5 years for which at least $6000 worth of irrelevant bills were charged.  I am lucky that my insurance covered it, but that doesn't change the fact that these were wasted dollars.

        It's too bad the school of hard knocks gives you the final exam before the first class

        by Imavehmontah on Sun Dec 07, 2008 at 02:01:52 PM PST

        [ Parent ]

        •  My Mother was taken to the hospital in (4+ / 0-)

          an ambulance recently.  The ambulance service charged Medicare more than a thousand dollars.  The drive from my parents' house to the hospital is four minutes on a good day and six on a bad one in their tiny town - the ambulances reside at the hospital where they took her just by the way.  My father in total freak out about her condition, received their charge in the mail and was close to ending up being hospitalized himself because he got so pissed off about the cost to Medicare of that charge.  Just for comparison's sake I was taken to the hospital recently where I live in an ambulance that cost about $300 dollars.  My ride wasn't all that long either in distance, but it took approximately 45 minues because of rush hour traffic.  

          These are the kinds of costs that could easily be stream lined and controlled if we were to take a hollistic approach to national healthcare.  There is no reason in the world why we should see such wide variations in charges for the same services.  I can see why there might be some variations, but not how it could cost my mother three times as much to be driven about a mile with no traffic than it does for me to be driven four miles in 45 minutes of traffic.  It is worth noting that neither of us received any medical care from the EMTs during our rides either.  No procedures, no drugs, just guerneys and manpower.  There was virtually no difference between the services each of us received.  Also worth noting that where they live the cost of living is about as cheap as it gets - while where I live is in the top ten or twenty most expensive places to live.

          •  Oh and this is probably an important difference (0+ / 0-)

            between my ride to the hospital and my mother's - my ambulance was a city ambulance and hers was a private company that contracts with their town.

            But the guys on my ride are paid better than the guys on her ride are....

        •  We need to be cautious about (1+ / 0-)
          Recommended by:
          Imavehmontah

          swallowing the Republican line that malpractice costs (especially from "frivolous" lawsuits) are a huge factor in rising health-care costs. Republicans have peple willing to give away their rights to seek appropriate redress in court when they are victims of malpractice.

          What we should be doing in preventing malpractice in the first place. We need the AMA and state boards to do a better job of policing the worst offenders. Placing arbitrary caps on malpractice awards will amount to barely a drop in the bucket of overall health-care costs. Furthermore, we have long-term data from many states in which caps were implemented. Guess what? Malpractice insurance rates did not decline. Insurance companies just made more money.

          •  Malpractice claims are an issue (0+ / 0-)

            not because of the awards themselves but because of the unintended consequences on the practice of medicine.  Malpractice claims should serve valid purposes:  They should allow compensation to victims for injuries that should have been avoided;  they should allow remedial training for physicians whose actions should be remedied, and removal from duty for physicians whose behavior cannot be remedied; they should allow gathering of data on variation in medical practice that allows improvement of best practice guidelines.  Punishment (except for criminal acts)and enrichment of third parties should be avoided. Probably the most damaging effects of large malpractice awards is in the area of inducing wasteful utilization of practices designed to reduce exposure to malpractice claims.  Development and use of best practice guidelines should constitute a strong defense against malpractice.

            It's too bad the school of hard knocks gives you the final exam before the first class

            by Imavehmontah on Mon Dec 08, 2008 at 06:48:18 AM PST

            [ Parent ]

      •  Please, tell Cheney this. (0+ / 0-)

        But is it a wise or cost-effective way to spend the taxpayers' money? Personally I don't believe so

        me neither..anyone disagree?

      •  This is the essence of the problem (0+ / 0-)

        The only solution to control cost is government based rationing vs market based rationing. I actually think this is a good thing, however it isnt clear how our society would react to denying services to an 80 year old with only a few years to live in favor of a child. How many vaccines could be provided for the cost of one heart bypass surgery?

        •  Our society seems to have no problem (0+ / 0-)

          with letting 45 million people be uninsured, and letting people go bankrupt and lose everything they have due to an accident or illness.

          Let's cut out the massive costs due to insurance company profit and overhead, and then we can talk about how best to ration care. This is not an insurmountable problem, and it's no excuse for complete inaction.

      •  Back in '92 I attended a meeting on health care (3+ / 0-)

        reform sponsored by, I think, the League of Women Voters, or maybe AARP.  Anyway, the majority of the audience were over 60 years old.  The high cost of care for the elderly was much discussed.  And the crowd was like, if that's what it takes to get Single Payer, we'll still support it. (though AARP, which sells insurance was agin' it)

        I was working with some advocates of Single Payer and when Clinton convened his wife's hobby, orgs were only allowed at the table if they agreed to drop the Single Payer angle, that's what I was told anyway.  I think only Citizen Action was involved.

        The NYTimes either didn't mention it or dismissed it out of hand.  They had several directors that were part of Big Pharma.

        I have never forgiven the Clintons for the mess they brought out of Jackson Hole.  Kill welfare, sure.  NAFTA, sure.  Piss of the military while not helping gays, sure.  A simple, elegant funding system for private providers, oh hell no.

        Thanks for your diary.

        "Yes dear. Conspiracy theories really do come true." (tuck, tuck)

        by tribalecho on Sun Dec 07, 2008 at 09:40:51 PM PST

        [ Parent ]

      •  A piece at a time (0+ / 0-)

        Ralphdog

        Why wait for a panacea to reduce healthcare costs or a one-size-fits-all solution?  

        We can make some progress by chipping away at it a piece at a time.  What works for one area or situation may not work for another one but we need to do more than pontificate and complain.

        One poster likened my ideas to fixing a train wreck with a screwdriver.  That's neat and thanks, but must we look to the feds to fix all our problems?

        I think that, except for Medicare and VA and the service healthcare functions, we need to take care of our needs at state, county, and local level. States license healthcare providers, not the feds, so that to me is a logical place to start.

        I need to go help drive some klunkers back from an aution so cannot spend much more time at the moment.  However, there may be ways that state, county, and local governments plus philantrophic efforts and civic groups can make a difference in reducing healthcare costs.

        Locally, the doctors are over worked and overbooked, so they need some help in the form of competition.  I hope to have more to say one this idea later but nothing works better than competition to hold costs in line.

    •  Funny you mention BushCo... (4+ / 0-)
      Recommended by:
      javelina, ER Doc, ms badger, cameoanne

      ... when in fact you are using their talking points.

      The diary is entirely readable... the fault is with your ideological "glasses." You are going to have to take them off before venturing to make any sense around here.

      Sheesh.

    •  Single payer is tort reform (6+ / 0-)

      A great deal of lawsuits, both malpractice and personal injury, are about seeking blame to decide who will pay for the real and honest out of pocket costs to a injured person.

      If instead, we simply agreed that someone who is injured needs to be repaired and treated, and spread the cost among everyone, there would be no need to sue. Lawyers are paid on a contingency basis; even 40% of 0 is 0. If there are no medical damages, there is nothing to sue for.

      We could focus then on reporting mistakes and transparency to reduce medical errors, and save lawsuits for the most egregious cases of negligence and malice and permanent disability.

      Fry, don't be a hero! It's not covered by our health plan!

      by elfling on Sun Dec 07, 2008 at 01:07:36 PM PST

      [ Parent ]

      •  Tort reform (8+ / 0-)

        Yet another Republican figment of the insurance industry.  Malpractice premiums are not high due to lawsuits - they are high because the insurance companies like to make money.  Period.

        Believe me, the insurance companies have put many obstacles in the way of the deserving plaintiff.  You really don't need to help them.  In my state, you have to jump through all sorts of hoops just to FILE a lawsuit, much less get actually paid on one.  

        And yes, I'm a lawyer, and NO, I don't practice personal injury or malpractice litigation.  But I know good lawyers who do, and trust me, they earn every penny.

        We do not rent rooms to Republicans.

        by Mary Julia on Sun Dec 07, 2008 at 01:23:24 PM PST

        [ Parent ]

        •  tort reform is an attack against our defenders (7+ / 0-)

          Simply put, lawyers are how the weak equlaize, neutralize, or defeat the strong when necessary.  Republicans dod not like this, and have sought to limit the ability of lawyers and therefor us to extract Justice.  The strategy of the insurance industry to raise premiums plays into this by falsely villainizing lawyers.

          The hopeful depend on a world without end, whatever the hopeless may say. --Rush

          by Leftcandid on Sun Dec 07, 2008 at 01:43:17 PM PST

          [ Parent ]

          •  But what do torts cover? (3+ / 0-)

            I understand and appreciate the role of torts in the current system, and I don't begrudge the fees that lawyers get in big cases.  But ask yourself: what are the torts recovering, and how would single payer affect that?

