Health Care and the alternative point of view

[jIM_Ohio]

jIM, if your main focus is to improve inefficiencies, then a "single payer system" may be the answer. We currently have a fragmented/disjointed system populated by too many parties talking different languages and not knowing (or caring) what other parts of the system are doing. A single payer that pays for all the tests, doctors' visits, surgeries, hospitalizations, etc, can (force?) standardize and streamline everything. For example, one thing this single payer can do is mandate some type of a national EMR (Electronic Medical Records) -- which for me as a physician is a big deal.

Most labs, MRI/CT suites, doctor's offices notes, hospital charts, insurance invoices are still done on paper.

Before having an EMR, I saw inefficiencies all the time. An MRI result read by a radiologist or blood lab results are sent either by mail or fax to the ordering physician printed on a piece of paper -- which must be collected and placed into a physical box called an "in box" (of course). The physician then looks over the paperwork and either place it in a another stack of paperwork "to be filed" in the chart (assuming that the patient's chart can be found). A letter is often dictated and sent to the patient or other physicians. If a patient was admitted to a hospital, their physician has no way of knowing why/when or what happened during the admission unless the patient brings the paperwork to the office.

Sometimes, the patient's chart can not be found! This happened to me quite often when I did not have EMR so I usually have to start "from scratch."

Sometimes, I can't read someone's handwriting in the chart or it may take me a long time (time I don't really have) to decipher the notes. If I can't figure out what was already done, I have to repeat what may have already been done -- this happened more times than I care to remember.

Because of our fragmented system, some hospitals (or systems of hospitals) have some form of EMR but they can not talk to other hospitals in the same city (different hospital system) and are completely incompatible. Some large hospitals actually brought (at millions of dollars) two incompatible systems at once, one for outpatient care and another for inpatient care. A pediatric hospital may have one EMR but the adult hospital down the street has a different one. Your OBGYN may still do everything on paper and so does your primary care physician so communication between them is via fax or snail mail.

I would love a robust EMR: over a secure server I can access all the patient's labs, imagining studies, inpatient, outpatient doctors notes all on the finger tips. For patients maybe you can email your physician with simple questions, book your own appointments online or look up your own labs yourself. Things would not get "lost in the mail" or "we never got the fax." And you will not get lost in the endless phone message loop asking for lab/imaging results, appointments, etc. By the way, it has already been shown that when patients set up their own appointments, they are more likely to show up for the appointment. Most physician I know don't like gaps in their schedule due to "no shows."



Ahhh, you have voiced the fear many are thinking (I include myself here) -- not the fear of dating the only ugly cheerleader in school, but the real fear of the unknown. Many people are comfortable with the system we know how to (somewhat) navigate. If your current healthcare thru your employer is at a reasonable cost to boot, there is more to fear. So you may be passionate about encouraging efficiencies and stamping out inefficiencies but what if this costs you more in terms of more taxes OR, God forbid, a single payer system? No easy answers here.

We currently have a fragmented/disjointed system populated by too many parties talking different languages and not knowing (or caring) what other parts of the system are doing.

Single payer could either remove inefficiencies or add more inefficiencies- depends on your interpretation of the problems, interpretation of supply and demand as it pertains to health care, and many other factors.

Here is why I am against single payer:

1) It is now up to whoever that single insurer is to pay for things. This is permanent price fixing, which will be bad for quality of care. Because people will provide care to meet the "certified cost", but not work to exceed the standard of care that provides.

1a) I mentioned fixing prices earlier in this thread, and most did not like that. Most doctors will tell you if the government sets prices like they do for medicare, they would go out of business faster than they are now.

1b) if the single payer system resembles medicare, realize that medicare is going bankrupt. Meaning you need to reform the system the reform is directing towards (if the first reform is single payer, then the system everyone is moving to will need further reform because its heading to bankruptcy). I feel like single payer would be racing to what happens next- US goes bankrupt, I die, or the system gets fixed. My money is on the bankruptcy if these are the 3 choices.

