This is why socialist health care doesn't scare me at all

[Goldy1]

Drug companies need to exist but I beleive profit is the main goal. To say not is like saying cigarette companies really want people to stop smoking.

I hate smoking, and I think it is the biggest evil of society after things like violence and drugs. it is so nasty that it makes my stomach turn.

Someone please tell me why a person would smoke? I get being addicted. I get that, but I don't get people who smoke and do not at least TRY to quit.

I have seen loved ones perish to smoking and will see more. (the cost of cigarettes are disgusting)

As far as depression goes, drug trials with placbos make them seem useless in many instances. (sure some may have brain chemistry issues, but many people need non drug alternatives)

[markusk]

I agree 100%. I've said before (perhaps in this thread but definitely on this site) that we need to focus far more on prevention. 75% of all healthcare spending in this country goes to treat PREVENTABLE diseases. Find a way to improve prevention and you solve the health care crisis. The money that would be freed up would be more than enough to provide insurance coverage for all those who don't currently have it.

Again, I agree that we need to shift our focus. Not just the focus of the doctors but, more importantly, the focus of the public.

I posted earlier that I am currently part of an experimental collaboration targeting diabetes treatment and education in my area. We are the "guinea pig" practice for what ultimately hopes to be a city-wide program. The original plan was to do a series of classes, 2 classes per group in July, August and September. They are being taught by a registered dietitian and certified diabetes educator. She (and the patients attending) realized by the end of the first session that 2 sessions wouldn't be nearly enough, so they expanded it to 4 sessions per group. The patient response has been tremendous. They are loving the concentrated teaching time. Patients who have been diabetic for 20 years are learning things about managing their disease that they never knew. And through the instructor, I've been learning information about long-time patients that I never knew that will help me better care for them. There is also an Endocrinologist working as part of this team and we've met with him a couple of times to help instruct us on better ways to manage our patients and their medical treatment. It is far too soon to know what lasting effect this will have on outcomes, but it can only be positive. If we can improve patient compliance, get people to take a more active role in their own well-being and understand the importance of diet, exercise and properly taking their meds and following up regularly with their doctor, we can reduce the long-term effects and complications that come from diabetes.

Sorry to ramble on but I'm just trying to illustrate that their are efforts being made to address problems in healthcare that don't involve the government. In fact, this program is being funded by a grant from one of the major pharmaceutical companies. So all the conspiracy theorists who believe that the drug companies don't want people to get better so that they can sell more drugs can go stick it.

Disneysteve, I think you bring up a very important point. Since we know that prevention is more cost effective in the long run, why are we not doing this all the time?

As I mentioned in other posts, the reason I think is rooted in the fact that healthcare in the US is still in a 19th century "fee for service" pay structure where physicians and hospitals can't help but look at patients other than "revenue streams." Empty beds in hospitals = lost revenue. Missed appointments or "no shows" by patients to physician's office = lost revenue. Returning patients phone calls = no revenue and time lost not seeing patients (insurance companies do not pay for phone call visits). In the 21st century, why don't we have a system where patients can email their physicians? Answer is simple: physician don't get paid for answering email.

Oh yeah, healthcare in the US is also fragmented with huge gaps in service with a slap-dash approach, with an inherent lack of comprehensive coordinated care.

Take the diabetes example you mentioned. Why don't ALL health insurance companies enroll all newly diagnosed diabetics to a mandatory class taught by a physician/NP/PA/endocrinologist every week (maybe twice or three times per week if the need is greater per given area)? They could go over the pathophysiology of the disease, complications, why it's important to maintain good sugar levels, etc. There could even be a refresher course for those who need it.

The fact the diabetic class you mentioned is an "experimental collaboration...'guinea pig' practice" tells us what? That insurance companies don't know how diabetes affects every organ system? That they don't know how expensive it is taking care of complications of diabetes? That insurance companies are not interested in saving BIG money in the long run? I don't think the answer is simply a matter of "insurance companies are only interested in profits vs keeping people healthy." We know preventing disease saves money. Saving money = bigger profits, bigger bonuses, and bigger dividends for insurance companies and their stock holders.

It sound like a no-brainer to me. But preventive classes like these are rare.

[swanson719]

There is always going to be those diseases and other complications that go unexplained. The more medicine advances, the more we realize we don't know everything. For instance, why do some diabetics go blind, have renal failure, or need amputations, while others with the same lifestyle live well into old age with little complication? There isn't a catch all explanation.