            The first piece of what torts tend to cover is covering the cost of treatment that someone may need after medical error.  Under single payer, this mostly goes away: the patient no longer needs it, since the system covers it.

            The second piece is punitive damages.  In a system where there is less incentive to do CYA,  providers tend to settle quicker, which I think reduces the case for this.  Also, there are better ways to improve medical quality.  Quality is best served by a system where providers admit and fix mistakes as early as possible, and keep good statistics to recognize when problems occur.  An adversarial system is not helpful in this, since it causes providers to reduce their transparency.

            Part of the reason that torts are so important now is that the system is that regulation is not set up to create transparency.  Fix the regulatory problem, and torts have less of a role, and less value.

            "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

            by mbayrob on Sun Dec 07, 2008 at 03:26:57 PM PST

            [ Parent ]

            •  oh, I'm on board (1+ / 0-)
              Recommended by:
              Leap Year

              I was aiming at the GOP's broad anti-lawyer strategery, which seemed to be the thrust of the initial comment.

              The hopeful depend on a world without end, whatever the hopeless may say. --Rush

              by Leftcandid on Sun Dec 07, 2008 at 03:43:39 PM PST

              [ Parent ]

              •  Defunding the Left as the paramount goal (2+ / 0-)
                Recommended by:
                Joe Bob, Leap Year

                Yeah, the GOP is always more about politics than policy.

                They see torts as an income redistribution problem: away from their donors, and towards ours (trial attorneys).  As they see bringing down the Big 3 -- breaking the UAW is the real prize.

                Still, what we need is higher quality medical care.  That torts are now a principle way of enforcing that is a failure of the system.  The torts are more a symptom of the problem than the problem themselves.  But as the symptom, having a reduced need for malpractice suits would be a good thing.

                "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

                by mbayrob on Sun Dec 07, 2008 at 03:51:28 PM PST

                [ Parent ]

            •  You don't understand what a loss really is, Sir (1+ / 0-)
              Recommended by:
              EmmaKY

              If your child, due to horrible malpractice, is permanently brain damaged for life, you suffer much more than lost medical bills.

              •  I'm not unsympathetic (2+ / 0-)
                Recommended by:
                elfling, Imavehmontah

                I come from a family of lawyers.  I understand and appreciate what they do.  But my own point of view is more economics-and-public-policy.

                Taking aside the right of a family to make a suit like this, and their right to have the advice of a lawyer, I'm looking at more how what the effects of these suits are on the system.  People talk a lot about their costs, but I'm not stressing these here.  AFAIC, torts are a sort of substitute for competent regulation, in the following sense:  if we could effectively regulate how medicine was practiced, so that doctors and hospitals did not make mistakes, why would we need torts in this case?  As regulation has been gutted over the last 30 or 40 years, the only way to fix problems in the system has been to sue, or to threaten to sue.  And certainly, the threat of torts has an effect like regulation.

                The problem is that it's a crap shot, as you likely know as a lawyer.  People who have been greatly wronged often get no satisfaction at all through the courts.  I'm sure that you can take on a fair number of very deserving cases, but very often you can only get them a fraction of what they deserve.  And for you and other lawyers to continue to practice this kind of law, you do need to make enough on the cases that you win to cover the cost of your practice.  I'm aware that lawyers can sit on these cases for years, and make nothing on them.

                But that also means that when you do win, the cost of the suit may fall disproportionately on a particular doctor or practice.  That's not saying that the doctor or hospital didn't deserve to lose.  But they may not have deserved to lose as much as the jury awards them (and I am aware as well, what survives on appeal).

                There are also other issues with regulation-by-law-suit.  The biggest is the conflict between your clients rights of discovery vs. the value of information being available and transparent; quality management really needs this.  But attempting to prevent errors is only part of the impact of avoiding law suits.  The doctors and hospitals also do as much as they can to inhibit and prevent your discovery.  This is a perverse incentive for medical quality, because the best defense for the doctor or hospital is to protect the incompetent, refuse to admit error (which often is part of what the client wants), or to settle as quickly as they should when they have made an error, and know it.

                In a number of other countries with similar legal traditions (for example, New Zealand) the bargain has been struck for more transparency at the price of restrictions on these kinds of torts.  The law being a balancing act between opposing interests, this is not necessarily a bad thing.

                "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

                by mbayrob on Sun Dec 07, 2008 at 09:30:26 PM PST

                [ Parent ]

        •  Actually, they're high and will be higher (0+ / 0-)

          because the stock market is down.

          Fry, don't be a hero! It's not covered by our health plan!

          by elfling on Sun Dec 07, 2008 at 05:00:04 PM PST

          [ Parent ]

      •  nicely done (0+ / 0-)

        a good reminder of how pervasive health care problems are.

        The hopeful depend on a world without end, whatever the hopeless may say. --Rush

        by Leftcandid on Sun Dec 07, 2008 at 01:44:10 PM PST

        [ Parent ]

      •  So, if you lose three limbs in a malpractice... (0+ / 0-)

        incident....all you're entitled to is getting the medical bills paid for whacking those limbs off?

        •  Read for comprehension (0+ / 0-)

          We could focus then on reporting mistakes and transparency to reduce medical errors, and save lawsuits for the most egregious cases of negligence and malice and permanent disability.

          Fry, don't be a hero! It's not covered by our health plan!

          by elfling on Mon Dec 08, 2008 at 08:45:05 AM PST

          [ Parent ]

    •  First, you need to do more (2+ / 0-)
      Recommended by:
      javelina, ER Doc

      research on your own lest you be dubbed a troll. Stupid comments such as:

      Gee, we cannot do that becaue then there would be high priced lawyers in the breadlines.  Those bozos make big bucks of four misery and off doctor's mistakes so we need a system that cuts them out of a piece of the pie.

      Gee golly Sarah, you may want to provide some numbers on your own instead of being "user".

      You don't solve problems by obfuscation, unless you are a Bushco schill.

      What % of GDP is the welfare program. Your answer: Get rid of poor people and the needy.

      WhAt % of cases has SCOTUS ruled in favor of corporate America vs "we the people"?

      What % have they heard where corporate America vs "we the people" are plaintiffs in the past 8 years?

      What was the final settlement from the Exxon Valdez disaster vs the initial settlement and what was the average payout to the lifes of the fishermen?

      Read, research and remain silent until you realize that there is such a thing as a stupid question and comment. Your drugs, food supply, bankruptcy protections and job security went out the door when litigants representation was discouraged.

      Shame on you Hannity, shame on you Limbaugh, shame on you O'Reilly...you prey on the ignorant.

    •  Being penny wise and pound foolish (5+ / 0-)
      Recommended by:
      elfling, javelina, ER Doc, Leap Year, SusanL143

      Nope, no one is dancing around anything.  Many of us have seen the statistics.  You are trying to solve the wrong problem.

      The problem with your approach is that you assume that people over-consume health care, and that this has a substantial influence on cost.  Your first assumption turns out to be only very partially correct.  You turn out to be very demonstrably wrong on the second.  And it turns out, you don't take into account the costs of your being wrong.

      You're only partially right because the kinds of health care people tend to over consume turn out to be relatively cheap in a system where the big costs are at end of life and/or from catastrophic illness.  Also, some of the over-consumption has benefits -- even a hypochondriac will occasionally come in with something real.  And things like seeing the doctor "too much" likely means that people will get better preventative care.

      You're wrong on the second because the big expenses aren't things that people "over consume": no one gets heart surgery for fun, and no one actually wants to die in a hospital.  But that's where the big money is.  And people who are relatively sicker during their lives tend to be the worse offenders here.  Your approach does little or nothing about this problem, and so, it turns out not to save much money.  This isn't a guess on my part: you look at the international statistics, and you see it clearly.  The systems that spend a lot of effort (and money) trying to keep people from "wasting" medical services turn out to be no cheaper than the ones that really don't bother.  And the ones that don't bother are a lot easier to deal with.  So if it isn't cheaper, why bother?

      The last problem is that your approach has hidden costs.  If you want to really cut costs, you need to cut end-of-life and catastrophic costs.  It turns out that the cheap stuff -- preventative medicine, with its greater emphasis on primary care -- is how you save money on the big stuff.   Like the essay's diabetes patient.  Had money been spent to prevent his diabetes or better manage it, he would be a lot cheaper to treat now.  That turns out to be the norm.  It is also why the Veteran's Administration is so much cheaper per patient that most of American medicine.

