I would like to open a thread to discuss healthcare reform. This is not to discuss the healthcare debate, rather, a chance for people to defend certain ideas, plans or even the status quo. This is not to moved to the politics thread. Please, do not post unless you wish to seriously contribute.

Personally, I think a big government program will fail because it will attract thieves the way honey draws flies. There will be so much money and so little effective oversight that it will prove a bigger boondoggle than the Department of Defense.

I think what we need is a network of clincs underwritten by the federal government. Put everyone on salary, and charge a sliding scale fee for anyone who wants to go in. This way the private sector will still thrive (thanks to people willing to pay extra for better and faster service). That ought to ease the pressure on the emergency rooms that treat people as a last resort.

We could also have a federal catastrophic insurance program. It would take anyone and it would provide care in the event of a catastrophic event. Individuals could sign up and pay premiums while healthy. I would give anyone who wanted to sign up a limited window to do so, say two years. It would be a form of wagering: if you think you are not going to need the catastrophic care, you don't sign up; but if you lose your bet you get no coverage.

That's my idea.

The first thing we need to do is recognize the inherent flaw(s) in a third party payment system.

In the U.S. we keep calling it "health insurance" when it is a combination of insurance (coverage of unanticipated expenses) and a payment system (paying basic, anticipatable costs).

What we are doing with our routine medical expenses is inflating their cost by paying someone else to pay the bill on our behalf. We further inflate them by requiring the provider to pay someone to collect the money.

Imagine if my auto insurance paid for oil changes and tires. My local garage would need to increase his fees by $2 - $5 per oil change to cover the cost of hiring someone to file the paperwork for him to collect his fee. There would need to be new employees hired by the payment company to process the claim, again another $2+ per oil change.

At this point my oil change has gone from around $25 to $29 - $36 or so because I'm paying someone else to process (most of) the payment for me. I probably still have a $20 copay but the rest of the cost is "invisible" as it is simply part of my monthly "insurance" premium which will start to creep up.

Additional price creep can be expected by servicing folks realizing that since I likely have a flat copayment they can simply increase the cost of an oil change by $5. They negotiate this with the insurance company and an additional couple of bucks per month shows up on my premium. Almost invisible to me, at first anyway, but a sizable inflation rate for auto care.

Since I personally pay the auto insurance bills I wouldn't likely stand for such a system very long.

But with health care we consider this the norm. In the U.S. the majority of those covered are covered by their employer. They have no idea what the costs are, nor motivation to keep them down.

We can whine about physicians earning too much money, but until WE personally pay for their time they'll be able to earn a substantial income that many view as excessive.

We can complain all we like about unnecessary procedures, but until we personally pay for the procedures, we will simply do what the physician tells us to do and never think about the cost or necessity of the procedure.

If my employer were to take whatever is paid for my current health coverage and give it to me directly, heath care costs would come down pretty quickly.

Not only would I be better motivated to monitor and manage my routine coverage, since I would be spending my own money, but the processing expenses could be reduced considerably.

I no longer take cash or checks to the grocery store--I have a debit card. I swipe the card, the store is paid, less a small fee, and I take my groceries home. Imagine the cost of groceries if I had to sign a claim form and the store had to send the claim in for processing. (Imagine the steaks I would buy if I has a simple "deductible" on my grocery bill!)

So, starting next year my employer adds to my base salary the dollars that would have been spent on health care. Federal law says that I have to have those dollars deducted and deposited in a health care account at the same bank where my paycheck is deposited. A health care IRA or escrow account.

My health care account is auto-billed every 3-4 months for a health care insurance policy that pays for unanticipated expenses, something with a largish deductible. That is a policy that is not going to be tapped to pay for routine medical expenses but will pay in the event of an accident or severe illness such as being hospitalized with H1N1.

I would get a debit card that would be coded to work only at qualified medical facilities--physicians offices, pharmacies, and medical supply stores. The debit card has fairly low processing fees and since there is no approval required from the insurance company, nor special paperwork to file, several people will be out of work, reducing processing costs.

Once per year, if my expenses exceed the deductible of my policy, the bank submits a complete report to the insurance company where it is analyzed to see if there were covered expenses incurred. Since most years I won't even reach my deductible, the amount of paperwork processed will be minimal. Insurance company staffs will be substantially reduced removing a cost that provides absolutely no health care to anyone.

For the poor and unemployed the system will need to be propped up in some manner.

The second key to reducing costs is practicing science based medicine. Both Blink and Gut Instincts illustrate improved--both in costs and outcomes--cardio care by basing decisions on a small number of key tests.

Normal practice is to give those showing up with possible heart attack symptoms a battery of tests, many of which are functionally useless for diagnostic purposes, but have the "feel" of good diagnostic tests. After obtaining an overwhelming amount of information from these tests the physician makes a decision that appears to be well informed, but is only somewhat better than throwing darts at a dart board.

Revised practice involves three decision points each based on a single, relatively quick, diagnostic test. The physician gets only the information they need to make a reasonable diagnosis given what is already known.

Where this has been done care has improved dramatically and costs have been cut significantly. Unfortunately the practices that lead to such changes are rare in the medical field. It is unfortunate that the practices often "automate" medical decisions in a way that is seen as dehumanizing by physicians and patients. It is also unfortunate that such procedures are of no interest to insurance companies that merely pass along the increased costs to whoever is paying the bill.

