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Too low for a bloated cost structure, sure :p
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CA10835 Posts
note/warning: sorry, this post is kind of all over the place but i just have a lot of different things on my mind
doctors are an easy target for the government if they are looking for ways to balance the budget. no one is going to cry for physicians when they get hit with 2% (beginning march 1), 5%, or even 10% (see: california) reductions in reimbursements because the american public believes that doctors already make too much. if they REALLY wanted to fix the healthcare system rather than putting a bandaid on it, they'd look at the real reasons why healthcare costs so much. physicians only get 20 cents per each healthcare dollar.
you might think that the 2% cut won't have much of an effect. i mean it's only 2%, right? think again, and check out this study. the study shows that if medicare reimbursement is reduced by 2%, 63 rural hospitals will no longer be profitable and 482 rural health care jobs will be lost nationally, primarily centered in the midwest and south where there is the greatest need for rural health care. there was a serious proposal to cut medicare funding by 26.5% that was barely avoided in the fiscal cliff bill. if a mere 2% reduction would have that kind of impact, imagine what a disaster 26.5% would be.
one of the next things on the chopping block is GME funding aka funding for residency programs (see the Simpson-Bowles commission, which recommended a 50% cut to residency funding, or $5.8 billion). there are cries about lack of access to healthcare but they want to cut funding so residency programs are forced to close due to lack of money? i don't know about you, but that doesn't make a lot of sense to me.
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here are some suggestions to improve the ACA, written by Dr. Lee Rogers, DPM
1. Give regulators the power to reject insurance rate hikes
The Affordable Care Act (ACA) provides federal oversight in 2014 to identify companies who have a pattern of excessive or unjustified rate increases, but they have no power to prevent the increase. The individual mandate incentivizes people to buy insurance or face a penalty, but there is no guarantee that the insurance will be affordable. Regulators should be allowed to reject excessive hikes for consumers much like our insurance commissioner does in California for other types of insurance.
2. Create National Insurance Exchange
Exchanges give individuals and small companies similar clout to large companies when purchasing health insurance. The ACA leaves the insurance exchanges to be created by each State. This does not allow the true competition of a larger national market. Residents in more than half of the states are subjected to a near monopoly by insurers. Opening up the market nationally will allow greater competition and keep prices lower.
3. Allow individuals and businesses to buy into Medicare
Patients deserve the choice of purchasing private insurance or public insurance. Individuals and businesses should be able to purchase into Medicare at cost. Medicare should be added as an option to the national insurance exchange.
4. Negotiate Drug Prices
The United States carries the pharmaceutical research and development burden for the entire world. We are essentially subsidizing the lower drug prices in wealthy countries like England, Germany, France, Canada, and Japan. Americans should not pay more for the same medication than they do in other developed nations. Medicare and Medicaid should be able to negotiate drug prices like the VA, DOD and other nations. I also understand it is costly to develop new medications. Patents should be extended a minimum number of years from the time the drug goes on the market and not start the clock while it is in development an unable to be sold.
5. Doctors Determine Medical Necessity
Insurance companies can determine what treatments are medically necessary for you. This is an obvious conflict of interest. Doctors should determine medical necessity for patients, not insurance companies.
6. Preempt the Provider Shortages
There is a shortage of physicians even without the addition of 33 million new Americans with health coverage. We need to make medical school more affordable and shorten pre-medical education. We need to make sure every doctor graduating medical school has a residency slot available. Telemedicine programs should be developed to bring specialists to areas of need virtually. We need to expand programs to train nurse practitioners and physician’s assistants. Nursing shortages pose a real patient safety problem and we should immediately offer visas to well-trained foreign nurses to fill shortages while we increase our domestic supply of nurses.
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"5. Doctors Determine Medical Necessity"
There's a conflict of interest if I ever saw one!
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CA10835 Posts
so who should? you can't just make a statement like that without offering a more viable alternative.
are you saying that insurance companies are more capable than a doctor of determining what treatment a patient needs for their medical conditions?
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On February 28 2013 10:18 JonnyBNoHo wrote:
"5. Doctors Determine Medical Necessity"
There's a conflict of interest if I ever saw one!
insurance companies are just as guilty. -__- I had my vitiligo treatment deemed cosmetic so they wouldnt cover it when I first started getting it around 15 years old. Anyone with half a brain would see that as complete bullshit but not the awesome insurance company 
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On February 28 2013 10:21 LosingID8 wrote:
so who should? you can't just make a statement like that without offering a more viable alternative.
are you saying that insurance companies are more capable than a doctor of determining what treatment a patient needs for their medical conditions?