      So you need to dance around this to a different tune.  Wise up and don't be foolish about saving money in all the wrong places.

      "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

      by mbayrob on Sun Dec 07, 2008 at 03:02:50 PM PST

      [ Parent ]

    •  Reduce the cost of skilled labor? (2+ / 0-)
      Recommended by:
      AmericanRiverCanyon, bigchin

      Are you nuts!  Patient Care Techs make minimum wage?  Resp, PT, X-ray phlebotomy techs maybe 10 an hour for a job that requires very specific skill set and specialized education all to work in a documentation heavy, incredibly accountable field where you handle expensive equipment, heavy patients and bio-hazardous materials all day.
      Nurses make 30 dollars an hour for a job that takes a four year degree, precepting at a lesser rate, then years of working nights, weekends and holidays plus being on your feet for 12 straight hours.  
      Physicians who do GP are not richly rewarded which is why you can find 10 pages of ads for boob jobs and hardly find someone to manage your diabetes.  
      Who in this list do you think is being overpaid?  If anything wages are so low and stress and workload are so high that you can barely find enough qualified people to staff hospitals.
      I think the most important thing we can do is pay only for what improves outcomes.  The endless paperwork, forms, calls just to get companies to pay what they promised to pay- total waste of time and money.  Those three employees who do nothing but fill out forms all day should be working on things that reduce health care costs- like running smoking cessation clinics, weight loss classes, meditation seminars, exercise groups.  That is what can infuse money back into the system.  Controlling illness before it becomes epic!

    •  Fox News Talking Points (0+ / 0-)

      You are new here and you seem to love Fox News Talking Points.  President Obama will address all the costs of the Healthcare System in his proposals.  

      We on this site are Progressive Democrats.  Listen and Join us if you wish.

    •  ivanm, you're talking about fixing a train wreck (0+ / 0-)

      with a screw driver.

  •  Excellent diary. (17+ / 0-)

    I wish so much that Republicans could take away their gr$$n-colored glasses and realize that what you are proposing is better for all of us--including them.

    With the economy in free-fall, we are truly in a health care crisis and it has got to change.

    God, I miss Paul Wellstone.

    by Naniboujou on Sun Dec 07, 2008 at 11:35:45 AM PST

  •  Have you thought about (43+ / 0-)

    posting this on Change.gov?  I have no idea how effective this would be but your perspective as a clinician with concrete examples would seem to carry great weight.  You see firsthand how policy is implemented in a practical sense and the detriment to the system of private insurance.

    I believe that anything less than expanded Medicare will fail.  I wasn't sure that Doctor's liked the terms but it seems that the "known" aspect of Medicare and the reduced paperwork may offset any downside.

    I want doctors to be well paid, just think of what we require of you.  Thank you for the work you do and for your perspective.

  •  A broken health-care system (36+ / 0-)

    Great ground-level view of how broken our health care system is, and how much time and effort is required to provide care in it.  Thanks for the time and effort you've put into this story, which well illustrates the current mess most of us find ourselves in when trying to provide care.

    Single-payer has long been my preferred solution, but with a caveat.  The routine brinksmanship Congress plays with Medicare reimbursements, trying in essence to sabotage the system, shows they cannot be trusted with administering the nation's health.  Far better, I think, to set up an independent body similar to the Social Security Administration to handle health care payments, with a dedicated income stream and as much autonomy from Congress and the administration as possible.

    Our long national nightmare is almost over. Congratulations and blessings to all.

    by Dallasdoc on Sun Dec 07, 2008 at 11:52:23 AM PST

  •  This family doc agrees wholeheartedly. (57+ / 0-)

    Medicare is a piece of cake to deal with compared to all the double-dealing private insurers or (worst of all) the repellant and deceitful for-profit insurers. Recently our local Blue Cross/Blue Shield carrier has instituted a "radiology review" program run by a completely unaccountable third party contractor. These vampires are now issuing a stream of retrospective denials for scans done months ago, and they swat down every appeal with disdain. Patients are recieving bills for thousands of dollars and calling me in tears, wondering how they'll pay, since their husband just got laid off.

    •  I'd be all for retroactive denials (0+ / 0-)

      if I could also "retroactively deny" my insurance company all those thousands of dollars in premiums, deductibles, and copays that they have received from me! Not really, but you get my point. Why is is so easy for insurance companies to completely ignore their end of the contract?

  •  Thank you, doctoraaron! (44+ / 0-)

     You have written down a superb narrative of the difficulties of maintaining a primary care practice.  My office partner and I had to close our practice two years ago because there were just two of us - and we could just not support the necessary employees needed to keep up with the Byzantine pathways of current third-party reimbursements while still trying to provide high-quality primary care.
     It matters not to the third-party payors if you are caring for a patient with multiple chronic illnesses (my typical Internal Medicine patient) or a patient with long-term AIDS on HAART requiring necessary high-dollar lab tests (my office partner's typical patient).  The reimbursement just doesn't match the time and work required to properly care for folks.
     No matter that we did not admit our own patients to the hospital, all our hours were spent in the office, there just were not enough hours in the day to see enough patients to make up for the money lost.
     Thank you for this superb diary.
     

    "Respect for the rights of others means peace" Benito Juarez

    by drchelo on Sun Dec 07, 2008 at 11:55:26 AM PST

    •  Excellent diary (15+ / 0-)

      And as I read your comment, drchelo, I realized how lucky I am to have a fine primary care physician who works in a two doctor office.  He and his partner give excellent care.  They are a satellite office to a bigger practice.  I have to drive all the way across the county to see them, but that's fine with me.  They are both great doctors, kind, interested, answer questions, everything you could ever want.

      I do not know how they do it.  I am a private pay (I pay for my own health insurance, well over $400 a month, but I have a Cadillac policy with BCBS). I have a myriad of chronic conditions; I have to take a LOT of prescriptions.  We all go a little crazy trying to figure out what is going to interact with what.

      Since I am a lawyer, I brook no hassle from my insurance company.  I am sure my file has LAWYER - will sue - stamped all over it, as I have made that threat when necessary. I am also one of those patients that should take a lot better care of myself. It's a good thing my guys like me!

      But I seriously don't know how you family practitioners stay sane.  If I had to run my law practice this way, I would have killed someone a long time ago.

      The diarist is correct, of course - the only efficient, economic model would be Medicare for all.  The political problem, of course, is that the insurance industry is not going to give up this huge part of their industry.  They will fight it in Congress to the death.  I think Obama recognizes this.  I wish he had the stones and political will to use the bully pulpit of the Presidency to achieve it.  But I live in Syracuse, New York, where it is cold and snowy today.  I have a better chance of going to the beach today then I have seeing Medicare for all in my lifetime.

      We do not rent rooms to Republicans.

      by Mary Julia on Sun Dec 07, 2008 at 01:04:40 PM PST

      [ Parent ]

      •  Expanded medicare is almost certainly coming (1+ / 0-)
        Recommended by:
        Leap Year

        I agree with others that that is the smoothest path. I suspect it will start with guaranteed programs for all children and work its way from there, possibly linked to the ability for the middle class to buy into it with extremely low premiums so it isnt viewed as a freebie.

        With everyone losing their jobs, inexpensive for the working (or even free medicare as an unemployment benefit) is a no brainer.

    •  I wasn't aware of your professional (5+ / 0-)

      history, drchelo, just about your courageous and ongoing battle with cancer. Best wishes from an admirer.

      I think, therefore I am. I think.

      by mcmom on Sun Dec 07, 2008 at 02:15:18 PM PST

      [ Parent ]

    •  Same with my own good doctor (1+ / 0-)
      Recommended by:
      kurt

      When I was living in Florida a few years ago, my most excellent doctor (internal medicine doctor) sent all her patient letters explaining that she could no longer afford to keep working as she had been. She said she was not making enough money with what the insurance companies were allowing her to charge to even cover the costs of her office expenses plus pay off her equipment. She'd been doing cosmetic surgery on the side to make ends meet, but when the local economy there started to tank even back then, that business had dropped off so much that she was now in the red despite the long hours she was working.

      What she did was to start a holistic medical practice, combining her medical knowledge and training with natural medicine. She no longer accepts insurance, and many of her procedures and treatments wouldn't be covered anyway. People have to pay out of their pockets, but she's really good (best doctor I've ever been to) and has been successfully earning a living for several years this way without having to be at the mercy of the insurance companies. I just googled her, and she's still operating her "wellness center."

