Technology vs. Reality

[maat55]

I respectfully disagree with the idea that we're riding the fence, and would argue that it's marriage to an ideology that makes the world appear that way.

It's certainly true that all problems don't have nice, fuzzy solutions. It's also true that each problem is complex and can't be solved based on a few predefined rules of thumb such as "free market good" or "everyone should have their needs met."

I want a solution that reverses the national debt, period. This thread was created to explore the difference in personal finance due to an explosion in technology.

We live longer, there are more goods and services, and it seems the only way to keep up with this is to spend future generations money. My stance is that whether it be, you or society, that cannot afford it, you should not have it, just because it exists.

[jIM_Ohio]

cschin4 - Excellent post. Healthcare is a very complex issue and there needs to be a link between the patient and the cost in order for there to be any meaningful or effective reform. Today, patients often don't know or care what the treatment they receive actually costs. All they know is what their copay is, what it costs them out of pocket. That has to change. People pore over the weekly ads to save $.50 at the grocery store but then go out and get a presciption filled for $100 at CVS that would have been half as much at WalMart, but since they aren't the ones paying the bill, they don't care. That needs to change.

ds- good post as well.

The single main issue with healthcare is that people want top care, but do not want to pay for it.

My wife and I are the type of people which avoid the ER and wait to see primary care doctor's first. Part of that issue is we have had a mis diagnosis or two with ER docs in the past, plus long waits.

I know there is a percentage of certain types of care which are not paid to hospitals (because of income and hospitals cannot turn any sick patient away). Any way to see this percentage? When my twins were born we saw this up close and personal (many of the babies in the NICU were probably not covered by insurance). My guess would be 20-30 percent easy.

[cschin4]

The problem is figuring out how to deter unnecessary care without deterring needed care at the same time. I've had patients refuse to go to the ER for evaluation because they have a $50 ER copay. They'd rather wait to see me where they only have a $15 copay. That's what we need to avoid.
__________________

Actually, I think the above is what is needed, not what should be avoided. We need to develop some type of "urgent care" or intermediate care clinics that are open and can handle the middle of the night emergencies and then refer to the ER for serious emergencies. A type of triage. Perhaps, we should have these clinics in ERs and people could be seen and then referred to the appropriate level of care at that point. And, leave the ER available for what it was intended for.

[disneysteve]

Actually, I think the above is what is needed, not what should be avoided. We need to develop some type of "urgent care" or intermediate care clinics that are open and can handle the middle of the night emergencies and then refer to the ER for serious emergencies. A type of triage. Perhaps, we should have these clinics in ERs and people could be seen and then referred to the appropriate level of care at that point. And, leave the ER available for what it was intended for.

I was referring to cases that actually warranted the ER, like someone who calls and says they're having chest pain and they'd like an appointment. Sorry, if you are having chest pain you need to proceed to the nearest ER immediately, not come see me in the office.

That said, I agree with you 100%. The fact that ERs are obligated to treat every patient who comes in needs to change. I've spent a lot of time working in ERs and up to 90% of visits are for non-emergency problems. The ER has to see those patients and the bills for even simple stuff run into the hundreds of dollars when a family doctor or clinic could treat the same patient for a fraction of the cost. There needs to be a system, as you suggest, for the ER to triage patients and send the non-emergency patients elsewhere for care at a lower cost.

Some teaching hospitals do have a system set up where routine patients are sent to the family practice clinic staffed by the residents. I tried to get something like that set up when I was a resident but the support and money wasn't there to make it happen.

Another thing that needs to change is the way doctors and hospitals are paid for services. Under the current system, how much an insurer pays for a particular procedure varies greatly based on who does the procedure and where it is done. If I see you in my office and order an x-ray, the x-ray might cost $75. If you go to the ER and they order the exact same x-ray, the charge might be $200. If you come to my office and I remove a wart from your finger, I might get paid $50. If a dermatologist removes the same wart, he might get $150. It doesn't make any sense and it increases overall costs to the system.