The biggest problem with preventive care is something DisneySteve has hinted on - whether or not we have a prevenative care system in place in the US, a large percentage of people will not utilize it, and those are generally the ones who are costing the system the most down the line. Take an obese smoker who abuses alcohol. Now put a prevention system in front of them. Do you honestly beleive they will use it? People who take care of themselves physically already are into preventive medicine for the most part. A doctor can tell a patient what to do to improve their health, but that doesn't make it law. With insurance, the patient can say they would rather "die happy" than live a life they don't like. And the only burden they place is on their family when they die.

If we change that system so that insurance can drop people who lead unhealthy lifestyles, it would seem to be advantageous. But how we do that and who determines a healthy lifestyle can't be arbitrary, and has to be pragmatic. We couldn't allow someone to be dropped for eating birthday cake or enjoying Christmas food. However, the person who is 40% bodyfat and smokes 2 packs a day is nothing more than a liability to themselves and the health care industry. Of course, they have a right to treat their body like a carnival, but do they also have an intrinsic right to have the American people foot the bill for their lack of care for themselves? This I have trouble with rationalizing.

There is a move by the Pentagon to phase in a smoking ban on the military in order to keep costs of health care down. If this is successful, it would set a precedent to be followed by nationalized health care. The military also has different physical training standards, body fat standards, etc. that must be met or you are kicked out. If our military has to follow these standards, which are needed, as a pretense to socialized medicine and a job in general, then how do we practically apply similair restrictions on the whole of American society? We have the conflict of the argument of "Health Care is a Right" against peoples "Right to Life, Liberty, and the Pursuit of Happiness". As a pragmatic measure financially, one or the other must be sacrificed in order to have a socialized health care system that will effectively reduce costs. Otherwise we see the attitude of "I'm not paying for it" that exists due to insurance now on a much more grand scale, which will only further inflate health care costs.

Health care reform is needed, no doubt. But how do we implement a prevention system that will work? We cannot force people to take care of their body any more than we can force someone to be a good parent. Both are objective measures. Without a prevention system, how do we control costs? And without controlled costs, how do we sustain nationalized health care?

[disneysteve]

The biggest problem with preventive care is something DisneySteve has hinted on - whether or not we have a prevenative care system in place in the US, a large percentage of people will not utilize it, and those are generally the ones who are costing the system the most down the line.

But how do we implement a prevention system that will work? We cannot force people to take care of their body

A few weeks ago, I would have agreed with you 100%. Now, my view has changed somewhat thanks to the diabetes program I mentioned. I was VERY skeptical about the potential success of this program. I would have bet against people showing up for the classes. I figured we'd schedule 10 people and have 3 or 4 show up.

The first week, 12 people were scheduled. All 12 showed up. The 2nd week, every single one of them came back for the next session! I was shocked. I've since spoken to both the instructor and several of the patients and they were all thrilled. The instructor said the patients were extremely receptive to the teaching, asked good questions and were very open about their own non-compliance and reasons behind it. The patients were very appreciative of the information and the opportunity to learn more about how to take better care of themselves. Keep in mind, I'm talking about some of my most difficult to treat patients.

So why isn't there more of this going on? As much as I oppose electronic medical record systems, they do allow for some very useful data collection and tracking of outcomes that a paper system doesn't. This whole citywide collaboration is based on compiling data from local hospitals, particularly ER visits. They started by looking at ER utilization and focusing on high utilizers, patients who were in the ER frequently over the course of the year. The worst case was a patient who had 115 ER visits in one year's time. They then broke out the data by diagnosis and found that asthma and diabetes were two big reasons for most of the high utilizers. Then they set out to devise a system to better care for asthmatics and diabetics to improve care, reduce utilization and costs and improve outcomes. The diabetic program I'm involved in now is the pilot program of those efforts. We're hopeful that what we learn by doing this program, working out the bugs and hammering out the best protocol will allow the program to spread citywide and beyond.

As for why the insurance companies don't do it, it is the same reason that non-healthcare firms don't take a long-term view of things. They are controlled by shareholders who demand short-term results. They want to show good quarterly earnings numbers. Nobody on Wall Street wants to hear that Aetna is making investments that will yield savings 10 years from now. They want to know why the stock price dropped 25 cents yesterday. People are short-sighted when it comes to money.

That is why you will see more and more prevention efforts that are NOT initiated or funded by insurance companies. As I said, the plan I'm in is being funded by a pharmaceutical company. The program at the Mayo Clinic is run by them, a private healthcare organization. We need to do this without the insurance companies.