2) That single insurer is government run (probably) and last I checked, the government can't run anything right. Toll roads need paving, bridges over rivers are collapsing and now I want to put my health into hands of these same people? Give me any other option. Government run anything needs a second choice to compare to.

2a) my take is if health insurance companies (the current system) have a level playing field- meaning they market their products like life insurance or car insurance companies, or other tax incentives for people which self insure are added, the competition between the insurance companies will be better than removing all the insurance companies.

3) I agree with this part of your post

We currently have a fragmented/disjointed system populated by too many parties talking different languages and not knowing (or caring) what other parts of the system are doing.

The system you want (computerized access to all records) goes against other laws the government has in place (HIPPA).

I am not naive to point where I think single payer is the fix to the problem. This is because what really needs to be done to solve problem is see what works in our system:

1) The quality of care is second to none, If you need health care, our system will give you the best care in the world, bar none.

2) If you have insurance, care is generally readily accessible. If I have to wait 12 hours for an appointment when I need my doctor (not a doctor, but MY doctor), that 12 hours is a LONG time. Its usually closer to 4-6 hours, and sometimes even less. If I call at 9am, I can often see my doctor before 5pm, and sometimes before lunch.

3) Most people have insurance. The numbers given earlier were 300 million insured to 30 million uninsured. Other people have suggested 60 million are uninsured. Regardless, if ration is 3:1 or 4:1 insured to uninsured, most people have access to insurance.


Those are the current strengths- those should NOT be compromised.

The obvious solution is to add more people to #3 (give everyone access to insurance).
If you compromise #2 when you do that, you actually made system worse I think (for the people which already have insurance).

Insurance companies need regulation, they do not need to be driven out of business (IMO).

As for some of your comments:

If you want all records on one system, can I opt out of that system? Do not tell me my records have to be online. NO WAY. That means I am one hacker away from my records being made public.

Could you imagine the uproar if Barak Obama had erectile disfunction and someone found that record when looking for my records? Of course that might explain a lot, but I digress.

If keeping consistent records is needed, what needs to happen is doctors need to work together and hospitals need to work together. I have been told in most cities hospitals compete with one another. In Cincinnati they work together. One of my kids was transferred from Good Samaritan Hospital (where he was born) to Cincinnati Children's hospital (I believe he was 7 weeks old when transferred).

When the transfer happened, all his records were transferred, and nurse stayed with him for first 4 hours at Children's to cover any gaps. The staff at both hospitals (and a third- University Hospital) rotate. The Neo Natologist at Good Sam has an office at Children's. The residents do rotations at each of the 3 hospitals. Cincinnati Children's is considered a top 5 hospital in the WORLD and it shares its staff within the city.

If we want records transferred, my doctor should hook up with an MRI provider, a hospital, and maybe some other specialists in the area. Then they can all choose the same software and system to store records on. That I am OK with because I trust my doctor more than I trust the government.

What this also does is allow different software companies the ability to compete for creating those systems (they exist now). If the government were to pick one software to standardize on, that company would become bigger than microsoft, and realize that microsoft is a monopoly, and last I checked windows sucks. Especially windows 7. If windows 7 was that fat guy's idea, and he's not a programmer, I now understand what the problem was- the person designing the system cannot program. But I digress...

In general, reform will be easiest if we tweak the existing system (like regulate the insurance companies and give the patient more rights than the insurances companies currently provide). If single payer is the solution, I am sure it could work, but that would mean higher taxes, and considering I have health care now, and my taxes are low, I do not need taxes to go up to give me something I am already receiving.

[disneysteve]

Single payer could either remove inefficiencies or add more inefficiencies

Agreed. The government is the pinnacle of inefficiency and waste.

The system you want (computerized access to all records) goes against other laws the government has in place (HIPPA).

That's not necessarily true. Just because records would be computerized doesn't mean HIPAA would be violated. The system could operate similar to what happens now but the access would be instant or close to it. Right now, if you walk into my office and I want records, you sign a paper release. I mail or fax it to the other provider. They have to pull your paper chart, photocopy your records and mail them to me. That might take 2-4 weeks. With a computerized system, I could fax that record release and they could e-mail me the records. That might take 5 minutes. Less staff time. Less postage. Less waiting for information.