[jIM_Ohio]

DS-

I assume hospitals charge more because of
a) overhead (larger buildings, more staff)
b) demand
c) often the bill for xray is included under one admittance to hospital

c) for example my wife had ultrasounds done every week in hospital. Because she had been admitted under a $100 hospital admittance fee (to insurance company) any other dollar charged is paid by insurance (each admittance was a $100 deductable then 100% covered).

I am sure the Hospital billed more for the ultrasounds than her primary care would have (as an outpatient). Do you think a) and b) trump c)?

I think c) trumps a) and b)- meaning hospitals charge more because insurance is covering the bill more. My thoughts, I know little about how industry works from where I sit.

[disneysteve]

I assume hospitals charge more because of
a) overhead (larger buildings, more staff)
b) demand

I think c) trumps a) and b)- meaning hospitals charge more because insurance is covering the bill more. My thoughts, I know little about how industry works from where I sit.

Let's say you fall and hurt your arm. You have two options.

1) Come see me in my office. I order an x-ray. You go to the local hospital to have that x-ray performed.

2)You go to the ER at the local hospital. The doctor examines you and orders an x-ray.

Both x-rays are done in the same place by the same people with the same equipment but the bill is different. The "emergency" x-ray generates a higher charge than the "outpatient" x-ray. That's what doesn't make sense to me. Either an x-ray of an arm costs $75 or it costs $150. It can't be both prices depending on who is paying the bill.

Of course, if you have no insurance and you go for the x-ray, there will probably be a third price charged different from the other two options.

[jIM_Ohio]

Let's say you fall and hurt your arm. You have two options.

1) Come see me in my office. I order an x-ray. You go to the local hospital to have that x-ray performed.

2)You go to the ER at the local hospital. The doctor examines you and orders an x-ray.

Both x-rays are done in the same place by the same people with the same equipment but the bill is different. The "emergency" x-ray generates a higher charge than the "outpatient" x-ray. That's what doesn't make sense to me. Either an x-ray of an arm costs $75 or it costs $150. It can't be both prices depending on who is paying the bill.

Of course, if you have no insurance and you go for the x-ray, there will probably be a third price charged different from the other two options.

If I came to you for an xray, is my only choice the local hospital? Something does not sound right.

My kids pediatrician has an xray downstairs.
My primary care also has an xray downstairs.
I had an MRI done around the corner from my house once. It is 20 minutes to nearest hospital.
My wife's ultrasounds are done at her primary care office most of the time. Once she was admitted she needed to use the ultrasound techs at the hospital.

True story- my wife's was admitted twice to hospital in her pregnancy. First time was a Tuesday, sent home on Thursday with orders of bed rest and see your doctor on Monday.
That Monday we went to primary care, had an ultrasound done (cervix was measured, I think) and the doctor sent her to hospital. Do not pass go, do not go home, go to hospital. "This is not an emergency, but go to hospital, now".
So she was admitted and they did another ultrasound... she had two ultrasounds done within 36 hours I think, and the logic used was that different xray techs and xray companies measure cervix length differently, they needed consistent data to measure the changing of the cervix length.

Being an engineer, I can appreciate more than one scientific answer or interpretation... but at what cost was this done? We paid $15 and $100. $15 for copay at primary care and $100 at admittance to hospital. I have NO IDEA what each cost.

So I do agree there are major cost efficiency issues (meaning things done without regards to cost). I agree there are cost discrepency issues. Same procedure, two costs depending on one factor or another. I did not see a menu which listed prices, so its not like the consumers are truly informed.

If I broke my arm and you ordered me an xray, what would happen if I asked you
a) "what will this visit cost me?" or
b) "can you set my arm in the cast without the xray?"
c) "what will this broken arm cost me?"