    •  Do you agree with his choice of private insurers (0+ / 0-)

      ...as the go between?  

  •  Thanks, Dr. Roland (11+ / 0-)

    Quite a diary, I need to read it again....
    I regret changing my dental ins. to a capitation plan. I would rather pay more to get the care I need without having to argue with a claims rep.  I believe that most patients don't know how their doctors get paid, or how little the payments can be.  

    "Never get out of the boat."

    by tlemon on Sun Dec 07, 2008 at 11:55:51 AM PST

  •  Two things - (5+ / 0-)

    first, if Medicare is so easy to deal with, why does it seem like so many more doctors aren't taking Medicare anymore.  My dad had to hunt for a doctor who took it; maybe that's the exception.

    Secondly, next year my husband and I will spend close to $20k between insurance and medical bills, I have a chronic condition and my husband HAS to have a yearly colonoscopy to prevent colon cancer, we are lucky and can afford it, for now, but most families simply cannot.  Our current health care systems kills people with survivable conditions.  It is deplorable.

  •  Thank you so much. (18+ / 0-)

    This eloquently lays out how so much of our medical talent and compassion is frittered away on making profits for insurance companies.

    Ten billion dollars. As of the April 2006 issue of Fortune magazine, the health insurance industry made over TEN BILLION DOLLARS in profits the previous year.

    And people suffer and die because of it.

    WereBear
    Pootie fan? Me too! Check out my cat advice blog.
    The Way of Cats

    by WereBear on Sun Dec 07, 2008 at 12:05:53 PM PST

  •  This is rec-list stuff. (8+ / 0-)

    Well-said. Thanks for sharing your views.

    The future belongs to those who believe in the beauty of their dreams. ~ Eleanor Roosevelt

    by va dare on Sun Dec 07, 2008 at 12:32:19 PM PST

  •  i am soooo printing out this diary! (15+ / 0-)

    (and the ones on TPM) then giving it to a few doctors in my RED area who need to read this -- i have tried to talk about single-payer, but they blow me off because i'm just a nurse (retired), what do i know??

    thank you, Dr Aaron!

  •  Well written (11+ / 0-)

    Though lengthy, I hope everyone can take the time to read it.  Single payer healthcare is the only long term solution for our country.  

    Healthcare should not be a for-profit industry that is able to separate those who can and cannot pay.  Imagine if everyone had access to preventative care.  It is far cheaper to take a long range approach than to use the emergency room for non-emergency healthcare.  

    This is our opportunity to make a significant positive change in our country.  Healthcare available for all, money no object.

    Fox is to "news" as WWE is to "wrestling."

    by skisb on Sun Dec 07, 2008 at 12:52:49 PM PST

  •  Medicare for all (11+ / 0-)

    Thank you for the run down of the medical insurance morass from the physican's point of view.

    I agree with the person who suggested you also post this letter with Change.gov.

    It seems so much of the reason not to go to a single payer health care system is based on preventing all the people working in private health care insurance from losing their jobs or businesses.  I've even had a friend say that she doesn't want to see the people working in the doctors' offices to handling insurance paperwork to lose their jobs.

    Surely, we can find a better way to employ these people. Instead we waste vast amounts of money and limit the population receiving good health care in order to maintain the status quo.

    We have the Medicare system already in place, as you point out.  Let's put it to use, right away, by allowing everyone to participate.

  •  I'm only paying $100/month for full medical.... (10+ / 0-)

    coverage here in the US. That also includes umbrella liability insurance of $2,000,000 and insurance against lost luggage and canceled flights.

    That's because I have travel insurance from Southern Cross New Zealand; they're New Zealand's largest private health insurance carrier.

    I'm sure that Southern Cross actuarials are as skilled as their US counterparts; they're quite capable of computing how much my premium should be, based on the risk I represent. So, I have to wonder: why do US heath insurance carriers charge 5-10 times as much as New Zealand health insurance carriers to cover the exact same risk?

    BTW: my insurance covers two pre-existing conditions and there aren't any copayments or other out of pocket expenses.

    This Space For Rent

    by xynz on Sun Dec 07, 2008 at 12:55:37 PM PST

    •  Are you a NZ resident? (4+ / 0-)
      Recommended by:
      mijita, kurt, bigchin, cameoanne

      Is that only available to New Zealand residents who are traveling? It may be because New Zealanders are statistically healthier than Americans.

      Or it may be because the carrier didn't invest in risky securities that now need to be subsidized by policy holders.

      A word after a word after a word is power. -- Margaret Atwood

      by tmo on Sun Dec 07, 2008 at 02:37:07 PM PST

      [ Parent ]

      •  I'm a dual US/NZ national who resides in NZ. (2+ / 0-)
        Recommended by:
        tmo, kurt

        Yes, this insurance is only available to NZ citizens or permanent residents who are traveling to the US.

        While NZers may be statistically healthier than Americans, they are not 5-10 times healthier.

        This Space For Rent

        by xynz on Sun Dec 07, 2008 at 04:48:53 PM PST

        [ Parent ]

    •  Statistically it's (2+ / 0-)
      Recommended by:
      elfling, bigchin

      probably more likely a New Zealand traveler would return to NZ to have any serious medical procedure done.  Most people, given the choice, want to be in the community where their support structure exists when they're recovering.

      the third eye does not weep. it knows. Political compass: -9.75 / -8.72

      by mijita on Sun Dec 07, 2008 at 04:48:11 PM PST

      [ Parent ]

      •  You have a good point. (2+ / 0-)
        Recommended by:
        mijita, Alexandra Lynch

        The insurance company also reserves the right to repatriate the client to NZ for treatment.

        But most health care claims are for "routine" or less serious health issues. I've used this insurance before, for precisely that reason. When I was visiting the US in 1999, I contracted a middle ear infection that incurred about $300 in claims for US urgent care.

        Also, how many people are willing to put off medical treatment if they really need it?

        This Space For Rent

        by xynz on Sun Dec 07, 2008 at 04:55:44 PM PST

        [ Parent ]

    •  Stay well and don't get sick (1+ / 0-)
      Recommended by:
      bigchin

      ....that coverage sounds like it is hanging by a string.

      •  Southern Cross is New Zealand's... (0+ / 0-)

        ...largest private health insurance carrier.  They've been in business for decades.  That's no guarantee that they'll stay in business, but they've been able to last this long.

        This Space For Rent

        by xynz on Mon Dec 08, 2008 at 03:57:25 PM PST

        [ Parent ]

  •  Thanks Doc! (8+ / 0-)

    This diary offers an excellent prescription for a sick system.

    Democrats give you the Bill of Rights; Republicans sell you a bill of goods!

    by barbwires on Sun Dec 07, 2008 at 12:57:37 PM PST

  •  Well (3+ / 0-)
    Recommended by:
    Persiflage, kurt, cameoanne

    What people are afraid of is a large government agency controlling healthcare. They don't want to have to go to an unfriendly office building and have bureaucrats decide their care.

    The type of plan that I would support is one where the doctors and drug companies remain private. The government would handle the reimbursements and the insurance companies would then shift to handling those responsibilities, as opposed to denying claims.

    I see that scenario happening because the insurance companies will not allow themselves to be thrown out of business. And if I were the CEOs of the insurance companies I'd start developing a business model along those lines.

    •  The idea that there will be some Orwellian (11+ / 0-)

      or Soviet-style gray building where a bureaucrat will determine your fate is a bit infantile. You've bought into some strange right wing fantasy/nightmare. No one advocates that, and certainly not anyone in this thread.

      We need to avoid the strawman arguments.  What we have sucks for the majority of the people.  The system you describe is almost the same as what we have, but with medicare for all.  Who says we need new scary buildings?  Who said drug companies would be privatized?

    •  The problem is that many of us (18+ / 0-)

      already deal with a large unfriendly office that decides our healthcare. Only, it's an HMO and for-profit. I cannot tell you the number of times I have had to fight for things like physical therapy only to be denied for the quick fix of a prescription like a painkiller that doesn't help me to recover. It masks the problem.

      I am thankful to this doc for sharing his perspective. It helps me to better understand the issue from the doctor's side.

      Change. Such a small word Full of grace, it comes alive As one embraces hope. The Radical Imagination: Dreaming of the future as it might yet be.

      by Edubabbler on Sun Dec 07, 2008 at 01:11:56 PM PST

      [ Parent ]

    •  I've got news for you - (7+ / 0-)

      with insurance companies you already have people in an unfriendly office building deciding health care.