[swanson719]

What incentive is there for a pharmacuetical company to fund a program like this? I ask because if insurance companies won't fund it, there's a disconnect between how it benefits one and not the other, because both have investors who are short sighted. Everyone has motives, usually self benefit or self preservation, and if we can find a way to show the benefits of the patient to also be the benefit of the insurance companies, then this would be transcendent throughout the industry and actually viable on a national scale.

The other question to it you bring up is the electronic monitoring system of med records. Is there a way to do this that is both secure from hackers and human abuse? What would be some of the accompanying unintended consequences to this? I see the downsides of it, but if the benefits outway the cost, then it's worth it. I just don't see the benefits of it, but I'm Joe on the street when it comes to health care stuff. This is where the public needs to be better educated in this dept.

[disneysteve]

What incentive is there for a pharmacuetical company to fund a program like this? I ask because if insurance companies won't fund it, there's a disconnect between how it benefits one and not the other

No disconnect at all when you think about it.

Patient A has diabetes but isn't taking care of herself. She isn't taking her medicine. She may not even be seeing her doctor regularly. Result is the insurance company isn't having to pay many, if any, claims. Saves money for the insurance company (in the short-term until the patient has a heart attack or stroke or some other complication). Diabetes drug company makes no money because patient isn't taking her meds.

Now, you put that patient into a diabetes management program. She finally understands the importance of taking her medicine and caring for her disease. She starts seeing her doctor regularly and he prescribes diabetes medicine for her that she takes every day as directed. Insurance company has to start paying claims but drug company gains another customer for their product.

The other question to it you bring up is the electronic monitoring system of med records. Is there a way to do this that is both secure from hackers and human abuse? What would be some of the accompanying unintended consequences to this? I see the downsides of it, but if the benefits outway the cost, then it's worth it. I just don't see the benefits of it, but I'm Joe on the street when it comes to health care stuff. This is where the public needs to be better educated in this dept.

There is a lot of buzz about electronic medical records today. They have pros and cons. They do help track outcomes much better but they are expensive to implement and maintain and most smaller doctor practices don't have the resources to do that. Doctors who use an EMR don't earn any more money so where are they supposed to get the10K or 20K or 50K needed to purchase an EMR system, install it, train their staff, convert all of their paper records to electronic form, etc. Sorry, but as much as doctors may truly care about treating patients and helping people, they need to be able to pay their bills, too.

What we really need (and this does exist with at least one company I've heard of) is a web-based platform that wouldn't require a huge monetary outlay for software and support on the part of the doctor. Charge a reasonable fee to subscribe to the service. That could also get around compatibility issues with different doctors each having a different EMR system that can't talk to each other.

[markusk]

The biggest problem with preventive care is something DisneySteve has hinted on - whether or not we have a prevenative care system in place in the US, a large percentage of people will not utilize it, and those are generally the ones who are costing the system the most down the line. Take an obese smoker who abuses alcohol. Now put a prevention system in front of them. Do you honestly beleive they will use it?

swanson719, I don't think it is a valid argument to say that we should not have preventive classes (for diabetes, asthma, etc) because we know people won't come. It depends on how the need for the classes are presented and how informative and useful the classes are to people.

the fact is that most people in this country does not like any one telling what to do ====== most people would be upset at the idea of having to do any thing Mandatory , and I don't blame them one bit , quite the opposite . I would not want any government telling me , that I have to take classes for a healthy diet...

RedThunderBird, maybe "manatory" is too strong of a word when used without context. I know we in this country have a strong aversion to anyone telling us how to live, etc.

So here is a way diabetic/asthma preventive classes can be presented:

We have an informative class on the life long disease of diabetes/asthma. The class will provide basic information that you will need to live with this disease for the rest of your life, including causes, prevention, complications and the resources available to you to help with diabetes/asthma. If you want to see an endocrinologist/pulmonologist, you must take this class because the physician will assume you have taken the class and know the basics of your disease; otherwise the physican will spend a significant amount of your appointment time going over the basic information that you lack (becasue you missed your class). In otherwords, the physician will have less time addressing your specific needs. This will allow the physician to spend most of your appointment time tailoring diabetic/asthma care to your specific needs....

If preventive classes are even mildly successful, then there maybe less need for office visits, thus opening up "slots" in a physicians schedule....which means less waiting time for everyone else.