No, I'm saying that more than one conflict exists. They both need to be taken into account and balanced against each other.
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Since this a thread about medical costs, the following is the fee schedule that doctors charge to the government of ontario for medical services.
http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/physserv_mn.html
In relation to drug pricing, do note that pharmaceutics have a limited span on patents related to drugs, usually around seven years and up. If you feel are you being "screwed" by hospitals, doctors, or even drug stores, you can easily look up the patent information regarding the drug and find average market pricing.
I won't say its the "fault" of patients, but rather the abuse of trust by these institutions, leading patients to believe fully in drug pricing.
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CA10835 Posts
On February 28 2013 10:31 JonnyBNoHo wrote:Show nested quote +On February 28 2013 10:21 LosingID8 wrote:
so who should? you can't just make a statement like that without offering a more viable alternative.
are you saying that insurance companies are more capable than a doctor of determining what treatment a patient needs for their medical conditions? No, I'm saying that more than one conflict exists. They both need to be taken into account and balanced against each other.
and how would you propose that we do that? in the current system, the insurance company has the final say in determining medical necessity. that doesn't sound like we're taking both sides into account and balancing them against each other, like you suggest.
i don't know about you, but if i had to make a choice between having an insurance company or a doctor dictate what medical treatment i needed for my condition, i'm going with the doctor every time.
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On February 28 2013 10:38 LosingID8 wrote:Show nested quote +On February 28 2013 10:31 JonnyBNoHo wrote:On February 28 2013 10:21 LosingID8 wrote:
so who should? you can't just make a statement like that without offering a more viable alternative.
are you saying that insurance companies are more capable than a doctor of determining what treatment a patient needs for their medical conditions? No, I'm saying that more than one conflict exists. They both need to be taken into account and balanced against each other. and how would you propose that we do that? in the current system, the insurance company has the final say in determining medical necessity. that doesn't sound like we're taking both sides into account and balancing them against each other, like you suggest. i don't know about you, but if i had to make a choice between having an insurance company or a doctor dictate what medical treatment i needed for my condition, i'm going with the doctor every time.
Insurers have some say in what they cover, but overall doctors have way more power in decision making.
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CA10835 Posts
doctors make decisions within the framework of what is allowed (aka what they are able to get reimbursed) by insurance companies.
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On February 28 2013 04:30 Dapper_Cad wrote:Show nested quote +On February 27 2013 06:42 Blargh wrote:
It's pretty normal for like, 90% of people to skip the OP. I generally read the first few pages (1-5 if it's interesting enough, then last 3 so that I can actually get into a discussion). I don't want to repeat what other's have said. And if I see an idiot is trying to make a shit-argument in the last couple of pages, I'll make a long post telling them why what they are saying is totally retarded and that it is actually like X.
But anyway, it'd be nice to see a detailed sum-up of other well-developed countries (Scandinavia, Japan, etc.) have their medical care distributed (not really distributed, but you know what I mean!). Japan has one (if not the longest) life expectancy and I imagine their medicine is great. But do they have a socialized medical system where hospitals are run through government or is it all privatized? Someone could have posted this but I missed it/forgot. Every developed nation in the world, except the U.S., has a socialized medical system.
The logic that your bring up in your second part isn't entirely accurate. Those countries also has some of the healthiest (on some metric) populations in the world. America on the other hand...not so good...
The other thing why American healthcare costs so much is defensive medicine due to lawsuit potential. Doctors almost always will recommend further treatment in situations where further treatment isn't necessary due to the simple notion that if something does happen, lawsuits will wreck you. Note that this has nothing to do with the actual lawsuits themselves, but rather the threat of lawsuits will push everyone further down the treatment path regardless of whether they actually need it or not. That's going to cost everyone more money.
Like your dentist wants you to take a X-ray every year, when you really don't unless you know something drastic has changed or they see something to suggest it. That's $110 around here, while not a lot someone is paying for it insurance or not.
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On February 23 2013 14:02 Angry_Fetus wrote:Show nested quote +On February 23 2013 13:54 Millitron wrote:
Insurance is the problem. Hospitals and pharma companies can charge that much because most of their "customers" costs are covered by huge insurance companies. Get rid of insurance, demand falls, and so will prices. Your solution is to get rid of insurance? Really?