What you said is also true (3 different prices based on insurance and whether admitted), but I do not think that paints the right picture (there are others which could do an outpatient xray, I THINK).

[disneysteve]

So I do agree there are major cost efficiency issues (meaning things done without regards to cost). I agree there are cost discrepency issues. Same procedure, two costs depending on one factor or another. I did not see a menu which listed prices, so its not like the consumers are truly informed.

Exactly. the consumer isn't informed. Thanks to insurance being the middleman, the consumer is often not involved in the payment decision.

Could someone go elsewhere for an x-ray? Sure. In my patient population, though, many people depend on public transportation. The easiest and cheapest place for them to go is the hospital as it is on a bus route, so my example is realistic.

This also explains the problem with overuse of ER services. My patient who fell goes to the ER, gets examined by a doctor and gets an x-ray and pays no more than if he comes to me to get examined and then goes for the x-ray. Maybe his copay is $20 at my office and $30 for the x-ray. At the ER, his copay is $50 and includes the doctor and the x-ray. So to him, the cost is the same. The bills that result, however, are not the same at all. The ER visit costs a lot more than the outpatient visit to my office, even though the exact same services were provided.

[cschin4]

Some teaching hospitals do have a system set up where routine patients are sent to the family practice clinic staffed by the residents.

That is a great idea. A 24 hr family medicine clinic. If ERs could add this as a layer of care prior to being admitted to the ER, it seems like it could save a fortune. Of course, there has to be a mecchanism to trigger emergency pass throughs so as not delay emergencies requiring immediate care. There needs to be some incentive put forth by insurance and/or govt Medicare, etc to develop and pay for such a system. At the very least, they should give some kind of grant to teaching hospitals to set this up and give it a trial and evaluate it.

[snafu]

Companies are closing, many people have lost their jobs, and more job loss is expected. What happens to their employer-linked health insurance? More companies hire on 'contract' basis, no benefits. What happens to medical insurance? Is it true that those who have pre-existing conditons, may not be able to qualify for insurance even if they are fortunate enough to gain employment with benefits?

[Inkstain82]

Exactly my point, the gov wanted everyone to have a house and look what happened.

A bunch of capitalist free-marketers jumped in and created a bubble that had little to nothing to do with housing for poor people?

[maat55]

A bunch of capitalist free-marketers jumped in and created a bubble that had little to nothing to do with housing for poor people?

Actually, it was probably a combination of both.

[irmanator]

I refuse to use the self checkouts since i am not being paid to run a cash register and i don't get a discount for doing their job so I am not doing it.

[disneysteve]

That is a great idea. A 24 hr family medicine clinic. If ERs could add this as a layer of care prior to being admitted to the ER, it seems like it could save a fortune. Of course, there has to be a mecchanism to trigger emergency pass throughs so as not delay emergencies requiring immediate care. There needs to be some incentive put forth by insurance and/or govt Medicare, etc to develop and pay for such a system. At the very least, they should give some kind of grant to teaching hospitals to set this up and give it a trial and evaluate it.

There are some things being done to incentivize non-ER care, but it is controversial. For example, in some areas, insurance companies are waiving copays for patients who go to walk-in clinics. As you might imagine, those of us in primary care are not too pleased with that. If a patient can go to the CVS Minute Clinic for free, why would he come see me where he has to pay $20?

Now they could pay the incentive to the hospital/clinic instead of the patient, but that might not reduce costs at all.

[disneysteve]

Companies are closing, many people have lost their jobs, and more job loss is expected. What happens to their employer-linked health insurance? More companies hire on 'contract' basis, no benefits. What happens to medical insurance? Is it true that those who have pre-existing conditons, may not be able to qualify for insurance even if they are fortunate enough to gain employment with benefits?

Lose your job, lose your employer-sponsored health insurance. You can pay for COBRA, but it is unaffordable for most workers.

Yes, I believe most states allow insurers to deny coverage of pre-existing conditions for a certain period of time.