There is a lot of buzz about electronic medical records today. They have pros and cons. They do help track outcomes much better but they are expensive to implement and maintain and most smaller doctor practices don't have the resources to do that. Doctors who use an EMR don't earn any more money so where are they supposed to get the10K or 20K or 50K needed to purchase an EMR system, install it, train their staff, convert all of their paper records to electronic form, etc. Sorry, but as much as doctors may truly care about treating patients and helping people, they need to be able to pay their bills, too.

disneysteve, I agree with you that there are pros and cons to EMR: the main "con" is the cost issue. But the other problem is the lack of integration. This is because most physician's offices are independent self-employed small business owners (my 19th century reference).

When I was a resident, I can't tell you how many paper charts could not be found for the appointment or the handwriting was so bad I would spend most of the 40 minute appointment time trying to make out what was already done. The short cut was to re-do all the tests -- at least this way, I could move on to the next patient in a timely manner. What a waste!

EMR itself, however, will not contain cost of healthcare. The main culprit, I say again, is the "fee for service" payment structure that rewards procedures over listening to/talking to/examining patients. A good friend of mine in the metro-DC area gave up practicing general medicine awhile back and now only does botox. He only works 3 days out of the week. He makes more money now than working 8am - 6:00pm Mon-Fri (plus calls on the weekend) seeing patients all day.

[disneysteve]

EMR itself, however, will not contain cost of healthcare.

Two of the biggest fallacies being promoted by everyone up to and including President Obama are that EMRs will reduce costs and reduce medical errors. The reality is that neither of those things is true at all.

EMRs increase costs because the doctors need to recoup the cost of the system. Plus, the EMR makes it much easier to "upcode" meaning charging for a higher level of service under CPT coding.

EMRs also do not eliminate errors. What they do is change the nature of the errors. You no longer have errors due to bad handwriting. Instead, you have errors because someone clicked on the wrong box or selected the wrong item on a drop down menu or ordered the right medicine but in the wrong dosage or the right medicine but for the wrong patient. We don't have an EMR in my practice by we have done electronic prescribing for over 3 years. That is one component of EMR. I can tell you quite honestly that I've made loads of mistakes using the system. They were almost all mistakes that wouldn't have occurred had I hand written the prescriptions.

[disneysteve]

the US is still in a 19th century "fee for service" pay structure

I wanted to comment on this. You are correct, to an extent, that we are still a fee for service based system (FFS). That isn't as true as it used to be, particularly in family practice, though. Capitation, where the doctor is paid a certain amount per patient per month has been around for quite some time. However, that isn't good either because where FFS encourages the doctor to do more, capitation encourages the doctor to do less, even if more might be needed. You can see the problem with that.

The movement now is toward a pay for performance system (P4P). Under a P4P plan, doctors would earn more based on outcomes and adherence to some standardized guidelines. 85% of your females patients have had their annual mammogram? You get a bonus. Only 60% of your patients over 50 have gotten colonoscopies? No bonus. P4P is intended to promote preventative care and compliance with treatment protocols.

The problem is that P4P links a doctor's income to patient compliance. I can tell all of my patients of an appropriate age that they need to get a colonoscopy or mammogram or PAP smear or PSA test, but I can't make them do it. Reducing my income because my patients don't follow my advice isn't exactly fair.

What is happening where P4P is in place is that doctors are discharging non-compliant patients from their practices. Doctor recommends a test. You don't get it. You lose your doctor. Not the best thing in the world for strong doctor-patient relationships.

[Goldy1]

I agree that folks with bad habits don't get check ups. I always did b/c I am health conscious. My smoking fast food eating friends don't bother. Why should I suffer from high cost of insurance b/c of them? That is a separate issue. Even if they go, are they gonna change thier ways?

I can tell you one thing though, When I worked in opthalmology, most of our pts were eldery meaning well over 65. It was RARE I met a smoker. I guess I figured unfortunately they were passed on before getting old.

[cschin4]

What is the answer?

Paying doctors salary certainly would not encourage doctors to do more than necessary. Salary only doctors would have no real incentive to do more than put in the required time. Why do more for nothing? So, I don't see that as a great option, though many people do work on salary but it isn't the perfect solution.

Pay for performance? That is OK to some extent but what does that really mean? A doctor who has worse "outcomes" may indeed be a better physician, may be taking care of more critically ill or challenging pts, etc. By paying for performance, doctors will have the incentive to only take on those who are most likely to do well. As for the very sick, chronically ill , infirmed, etc. they will be left out. So, I don't see that as a perfect solution either.

In our present system, more cases, more patients equals more money. The obvious drawback to this is it may promote physicians to do more money making procedures and simple procedures that pay well versus time consuming, complex procedures that don't pay so well. And, I think that is what we are seeing now.