None of this requires the information to be out there on the internet for hackers to view. It could be in-house at each facility, just easily accessible and transferable to other providers on an as-needed basis. Or, it could be online. I just got the iPhone app for Quest labs that lets me view my patients lab results on my phone from anywhere.

Most people have insurance. The numbers given earlier were 300 million insured to 30 million uninsured. Other people have suggested 60 million are uninsured. Regardless, if ration is 3:1 or 4:1 insured to uninsured, most people have access to insurance.

One fact often overlooked is that many, if not most, of those who are uninsured have access to insurance but either choose not to buy it or feel they can't afford it. Many younger people, like under 35, choose to skip insurance because they feel they don't need it.

[feh]

Agreed. The government is the pinnacle of inefficiency and waste.

It bothers me when people say this. It's pure rhetoric. If you want to discuss government inefficiency, please cite a specific example. I'm not saying government inefficiency doesn't exist - I'm saying people paint with a very broad brush when they make a statement like this.

A point on efficiency related to this thread - administrative costs for Medicare are much lower than private insurance companies.

[cptacek]

If you want to discuss government inefficiency, please cite a specific example.

Here's 50:
50 Examples of Government Waste | The Heritage Foundation

[feh]

Here's 50:
50 Examples of Government Waste | The Heritage Foundation

The Heritage Foundation?

This is an example of what I'm talking about. People live in echo chambers, only reading what they agree with. They read/hear the same thing over and over and over, accept it as fact, and then repeat it over and over and over.

Again, I'm not stating government waste doesn't exist. It's rhetoric like "the government can't do anything right" that is troubling.

[geojen]

Single payer could either remove inefficiencies or add more inefficiencies- depends on your interpretation of the problems, interpretation of supply and demand as it pertains to health care, and many other factors.


I believe markusk made this point as well, but I'll reiterate. Medicare has a fraction of the overhead/administrative costs that private insurance companies have. Calling the government the pinnacle of inefficiency is a logical fallacy, because large private industies are just as wasteful and ineffienct. That is a consequence of economies of scale.




1) The quality of care is second to none, If you need health care, our system will give you the best care in the world, bar none.
.

I often hear this "fact" bandyied about a lot, as if it were actually true. But it isn't. Not by any measurable standard is it correct. Studies recently released by both the Commonwealth Fund and the World Health Organization show that we rank pretty low in health care outcomes in this country compared to other countries. WHO put us at 37th, in fact. Especially if you are a woman, you are much more likely to die during pregnancy and childbirth than in any other industrialized country. Pretty sad results for what we pay as a country.

Now, you can argue that a large part of our problems are brought on by our diet and lifestyles, and you would undoubtedly be right. But it doesn't change the central fact that we do not have the best health care in the world. We just don't. And how would we change these outcomes? People usually need some kind of financial incentive to do the right thing, even if it means saving their own health. That is why the idea of taxing soda, removing the subsidies for unhealthy foods, etc are gaining air time.

[cptacek]

The Heritage Foundation?

This is an example of what I'm talking about. People live in echo chambers, only reading what they agree with. They read/hear the same thing over and over and over, accept it as fact, and then repeat it over and over and over.

Again, I'm not stating government waste doesn't exist. It's rhetoric like "the government can't do anything right" that is troubling.

The article has footnotes to its sources for each of those examples. Just because the Heritage Foundation compiled it doesn't mean they made it up. Echo chamber indeed.

[feh]

The article has footnotes to its sources for each of those examples. Just because the Heritage Foundation compiled it doesn't mean they made it up. Echo chamber indeed.

It's not the source data I necessarily distrust; it's the analysis/filter it passes through. I don't have the time or desire to wade through their "report" determining what's accurate and what's a bunch of baloney.

[jIM_Ohio]

It bothers me when people say this. It's pure rhetoric. If you want to discuss government inefficiency, please cite a specific example. I'm not saying government inefficiency doesn't exist - I'm saying people paint with a very broad brush when they make a statement like this.