      They are not government workers following established rules for claim payment.  They are insurance company workers following corporate guidelines intended to maximize profits and to deny as long as legally possible any questionable claims requiring further information.  Many claims simply expire due to failure to respond to questions, or a misunderstanding of the confusing recourse process.

      The insurance companies still handle Medicare payments - the huge Medicare contracts are awarded to large insurance companies who do the actual work of processing medical claims and issuing payment.  It is just another division of the company.

      The insurance companies do not want single payer because the current system is too much of a cash cow - sharp operators can squeeze a lot of profit out of healthcare in a myriad of ways - underwriting, contracting physicians, repackaging care and taking facilities from non-profit to for profit corporate status - all of these at the expense of the patient/consumer.

      I worked in the industry long enough to know it needs to die a well deserved death in its present form.  The change to single payer using the medicare model would be remarkably easy - the base structure is already there.

      * "If you're going to play the game properly you'd better know every rule." - Barbara Jordan

      by jarotra on Sun Dec 07, 2008 at 05:08:46 PM PST

      [ Parent ]

    •  Unfriendly bureaucrats already decide your care (1+ / 0-)
      Recommended by:
      SingleVoter

      They work for claims departments of your insurance company.

      People need to pull their head out on this one.  Corporate bureaucrats can be as bad or worse than government bureaucrats.  And they charge way more for their services.

      "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

      by mbayrob on Sun Dec 07, 2008 at 11:50:51 PM PST

      [ Parent ]

  •  I was expecting another whine... (14+ / 0-)

    ... from a physician who thinks s/he doesn't get paid enough. Instead, I found a long, thoughtful diary pointing to support for a universal, single-payer health care plane for all Americans.

    Very, very refreshing. Thanks for this diary!

    Oh, yeah. My 2 cents' worth: Add one age group to Medicare every year. For example, in 2010, add the 60-65 year old group; in 2011, add the 55-60 year olds; in 2012, add the 50-55 year olds; etc., etc.

    I don't know squat about the demographics of each age group, so my "plan" is the idea of adding more folks each year rather than intending to be specific about which groups get added. I've selected the criterion of age, from older to younger, because Medicare covers older folks anyway. It seems like an easier way to add folks than by increasing income levels, which might make more sense but would cause much more howling among conservatives. (Although perhaps if we added people by decreasing income levels, with the wealthiest being added first, the wealthy folks who control our country might be more easily pacified [unless they decided that once they got theirs, the rest of us could just go off and die]...)

    Fucketh not with the MF diary, for you have but 5 HR, and we (collectively) have hundreds.

    by SciMathGuy on Sun Dec 07, 2008 at 01:08:18 PM PST

  •  From a retired RN, great explanations for public (11+ / 0-)

    I am also printing this out to give away.  Thank you for taking the trouble to do this.

  •  Excellent Diary. Thank you (22+ / 0-)

    I'm a retired RN who remembers what truly patient-centered care was like. (as opposed to profit-centered care). I saw my role change from being a primary care giver, to being a pill pushing, paper shuffling cog in a profit making machine. Where once I garnered excellent evaluations for my patient care skills, by the end I drew reprimands instead for "poor time management". (IE: spending too much time with my patients even as I was being expected to care for twice as many patients)

    My heart goes out to you and to all the dedicated health care professionals and workers who choose this work because of a sincere desire to heal the sick, and now find themselves in circumstances that make doing this so incredibly difficult, in order for business to rack up obscene profits. It goes out even further to all who need medical care and can no longer count on being able to get it, or who suffer terribly from the inevitable decrease in quality of care by over worked and over stressed staff. As always, it's the poorest and most vulnerable populations, who have no voice at all, who suffer the most.

    In my mind, it is unethical and immoral to profit from the suffering of the sick, disabled and aged. It is just plain wrong and it makes me feel ashamed of my country.      

    Silence is Complicity

    by scribe on Sun Dec 07, 2008 at 01:18:16 PM PST

    •  Wow (5+ / 0-)

      Apparently there are a number of us ex-nurses around here! I had exactly the same career experience you did. I loved nursing when I started out. A certain amount of paperwork was always necessary, but patient care was absolutely primary. I was treated as a respected member of a professional team. By the time I quit my last job, two years ago, hospital staff had been cut to the point that I had almost zero time with patients beyond handing out medicines. Instead, my time was spent answering phones and doing mountains of paperwork. Real teamwork no longer existed.

      But I'm told that the hospital chain I was working for made record profits. In my opinion, for-profit hospitals should not exist, and neither should for-profit insurance.

  •  3 out of 5 Doctors Support Single Payer (10+ / 0-)

    40% of doctors are a-hole get rich Republicans like my ex father in law the fraudulent cardiac surgeon. Who managed to keep his skirt neatly pressed as his partners and colleagues were swept up in a huge medicare fraud criminal indictment for unnecessary heart bypass surgeries.

    Helps if your son is a shady "connected" attorney and your partners are from India and you are white Irish and a rich "upstanding" member of the community. Whose the DOJ and FBI gonna believe?

    No worries. Off to Aspen for the holidays.

  •  Imagine (4+ / 0-)
    Recommended by:
    elfling, quadmom, cameoanne, dle2GA

    what would be ideal and then design a system, damn those that get in your way. It is so easy...but there is no room for private insurance.

    • Private health insurance need not be outlawed, just made useless.

    Ask the private insurers "did you ever worry about eliminating a person in medical need"? Then, give them the same consideration.

    Our anwser is contained in the question. We know the answer, we all know the answer. Obama knows the answer..don't let him walk away from the truth. That is our job.

    We have to stop being enablers to failure.

  •  Bureaucracy (11+ / 0-)

      It's an article of faith among the those opposed to any kind of government health care that any such programs would inevitably lead to a massive increase in government bureaucrats, a class of mandarins who would answer to no one - yet what is it we have now?

      As more physicians settle into specialties, it's a nightmare to get a referral, deal with all the insurance complications, the inability to share records easily or even know who is going to pay for what, or how much it will cost.

       And anyone who claims that government medicine will lead to health care rationing is ignoring the de-facto rationing we have now where millions of Americans can't get any kind of health care except on an emergency basis.

      Further, can anyone justify the co-payment scam? The rationale is that you make patients pay some fee to control costs, by giving them an incentive to not go for medical care unnecessarily. Yeah right - is there really that big a group of people who would just decide "I'm bored - I think I'll go see a doctor just for something to do."

       Co-payments are counterproductive. They discourage people from getting routine preventative care, like vaccinations or physical exams. They discourage people from getting health care at the early stages of a developing condition, when treatment is often most effective and simplest. People hold off going until they can't ignore a problem any more - or until they end up in the emergency room.

    "No special skill, no standard attitude, no technology, and no organization - no matter how valuable - can safely replace thought itself."

    by xaxnar on Sun Dec 07, 2008 at 01:54:49 PM PST

  •  Even though your argument makes sense... (1+ / 0-)
    Recommended by:
    catdevotee

    "As I look at my office budget, the $36,144 that I currently spend on employee health insurance  is less than the $44,498.97 that I calculate would be owed under a tax of the magnitude contemplated by authors of single payer reforms. "

    This will give the conservative, republican blow hards just what they need to convince enough people that it's just another example of Democrats raising our taxes.  

    "[People] are anxious to improve their circumstances, but are unwilling to improve themselves; they therefore remain bound." - James Allen

    by gchap33 on Sun Dec 07, 2008 at 02:02:47 PM PST

  •  Rock on. (4+ / 0-)
    Recommended by:
    elfling, CoolOnion, kurt, Ming Vase

    Keep voter registration forms in your office.
    Ask about voter registration as part of a general history.

    That's awesome. We had voter reg forms placed at a lot of clinics and public health centers to register folks who can be otherwise difficult to find because they work so many hours and may not live in accessible neighborhoods.

  •  capitation (8+ / 0-)

    This is my new word for today.  I had to read the sentence containing this word four times before my brain relented and accepted the meaning of this new word.  

    I'm still having a hard time adjusting to this new word.

    The concept of payment based on the number of patients assigned to a Dr. instead of the number of patients the Dr. treats seems so odd.

    I'm trying to think of other industries where this is common.  Can anyone help me?  

    A little quick research tells me I'm late to the game since this has been around for quite a while.  

    Is this another bean counter's dream that turns into a nightmare at the reality level?

    Is this a wise approach to medical care?