RE: third party payments. There is an article over at Slate about people getting nailed by their insurance company for tiny errors on their applications, and thus losing the insurance coverage at a critical moment. I'll see if I can find it.

There's a doctor here in Tucson who did the math and found out that by charging $50 a visit--cash only, no checks or credit cards, no insurance--he made more money and gave better patient care, since all the work of his staff and he himself went to patient care. That man is on to something.

RE: salaries for doctors. I never beef about this. Let them make their fortunes, they are honest fortunes. Consider the time spent in college, acquiring the knowledge. It's like 12 years! and they have to keep up with their reading and novel practices as well. Then there's the whole rubber-glove thing. What doctors earn they earn. Whining about rich doctors is the complaining of envious know-nothings.

I am quite concerned about this too, fraud I mean. The crusader (an obsolete artillery weapon) was canceled over 5 years ago, and DOD just now sent out the cease work order to United Defense. Thus, UD was getting paid to do work for five years on something that the government would never use!

However, despite this, I don't consider the entire DOD a "failure." Anytime you spend over half a trillion dollars, there will be fraud and waste. That does not mean we can just say, well, fuck this, let's not bother then. Personally, I favor something like favor like you propose for other reasons.

Say we have a large network of private clinics, with all cost paid for with taxes and a small co-pay to give people an incentive to act responsibly. People would be able choose their doctor and/or clinic, and of course clinics would compete for business and patients.

Prices would be set and controlled by the gov't in association with healthcare providers, since I believe that market forces will not be able to control costs for a variety of reasons. Mainly due to the life and death situations inherent to medical treatment, and the expertise it takes to judge and negotiate prices for healthcare.

Secondly, I think that Spock is right about the whole middle man factor. Insurance should be for catastrophic maladies, not check-ups.

And lastly,



I have a had time believing that outcomes and IMPROVED rather than stay about the same, thus saving lots of money with compromising care. How would doing too many tests actually hurt patients other than wasting their time? How would this hurt the doctors ability to deliver care? Unless your getting at the whole "paralysis of too much information" thing.

Please do. I find the whole idea of a third party payer to be misguided. Getting rid of third party payments is going to dramatically shrink the "insurance" industry and they are understandably not interested in any such system.

For minor procedures a savings account under your personal control doesn't cause these sorts of headaches. I'm not sure if having true insurance will necessarily address this type of problem, but it can't possibly get any worse.



I've been seeing stories like this for well over a decade. They are a driving force in my view that we need to (mostly) get rid of third party payment systems.

The right wing should be jumping all over this type of story rather than making stuff up about euthanizing the elderly. The libertarian/business wings of the republican party should just be in love with such an approach.



I give them no credit for time in school...I spent just as many years in school and earn considerably less. I'm also expected to stay current, which is part of the reading load I was complaining about in GW thread.

But I DO give them considerable credit for rubber glove stuff and 2 a.m. calls from freaked out parents. That earns them double or triple my salary, but not 10x.

I do favor some sort of a salary system for physicians. It just seems wrong to pay physicians on a piece work basis. In some discussions of the topic (e.g., NPR recently ran a series on health care reform) it has been pointed out that the third party payment system reimburses for procedures at much different rates. One procedure might take 8-10 hours and earns the physician $x, while a comparably different procedure that takes 3-4 hours earns the physician $3x.

It isn't too hard to figure out that given a choice the physician is going to perform the second procedure a lot more often than the first. On a unit-time basis the second procedure is roughly 6x more pay. A fixed salary addresses that.

At first glance it seems counter intuitive--as a species we really believe that more information improves our decision making. But there are converging lines of research in Cognitive Psychology that suggest 1) we tend to make our decision very early in the information gathering process, whether the information we have is relevant or not, and 2) all additional information does is increase our confidence in the original decision--whether that decision was correct or not.

In the medical situations what was found was that ER physicians handed a stack of possible heart attack patient folders made only somewhat overlapping decisions about the same group of patients. In several cases the same patient was assigned to intensive care by one physician and sent home by another.

Some tests provide very good diagnostic information, others provide little or no useful information, but without explicit standards all are used and weighted equally. Obviously non-informative tests are a waste of money. But worse is that if you physician received non-meaningful test results first they will make a decision and then treat the informative test as either confirming the original decision or as irrelevant!?

So, cutting the number of tests not only reduces costs, it increases the chances of getting the correct diagnosis/treatment.

A secondary benefit of standardized procedures is it reduces malpractice claims. If A physician judges that you don't need a test (maybe s/he read an article which pointed out that the test had little/no diagnostic validity) you are still allowed to sue for malpractice if the test is utilized as part of normal practice and you end up sick/injured. You may not win, but there are plenty of cases where you will because a jury will dismiss scientific evidence in favor of established practice.

There is an added problem that has gone unaddressed: the politicization of treatment. I don't mean judging outcomes or sending Aunt Sally to the hospice. I mean the use of political pressure to provide worthless treatments like homeopathy or laetrile. It will be the Crusader cannon times one million; every quack who has a following will be pushing his agenda, and by God his followers vote! All hell could break loose. The only thing that keeps those clowns down is the decentralized nature of our health care system; they live in the cracks, but with a federal program they could take over, the way Krylenko took over Soviet agriculture.

No doubt...the alternative "medicine" crowd is, politically, extremely effective---they've even got senators attempting to legislate the effectiveness of their "treatments." The last thing we need is politicians practicing medicine.

I'm guessing a gov't third payer system is the most susceptible to this sort of problem.