A point on efficiency related to this thread - administrative costs for Medicare are much lower than private insurance companies.

Two points-
feel free to document HOW and WHY medicare has lower administrative costs? Probably because they set such a low price on their reimbursement and the choice is accept the lower price or do not get reimbursed. In this same thread there is a document that this technique costs you and me each another $1700-$2500 in health care costs per year (assuming we have coverage thru an employer or on our own).


Second point, Indiana turned over maintainance of its roads (turnpike) to a private company- it was on 60 minutes within last year. The roads now are in better shape than the state could ever keep them in. My parents drive on I-90 to I-71 to get to my house (from NY to Ohio). 90 has potholes and what not all over it, its a toll road, and once they hit I-71 in Ohio (a non toll road) the roads improve. Clearly the NYS government is wasting the tolls if its roads are bad.

In Minnesota, a bridge over the Mississippi river collapsed. The state is given funds to maintain its roads (federal money goes to maintain interstates) and yet the bridge collapsed, killing many people.

Do you think politicians are good stewards of money? When SS was introduced, the payroll tax was something like 1-2%. It is now 6.2%, and yet people say the system cannot last. How much financial corruption needs to exist before we say spending (and higher taxes) need to stop?

[cptacek]

It's not the source data I necessarily distrust; it's the analysis/filter it passes through. I don't have the time or desire to wade through their "report" determining what's accurate and what's a bunch of baloney.

You are really something. You say the government is not inefficient and want examples. I give you 50 examples of innefficiencies with footnotes to other news articles, GAO reports and IG reports, and you say "those don't count".

[feh]

Second point, Indiana turned over maintainance of its roads (turnpike) to a private company- it was on 60 minutes within last year. The roads now are in better shape than the state could ever keep them in. My parents drive on I-90 to I-71 to get to my house (from NY to Ohio). 90 has potholes and what not all over it, its a toll road, and once they hit I-71 in Ohio (a non toll road) the roads improve. Clearly the NYS government is wasting the tolls if its roads are bad.

In Minnesota, a bridge over the Mississippi river collapsed. The state is given funds to maintain its roads (federal money goes to maintain interstates) and yet the bridge collapsed, killing many people.

Failures and examples of waste are easy to find. Please explain how these instances make a blanket statement such as "government run anything is bad" correct?

Do you think politicians are good stewards of money? When SS was introduced, the payroll tax was something like 1-2%. It is now 6.2%, and yet people say the system cannot last. How much financial corruption needs to exist before we say spending (and higher taxes) need to stop?

Demonstrate that the SS increase is due to waste and not other factors, such as the increase in life expectancy. And I don't know what higher taxes you're referring to; they are no higher now than they have been in the past.

[feh]

You are really something. You say the government is not inefficient and want examples. I give you 50 examples of innefficiencies with footnotes to other news articles, GAO reports and IG reports, and you say "those don't count".

Please quote me where I said "those don't count".

[cptacek]

whatever feh. You said "The Heritage Foundation SMIRK". Was I supposed to take that to mean that you held your nose while looking at the article? Or did you dismiss them because of the source? I'm guessing you dismissed them. If you didn't, I look forward to your defending them. If you did, your actions say "those don't count"

[jIM_Ohio]

I often hear this "fact" bandyied about a lot, as if it were actually true. But it isn't. Not by any measurable standard is it correct. Studies recently released by both the Commonwealth Fund and the World Health Organization show that we rank pretty low in health care outcomes in this country compared to other countries. WHO put us at 37th, in fact. Especially if you are a woman, you are much more likely to die during pregnancy and childbirth than in any other industrialized country. Pretty sad results for what we pay as a country.

Now, you can argue that a large part of our problems are brought on by our diet and lifestyles, and you would undoubtedly be right. But it doesn't change the central fact that we do not have the best health care in the world. We just don't. And how would we change these outcomes? People usually need some kind of financial incentive to do the right thing, even if it means saving their own health. That is why the idea of taxing soda, removing the subsidies for unhealthy foods, etc are gaining air time.