    •  I keep repeating this to my students (3+ / 0-)
      Recommended by:
      Sychotic1, ER Doc, bigchin

      I think we all have a hard time believing it. Hey, if one thinks the main problem with the U.S. health care system is that people are getting too much care, capitation certainly gives doctors an incentive to put a lid on it!

      •  That was exactly the point (6+ / 0-)

        Capitation systems were set up so that doctors had a financial incentive to personally ration care. The theory was apparently that the rationing decisions would be more acceptable to patients if they were being made close to home, by the patient's trusted physician and his partners, rather than by a faceless bureaucracy. Under the capitation system, the clinic was responsible for paying the cost of outside referrals and surgery. I remember going to "care committee" meetings early in my career, when I was in family practice, and arguing with the committee (composed of the senior physicians who were my employers) about whether we'd have to spring for the hip replacement surgery, or whether my patient could walk on his deteriorated arthritic hip for one more year.

        -5.12, -5.23

        We are men of action; lies do not become us.

        by ER Doc on Sun Dec 07, 2008 at 04:49:02 PM PST

        [ Parent ]

    •  Capitation is a potential financial (0+ / 0-)

      and ethical minefield.

    •  It beats decapitation (0+ / 0-)

      at least for most non-Republicans.  The GOP faithful wouldn't notice the difference.

      "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

      by mbayrob on Sun Dec 07, 2008 at 11:55:45 PM PST

      [ Parent ]

    •  Capitation needs to be combined with (0+ / 0-)

      excellent and accurate health information systems and use of best practice guidelines.  The incentives for providers to behave in ways that are the opposite of the incentives of fee for service care are just as dangerous.  Providers are well meaning and generally trustworthy people.  But that doesn't mean that we can do without some modicum of checks and balances, or that we should stop providing feedback that keeps the system performing optimally.

      It's too bad the school of hard knocks gives you the final exam before the first class

      by Imavehmontah on Mon Dec 08, 2008 at 07:45:29 AM PST

      [ Parent ]

  •  Good statement -- but --- (7+ / 0-)

    Stop Dancig Around The Issue

    (The statement is good but I don't agree with the rest of that post.)

    One of the biggest issues that everyone is dancing around is the outrageous profits made by the health insurance industry.

    They profit from denying people coverage: their stockholders profit from that too. Their stockholders are more important than their patients. Period.

    Doctor Roland, thank you for a detailed and sober look at the problem. I look forward to your next diary.

  •  When will all the health insurance companies... (1+ / 0-)
    Recommended by:
    blueocean

    ....be requesting a bailout?

  •  I've Had Serious Misdiagnoses Due to the Speed (9+ / 0-)

    required of doctor examination. I'm dealing with one right now of an infection that's become pretty scary.

    We are called to speak for the weak, for the voiceless, for victims of our nation and for those it calls enemy.... --ML King "Beyond Vietnam"

    by Gooserock on Sun Dec 07, 2008 at 02:22:28 PM PST

    •  Been there, still dealing with it too... (6+ / 0-)

      My previous doc didn't care about actually treating the root cause of my severe anemia, because she didn't like the fact that I am obese.  She never made any attempt to hide it, and used it as an excuse to avoid treating me for anything at all, even something as simple as a sinus infection.  

      My anemia has progressed terribly, to the point that my iron is at a paltry 17ug/dL, and I have zero stamina and very little energy.  Naturally, weight gain due to lack of physical activity is making more problems with high cholesterol,not to mention, sugars have reached a level that could qualify for diabetes.  All because the cause of my severe anemia has never been properly treated.  My doctor's answer to everything has been "You're fat.  Lose weight."  End of appointment.  

      We have just started seeing a new PCP, who was appalled to see my lab results. We're finally going to be on track to find out what the real cause is and get it treated.  I only hope that because my insurance is changing on 1/1/09, I won't be locked out due to a pre-existing condition.  

      •  Sometimes (2+ / 0-)
        Recommended by:
        ER Doc, kurt

        .... gluten intolerance can cause this. And yes, there are some people whose metabolism goes whacko in the other direction and they get chubby because of it instead of skinny, altho you don't meet many physicians who know this.  Once the person gets their diet in order and perhaps gets the other underlying auto immune conditions treated that the glu intolerance caused in the first place, then they can get their weight back down.  
        Get genetic testing (can be done anon by mail order if worried about the pre existing conditions garbage) to see if you carry the right genes if the blood test comes up negative.    
        Untreated Lyme can also cause gluten intolerance can cause thyroid problems can cause weight gain, pcos, anemia.
         

        "Toads of Glory, slugs of joy... as he trotted down the path before a dragon ate him"-Alex Hall/ Stop McClintock

        by AmericanRiverCanyon on Sun Dec 07, 2008 at 04:34:56 PM PST

        [ Parent ]

        •  After a gall bladder attack (3+ / 0-)

          I had an upper GI scope where they took a sample to test for celiac which came back negative.  I've got some stuff scheduled this week which should give us some insight... I hope.  Thyroid numbers are fine too.  Whatever it is that's causing this, it's sneaky. My new doc is determined to uncover it, though.  I'm so glad to have someone in my corner finally.  

  •  For what it's worth from someone on Medicare - (13+ / 0-)

    I was terrified when I had to give up my private insurance to go on Medicare at a young age (47) through disability. Guess what? I pay less, see the same doctors, have almost no paperwork to deal with and because I buy a supplement to my Medicare policy (for just over $100/month), I have no co-payments, and am covered for many routine things 'original Medicare' doesn't cover. I've never seen or heard from a scary bureaucrat. With the exception of Medicare Part D (the prescription drug part pushed through by Bush that suffers from most of the problems involved with private insurance), Medicare is an outstanding health care system system.

  •  Time wasted that could be spent providing care (6+ / 0-)

    I am quite certain that the wasted effort this system creates is so great that if we had a unified system of health care I could see 10-20% more patients – with two fewer staff.  Looked at from another direction, at least 10-20% of my current income is wasted on insurance bureaucracy which benefits no one.  

    I'm hazarding a guess that you didn't go to medical school to deal with insurance bureaucrats. How can there be any argument that the system we have is irretrievably broken?

  •  Medicare for all is the only reasonable (2+ / 0-)
    Recommended by:
    maracucho, ER Doc

    plan, that is, if government doesn't screw it up.  By that I mean with unneccessary paperwork, and a party like the Republicans coming into power and being able to dismantle the system because they think it is socialism.  However, I think government employees need to give up their healthcare and go with what all Americans are receiving as healthcare.  No special deals for Washington anymore.

    One other thing doctor, insurance keeps the wealthy and poor separated, and there are many doctors who feel entitled to absolute wealth and power, so how will doctors other than family doctors deal with a overall healthcare plan for all?

    Moreover, after being seriously chronically ill myself, and six neuro-surgeries, I really think we need to have more discussions on death in this society.  Death is a part of life and after being so close to it a few times I really have some questions that few are will explore.

  •  Thank you for a detailed and valuable diary (2+ / 0-)
    Recommended by:
    AllisonInSeattle, ER Doc

    More lawsuits are not the answer.

  •  A single payer system is the only thing (3+ / 0-)
    Recommended by:
    Alexandra Lynch, ER Doc, Imavehmontah

    that makes any sense.  The insurance companies, the endless documentation they demand while insisting on lean medical staffs, lowering compensation for health care providers while gambling with insurance money in the stock exchange is just obscene.

    In essence we have commodified human illness and suffering.

    A single payer system is the only thing that will make sense.  It is also one of the ways we can begin to be competitive in world markets.

    It is also a national security issue.  Given our current state of affairs, with lab tests etc. at the discretion of the insurer, rather than mostly with the Dr. an anomalous epidemic will spread far faster and create needless suffering due to a completely failed system.  A single payer system could not possibly result in more byzantine and inefficient, wasteful care than the cluster*uck of 1300 + different companies competing to stay in business by dumping clients from their roles, enacting paperwork and additional staffing to address it at the careprovider's expense, and refusing payment when the endlessly expanding documentation shell game isn't played to their satisfaction.

    You can thank these insurers for the increasingly lowered quality of health care; the fact that there are more administrators and clerks in hospitals than there are doctors and nurses.

    It is even worse in nursing homes.  I have heard stories about severe patient neglect because performance evaluations are now about the paperwork, not necessarily the quality of care, but documentation to prove quality of care.  Obscene.

  •  Thanks ....Plus more resources for us all... (4+ / 0-)

    A recommendation for all of us, if you haven't seen it, watch Frontline Special, 'Sick Around the World'. This provides some excellent perspective on how other advanced countries address the right and obligation to provide basic care to their community members.