So, those of you who think the govt is going to somehow "fix" everything are very naive to say the least.

[cschin4]

I agree that folks with bad habits don't get check ups. I always did b/c I am health conscious. My smoking fast food eating friends don't bother. Why should I suffer from high cost of insurance b/c of them.

Why do you assume that their costs are higher and yours are less? Preventative care isn't cheap. There are LOTS of expensive procedures like routine colonoscopies, medications, doctor visits, lab tests and on and on that add up to a fortune. Someone who doesn't seek as much care or who even lives an unhealthy lifestyle may die sooner and in the long run may be have lower costs than you.

Which also brings up another point - Patient Autonomy. Do I or anyone else have the right to decide what treatments, tests and procedures I do and do not want? I do NOT want a lot of medical intervention throughout my life. I seek treatment as needed but there are tests and procedures and medications that I do want. If I die earlier because I refuse these things, so be it. I will sign a waiver or whatever. But, because the patient does not want to jump on board with every recommendation should not be a barrier to care or should it?

[swanson719]

Markusk, I'm not suggesting we not have preventive care - rather the opposite. The public needs to be better informed. DisneySteve has repeatedly given examples here and in other threads where patients are genuinely surprised that they aren't leading a healthy lifestyle, and when given the opportunity, try to correct that. I'd be interested to know the number who just blow him off as well though. It is not to say that it is not worth spending the money to help those who want to help themselves, but rather that for the addicts and obese who later in life have major illnesses and end up with diabetes, a pace maker, renal failure leading to dialysis, and all of the expenses that go with it, these throughout long term end of life care will be far more expensive than preventive care.

Cschin, I'm not suggesting that all people who don't have a regular doctor visit and check on everything cost the system more. If my job didn't require me to have a full physical every six months and a full set of labs, I wouldn't. What I am suggesting is the people who get sick and know they are getting sick and chose to do nothing about it until the preventive care measures cannot prevent anything and they choose to have a preventive chronic or malignant disease cared for, they cost the system more than any other. A colonoscopy and a mammogram are both much cheaper than treating bowel or breast cancer that is 2 years down the road.

As far as how the system is paid for, no matter what pay system we are on, there is always going to be different monetary incentives to abuse that system. Pay construction by the hour, in general, they will do things right and take their time. You pay more, but usually get a better product. Pay peice work, and they will fly through it as fast as they can and cut all corners that won't be noticed. The same happens in the medical field, in a business office, and in school. There is no "silver bullet" remedy to this.

We could always try a flat rate plus commission system, like what some car dealers do. Have the doctors get paid such an amount for coming to work and doing their job - and then they get an extra % for, as Disneysteve put it, patient compliance more or less. This would give the doctor the incentive to both take care of their patient, and ensure they take care of themselves, instead of dragging out care to ensure more office visits, etc.

[cschin4]

What I am suggesting is the people who get sick and know they are getting sick and chose to do nothing about it until the preventive care measures cannot prevent anything and they choose to have a preventive chronic or malignant disease cared for, they cost the system more than any other. A colonoscopy and a mammogram are both much cheaper than treating bowel or breast cancer that is 2 years down the road.

That may seem logical and intuitive but I am not really sure that is the case. Doing colonoscopies and mammograms on a nationwide scale and on everyone carries its own expenses. Maybe per person the cost is lower but in the long run, treating actual problems MAY be less expensive than preventative care. The old "if it ain't broke, don't fix it" line.

[mom-from-missouri]

My 2 cents

I don't agree with the above posters idea of placing a $250,000 cap on malpractice suits. Why? #1, a high school friend of mine died on the OR table as the result of an error in surgery for having her tonsils out(was given the wrong gas-tank was clearly labeled). She was a young mom to 6 kids, recently graduated from college and starting making around $55,000 a year. $250,000 would not begin to cover her childrens education and her lost income for the family.

#2. A 58 year old woman in a former church I attended went in for some back surgery. The doctor was under the influence and as a result she came out paralized from the waist down. $250,000 would not begin to cover medical needs-wheelchair, new bed and such. After her husband died she went to the nursing home as she needed full time assistance.

I do think changes need to be made in the malpractice industry--I have read of people who make their living by suing doctors. That needs to stop.

I don't agree with the socialist health plan for several reasons. I am sure I will hear back from those who disagree with me, but I for one, as a Christian don't want my tax dollars paying for someone elses abortion.