Like I put in my other post, just because medicare does not have the administative costs of private insurance does not make it a good example. It takes more than a macro statement to use this as a position.

If your position is

administrative costs for Medicare are much lower than private insurance companies.

Lets look at details of what we know:

1) Medicare reimbursement to health care providers is MUCH lower. Lower MRI reimbursements, Lower surgery reimbursements, lower everything.

ask yourself why?
Is it because they set a low (broad) fixed price for what they will pay?
Is it because they are more efficient at what they do?
Is it for other reasons not listed?

I will take the stance of they have a low fixed price. That makes their costs lower, but that does not make them efficient (it does not make them inefficient, just saying lower costs are not the measure of efficiency necessarily).

If that is true (they have a lower amount they will reimburse for, more questions need to be asked.

1) Can the hospitals and doctors turn a profit if EVERYONE paid the medicare price?

Steve will probably tell us no from his viewpoint.
My gut instinct tells me no as well.
There is a study linked earlier in this thread which suggests you and I (with private insurance) pay between $1700 and $2500 more in premiums and co-pays each year because medicare reimburses at a lower level (so the lower administrative costs, at minimum, is costing tax payers $2500 per year, yet that $2500 is not tacked on to any study which looks at medicare reimbursement, the efficiency of medicare, or the administrative costs of medicare).

2) If more people are using medicare (meaning the 270 million people with insurance switch to medicare) could it operate at same level of efficiency? At minimum it would need to hire more people to process claims. It might also start dealing with procedures and treatments it has less experience with.

My additional points in this regard would be if a company has 200 million "customers" and another company has 30 million customers. If the 200 million customer company had revenues of $5 billion and the 30 million customer company had revenues of $1 billion, a few generalizations can be made:

1) the higher revenue company will have more pet projects and more inefficiencies- nature of being bigger. I see this in software industry all the time (I work with many small and big customers/suppliers/clients). The larger customers add more overhead, but they need the system to do more, so that is OK. The smaller customers need to get more efficient to compete with the larger competitors, so they use our tools... but they do not use them the same way- they might be using them as a requirement (like going into a small mom and pop injection mold shop to implement a 20 seat license because they supply Ford and Ford requires them to use the software. That Mom and Pop shop uses less resource from our company and also does not have nearly as many pet projects going on.

2) Efficiency can be measured in many ways. Its possible the process of the big company is less efficient, but with that less efficient process, the company makes LOTS more money.

3) the company with less customers will usually be a nitch customer- meaning they fill a small nitch, but if that nitch were to grow, they would add inefficiency to get bigger.

Extrapolating this to medicare (to make my points)- Medicare would have more people filing claims, and does not have the bandwidth to handle that now. In addition medicare is not solvent right now- it spends more than it takes in and will be completely bankrupt within a certain number of years unless it is reformed.

In general my experience when I worked for the government is that there is a layer of people which push paper as something gets bigger. We did acoustic testing on submarines, and it appeared there were as many people doing the testing (contractors like me) as there were managers to secure funding and debate which ships get tested. The managers are clearly overhead. The postal service looks the same to me (they keep raising the price of stamps you know).

If medicare was run with the #1 criteria being it had to reimburse actual costs, people's medicare premiums would skyrocket and then the costs could be reexamined for a true cost comparison.

The people running medicare are government workers, they get paid at a lower pay scale than the private sector... probably have more job security too. This contributes to their lower costs. Adding people to process claims will add more middle managers, and middle managers are the cause of most inefficiency in corporations big and small.

[feh]

whatever feh. You said "The Heritage Foundation SMIRK". Was I supposed to take that to mean that you held your nose while looking at the article? Or did you dismiss them because of the source? I'm guessing you dismissed them. If you didn't, I look forward to your defending them. If you did, your actions say "those don't count"

As I previously stated, I'm not interested in wading through the article you referenced in an effort to determine what's accurate and what's been filtered/twisted. They are clearly an extremely biased organization.