    If we are going to create a workable new structure we have to get ourselves informed, and get our communities informed. This is a complex problem, and until we address the problem with some strategic depth as a country I suspect we will not succeed in creating positive change.  I believe we face enormous misinformation, because those who have the information - big pharma, the AMA and the insurance companies - ALL have too much corrupt vested interest in maintaining the status quo, or at the very least making sure any change affects them minimally, and without real regard for broader societal well being.

    In order to succeed it will be CRITICAL to bring genuine impartiality to the planning with concern first for our community members (that's ALL of us), and also a genuine concern for health care professionals (who this system has disheartened and frustrated). We also have to have some respect for the overall society, our investment in ourselves and appropriate use of our resources.

    We cannot afford to allocate 15% of our resources to care so badly for ourselves.  While it may be difficult or uncomfortable, the only genuine basis for real health care cost reduction must include real lifestyle improvements. We must integrate preventive care, as well as address cost reduction through technology and removing corruption in over prescription, excessive end of life care, and other clearly nonsensical expenditures.

    Have a look at a few more resources:

    Crossing the Quality Chasm, A New Health System for the 21st Century  Excellent work done, simple summary recommendations that make common sense.

    Overdosed America: The Broken Promise of American Medicine Harvard lecturer, family practitioner, left practice to discover the truth about 'medical research'. A must read.

    Best Care Anywhere A bit of truth about the VA medical system.  They deliver by many accounts the best care available, they 'own' the patient, so they make sure that care is administered early, unlike health insurance companies that don't do early intervention, since they don't 'own' the patient long term, and can gamble that someone else will have to pay for what they didn't treat early on.

  •  I lived in Canada for fifteen years... (10+ / 0-)

    and I can tell you that even though there are some frustrations (not enough specialists because Canada trains specialists only to have them come to "the States" because they can make more money here) overall, their system works quite well.  My understanding, from talking to friends in Ontario, is that the system is improving as many Canadian docs are going back home.  

  •  Daschle wants your health care stories (5+ / 0-)

    This is something I read on America Blog. I thought your insights ought to be posted there.

    "They pour syrup on shit and tell us it's hotcakes." Meteor Blades

    by JugOPunch on Sun Dec 07, 2008 at 04:25:49 PM PST

  •  i'm assuming, since you post the link, (1+ / 0-)
    Recommended by:
    ER Doc

    that you've managed to put this verbatim at change.gov? and thank you for the clear words as we all need clarity to drive down these new roads of change.

    I AM living in interesting times: and my hovercraft is full of eels!

    by greenbird on Sun Dec 07, 2008 at 04:44:18 PM PST

  •  Impressive diary! (1+ / 0-)
    Recommended by:
    AllisonInSeattle

    Dr Roland, thank you. THANK YOU!!! I make my living now helping to keep Medicare systems secure, to put it simply. I spent years developing and supporting a billing system for health care providers. Dealing with the complexity of the system has supported me financially for almost two decades.

    But I see the waste, the regulations and hoops that control this industry, the things that you and your staff must go through, and I completely agree with you. Get a single payer system!!!!! So much energy could be directed toward health CARE instead of to the stupid games that must be played.

    This diary is a keeper - and to be passed around. I wish you luck in your efforts, look forward to your future diaries.

  •  I was rejected for being a cash pay patient by an (3+ / 0-)

    orthopedist's office last week.

    I have some problem with a joint on a finger. My gen prac dr. (actually his sub as he was out of town) wasn't sure what to do, so he referred me to an orthopedists' ofc. across the street.

    I called the orthopedist's ofc. and they informed me that he rarely takes non insurance clients and to be taken as cash pay, I'd have to 1. give a refundable $250 cash deposit before the office visit and 2. submit to a bunch of informational questions over the phone and 3. they'd have to ask the dr. for approval for seeing my case. The receptionist added that what if I had to have surgery yet I had no coverage, how horrible!

    Nice treatment, for a finger that likely needs nothing more than a correct splint fitting and proper diagnosis and no surgery whatsoever.

    Needless to say, I am shopping for services elsewhere. But I was shocked at this treatment. I was not offered any referrals from the orthopedist when I asked for some, that seemed unprofessional to me.

    All this for a minor problem. Now I'm not sure whether to go back to my regular dr. for another apt. since he's back from vacation, or go to a community clinic, or shop for another orthopedist office.

    This is another obscenity from our idiotic insurance price inflating system. Don't get me started on how insurance has inflated the price of dental care into unaffordability for even insurance policy holders.

    Children in the U.S... detained [against] intl. & domestic standards." --Amnesty Internati

    by doinaheckuvanutjob on Sun Dec 07, 2008 at 06:01:12 PM PST

    •  I had a similar experience with a rheumatologist. (1+ / 0-)
      Recommended by:
      doinaheckuvanutjob

      I needed an evaluation and formal diagnosis of my condition. You would think that such a visit is pretty much a bread-and-butter thing that they do all the time, right?

      They had to call me back after they figured out how much it would cost a self-pay patient. I finally said, "I am going to bring money with me. I want to know how much to bring. I am willing to have you bill me for extra if extra services happen. I want to know how much I am going to have to write the check for if nothing extra happens."  I honestly felt like I was talking to third-graders.

      But of course, if they're used to insurance doubletalk and games, simple questions would throw them.

      Incidentally, I now have management of my rheumatic condition done through my family doctor. I got tired of paying three hundred dollars for nine minutes of what was not at all his full attention, and having to take a day off work to get there and grovel for the meds I need to manage the said condition.

      •  Yup (0+ / 0-)

        My genl prac dr. is now cheaper for me to see now that he gives a 40% discount for immediate cash pay. Makes office visits to him way more affordable and even cheap in today's market. This policy appears to be the Sutter Corporation's decision as they were bought out by them, at least his office folks claim Sutter made the change.

        Navigating this newly developing insanity of muddled and often really stupid practices is really something. The orthopedist who won't be getting my business apparently thinks all self pay-ers are ne'er do wells who should be stiffed, instead of cash in hand. Of course the needs of the patient, and the needs of society and health are completely outside of the equation in our brave new medical system.

        Children in the U.S... detained [against] intl. & domestic standards." --Amnesty Internati

        by doinaheckuvanutjob on Mon Dec 08, 2008 at 02:43:39 AM PST

        [ Parent ]

  •  Thanks ---from spouse of solo family doc of 30 + (2+ / 0-)
    Recommended by:
    mbayrob, cerulean

    My wife has fought the good fight for over 30 years as a wonderful, kind, well respected family practice doc in a 50,000 + area.  She and about 4 other "old timers" are struggling to hold on and provide care despite making very little money after all the payments to all, including a dedicated staff.  Most of the big clinics have nurse practitioners, nice, but not MD's see folks for care.

    A single payer plan for all usual care with private insurance for extra---cosmetic--or whatever tests and pills the TV convinces you to ask for---coverage is the way to go.  

    Let insurance companies advertise and sell whatever they want, but let everyone have basic coverage and a simple system for payment of those 90+ % of patients.

    With help, like you suggest, Sen. Tom Daschle can make it happen.

  •  A couple of points (0+ / 0-)

    you're going after an industry that constitutes 20% if our GDP, dwarfing the auto industry in employment.

    What about research? Though it's horribly inefficient now, how will it be funded under single payer at all?

    •  Most research is conducted through publically (4+ / 0-)

      funded universities and has nothing to do with insurance companies at all.

      •  but, it is ultimately expensed to the product (0+ / 0-)

        Companies provide medical products such as pharmaceuticals and medical devices. The nation spends a substantial amount on medical research, mostly privately funded. As of 2000, non-profit private organizations (such as the Howard Hughes Medical Institute) funded 7%, private industry funded 57%, and the tax-funded National Institutes of Health supported 36% of medical research in the U.S.[15] However, by 2003, the NIH provided only 28% of medical research funding; finance from private industry increased 102% from 1994 to 2003.[16] Research and development for applications is primarily done in commercial labs, while the government and universities fund the majority of general research.[citation needed] Much of this basic research is funded or conducted by governmental research institutes such as the NIH and NIMH.

         Wikipedia

        •  An example why you should be skeptical (1+ / 0-)
          Recommended by:
          AmericanRiverCanyon

          of some of the stuff you see on Wikipedia.

          Insurance companies are not a significant funder of medical research anywhere I know of.  I'd check the history of that article; there are PR firms that do that kind of shit on behalf of their corporate clients.

          "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

          by mbayrob on Mon Dec 08, 2008 at 12:01:27 AM PST

          [ Parent ]

    •  The insurance industry (5+ / 0-)

      contributes nothing to research, unless you consider design of new insurance "products" to be research

      Dr. Aaron Roland is a family physician in Burlingame, CA.

      by doctoraaron on Sun Dec 07, 2008 at 08:29:19 PM PST

      [ Parent ]

  •  We need single payer system NOW (1+ / 0-)
    Recommended by:
    bigchin
  •  An an ex-pat living in Canada (9+ / 0-)

    IMO, the reason the US health care never seems to change, is the framing. NO ONE seems capable of saying "health care" w/o saying "insurance". They want to "reform health care insurance". That's a ticket, not to nowhere, but to exactly where we ARE.

    Single-payer is the ONLY option that will truly change US health care. NOT "single-payer INSURANCE". As long as we attach "insurance" to "health care" we'll get no where.

    Health care is a BASIC HUMAN RIGHT. I don't need "insurance" to vote, speak my mind, "pursue happiness", etc - and I shouldn't be required to have insurance in order to be "allowed" to be healthy.

    I moved here to marry a local; we've since divorced. I truly love Canada - but NOT at the expense of the US. I'd like to at least have the OPTION of returning to the US, should I choose - but, as I've stated before, were I to return to the US, I'd be medically indigent THE INSTANT I CROSSED THE BORDER. That is unconscionable, IMNSHO.

    "Anyone who believes exponential growth can go on forever in a finite world is either a madman, or an economist." -- Kenneth Boulding (an economist...)

    by grndrush on Sun Dec 07, 2008 at 07:28:51 PM PST

  •  What an eye opening essay- thank you. (3+ / 0-)

    I am one of the 44 million without health insurance.

    We are not poor- we just happen to work for very small companies that don't offer medical benefits.

    Individual plans are out of our reach.

    I hope that one day soon, not one citizen will have to forgo medical attention ONLY because of cost.

    I would like to see an end to all private insurers-and have medical CARE for all.

    YES WE DID! November 4th, 2008

    by Esjaydee on Sun Dec 07, 2008 at 08:33:52 PM PST

  •  thanks doc (0+ / 0-)

    passing your diary to everyone i know...good luck in your practice...

    They always say time changes things, but you actually have to change them yourself. - Andy Warhol

    by reesespcs on Sun Dec 07, 2008 at 08:41:17 PM PST

  •  Dismantling our insurance infrastructure (1+ / 0-)
    Recommended by:
    Fire bad tree pretty

    suddenly is probably not realistic.  The employment dislocation is probably the biggest issue.  My feeling is that it will be a multi-step process with one of the options being that people will have a government provided health option and  slowly but surely people will discover it is the best option and move in that direction. This will give the economy  a chance to absorb the dislocated workers.   Single payer is a no brainer except for the issue of what to do with the people who made a living off of the current complexity of the existing system.  

    This is another example of the free markets not be the most efficient.  Free markets are almost never efficient for end users...they are mostly just self serving.  

    •  Great points (0+ / 0-)
      I think that the other way single payer could be introduced gradually is through reform at the state level. But I would love to see Obama offer single-payer as an option in his health care reform and I am sure you will then see people voting with their feet.

      And the critics will be confounded by the stampede!

    •  Emancipating the slaves cost taskmaster jobs (0+ / 0-)

      Some people really need to lose their jobs.  The industry is an evil, and working for it is cooperating with evil.

      That's very strong, but it needs saying

      "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

      by mbayrob on Mon Dec 08, 2008 at 12:03:50 AM PST

      [ Parent ]

  •  I hope you or spokes people for this point (0+ / 0-)

    of view get "a seat at the table"
    At town halls Obama always talks about the seats at this health care negotiating table and he includes doctors and nurses there and advocates of all sorts along with the insurance companies...but he has himself there too (in the biggest chair) and has CNN covering it all so all the negotiating is for public view so there will be more traansparency and accountability...and public pressure. Presidents don't usually sit at such negotiations so maybe it was just pretty talk.

    But I hope the voices of this diary is heard. I'm surprised only Denis K. came close to it. Wonder what Ted Kennedy has planned. God knows he will be especially listened to now.

    This doesn't aound like Obama's plan at all though

    The Obama Plan, employer-mandated private insurance with a network of subsididies for those who can't afford to buy private insurance on their own

    Only large employers are required to buy insurance or pay in. Small businesses have no mandate. If they do provide decent insurance get a 50% tax credit. There will also be like a co-op where they can join together for more buying power. To make insurance cheaper for business there would be federal reinsurance so a catastrophic illness won't shoot the rates up.

    Also people have a choice of private insurance or a public plan. My vague hope was the public insurance would be so much better in msany ways that it would be a step toward single payer...but I heard that Baucus assured private insurance that would not occur...not that his plan or way is any final word.

    One good thing about Obama's plan was that adult children up to age 26 could be covered under parent's plan even if they are not in college. That is a group often uninsured so I really like that.
    There are some other very good things too...for instance better pay for family doctors, more emphasis on wellness and preventative care, more home care...
    But I have no idea how much he will have to do with the forming of the plan now.

    •  Obama's plan (2+ / 0-)
      Recommended by:
      joynow, vbdietz

      would be a major incremental step that would provide better coverage for a large number of people if it is adequately funded.  The problem is that with this sort of plan there will still be millions who fall through the cracks and that the tremendous waste created by private insurance companies as I've outlined in the post will still exist.  In health care financing an incremental change is just not going to come close to solving our problem.

      Dr. Aaron Roland is a family physician in Burlingame, CA.

      by doctoraaron on Mon Dec 08, 2008 at 05:20:03 AM PST

      [ Parent ]

      •  I agree! It just wasn't what the brief (0+ / 0-)

        description stated.

        All the major candidates had pretty bad plans. Mandates when you are talking private for profit insurance was no answer either. People will fall through. We are giving undue respect to the existing structure as though not hurting the insurance companies matters more than getting people the care they need in the simplest, surest way and at the least cost.

  •  A story from Italy (0+ / 0-)

    I live in Italy and am covered by the state system.  My employer failed to meet promises when I moved here (grr grr grrr), and I had just given up my previous private plan from another European country when I had a gall bladder attack before my new supplemental coverage kicked in.  I have a large gall stone.

    I have waited since August for my surgery to remove the gall bladder.  At the end of November I was given two days notice and told to check in to the hospital.  This was delayed at the last minute and I checked in last Monday.  Nothing happened on Monday.  On Tuesday they took some blood tests.  On Wednesday they gave me an EKG and checked my lung capacity and breathing.  On Thursday they took some x rays, presumably for smaller stones that may have been in the bile duct.  Then I was informed my surgery was delayed and might be a week later because they only do emergency procedures on weekends and today is a public holiday in Italy.

    It was not possible for me to come home and check back in the day before surgery, I would lose my bed.  Luckily we found an Italian solution where I sign myself out in pencil so if anything happens the hospital is not liable, but I come back each evening so my bed is not listed as free for another patient.  But all told, two weeks in hospital BEFORE gall bladder removal, costing the government 800 euros a day.  If the keyhole procedure works and the doctor doesn't need to convert to open surgery I will be in for 2 days after the operation.

    Now this is extreme even for Italy as I've heard.  I'm at a large teaching hospital, in Rome, so it is not always so chaotic.  I am also extremely grateful that the operation is covered, i understand my situation is not serious or life threatening, I appreciate the amount of foresight in checking my heart and lungs before anesthesia, but I wanted to share my experience abroad.  My German fiance is having fits ; )

    The sun is shining, I have my furlough, so I am going out walking and appreciate my mobility!  When I go back to hospital tonight I'll have to stay during the week in case the surgeon shows up, or an operating room is free, so I will be stuck there again.

    "Our time has come, our movement is real, and change is coming to America."

    by lizah on Mon Dec 08, 2008 at 02:16:47 AM PST

  •  your last point is not exactly true (1+ / 0-)
    Recommended by:
    doctoraaron

    Private health insurance need not be outlawed, just made useless.

    If they are allowed to compete with the single-payer menu in any way, they will cherry-pick from the risk pool, thereby diminishing dollars to the single-payer kitty.  Not good...

  •  I got a headache just reading about the headaches (0+ / 0-)

    you and your staff experience.  Wow.

    Change has come to America. Change.gov

    by Chi on Sat Dec 13, 2008 at 07:20:50 AM PST

  •  Wow! I'm sorry I missed this when there was (0+ / 0-)

    time to recommend it!  Great stuff.

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