I don't agree with getting rid of insurance companies completely. But a much better solution would be for our government to become more active in moderating and keeping a check on insurance companies. There are multiple bills that have taken a step in this direction such as the Stark Bill. But there is a fine balance between what can and can not be done through our government. Clinton's bill was to provide basic health coverage for all citizens which is unrealistic and would just destroy funds. The upside to it though was it would force insurance companies to compete and lower prices. Still, the cons to the bill exceeded it's pro's.
How our government could take more of a part in regulating insurers is a little beyond me. I feel they already have a ton of power, which as was already stated, is the problem.
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On February 28 2013 11:00 LosingID8 wrote:
doctors make decisions within the framework of what is allowed (aka what they are able to get reimbursed) by insurance companies.
This really hinders the quality of care though. Sometimes doctors are unable to make the most logical call simply due to reimbursement. Malpractice insurance factors in here big time. Which is a major problem that correlates with corrupt insurance companies.
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On February 28 2013 10:18 JonnyBNoHo wrote:
"5. Doctors Determine Medical Necessity"
There's a conflict of interest if I ever saw one!
wow?
So you guys (americans) get ripped because you dont have a national healthcare system and the crook is the doctor??
lolll
it never crossed your mind that the insurance company denying you treatments might not have your well being as their first priority as opposed to the doctor who is treating you?
If the doctor doesnt have the right/ the legitimacy to tell you what you need as far as the treatment goes who does?
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Doctors would more likely "up code" in gray situations though, so wouldn't it increase quality of care? I am not sure what your definition of QoC is.
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On February 28 2013 11:00 LosingID8 wrote:
doctors make decisions within the framework of what is allowed (aka what they are able to get reimbursed) by insurance companies.
Here's my understanding of the matter (emphasis mine):
The corporate practice of medicine doctrine provides that firms—whether hospitals or HMOs—cannot direct how physicians practice medicine because the firms do not have medical licenses, only the physicians do. Although some states allow hospitals to hire physicians as employees, that change in formal status does not help much if the employer cannot tell the employee what to do. Even if the law did not prohibit such interference, tort law generally penalizes firm decisions to interfere with the medical judgments of individual physicians, making it unprofitable to try, as Professor Blumstein observes. Further, hospital bylaws usually require leaving the medical staff in charge of medical decisions, and those bylaws are in turn required by hospital accreditation standards and often by licensing laws. By dictating autonomy for the various providers involved in jointly producing health outcomes, these rules largely dictate separate payments to each autonomous provider.
Private insurer efforts to directly manage care have likewise been curbed by the ban on corporate practices of medicine and the threat of tort liability. In addition, states have adopted laws requiring insurers to pay for any care (within covered categories) that a physician deemed medically necessary, banning insurers from selectively contracting with particular providers, and restricting the financial incentives that insurers can offer providers.
Link
The idea that individual doctors hold decision making power, to an extreme of sub-optimal results, also dovetails with a lot of Atul Gawande's writings (Ex. Big Med).
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CA10835 Posts
btw i just wanted to clarify Dr Roger's 4th statement for those who don't know how the drug patents work
4. Negotiate Drug Prices
The United States carries the pharmaceutical research and development burden for the entire world. We are essentially subsidizing the lower drug prices in wealthy countries like England, Germany, France, Canada, and Japan. Americans should not pay more for the same medication than they do in other developed nations. Medicare and Medicaid should be able to negotiate drug prices like the VA, DOD and other nations. I also understand it is costly to develop new medications. Patents should be extended a minimum number of years from the time the drug goes on the market and not start the clock while it is in development an unable to be sold.
the part in bold is the key part. there are a lot of different cases and scenarios, but i'll talk about the most common way. the way it works now is that drugs have exclusivity for 7 years. this means that the company has sole rights to market this drug, without the threat of generics developed by other companies. 7 years sounds quite reasonable, when factoring in the considering R&D costs associated with developing a drug.
however, the drug approval process by the FDA is very lengthy. the 7 years of exclusivity begins while the drug is still in clinical trials (aka the company can't profit off of it because doctors can't prescribe it, since it isn't FDA-approved). these clincial trials and the resulting FDA approval process can take years, and meanwhile the 7 year profit window is ticking.
let's say it took 3 years for the FDA to approve a drug. now that company only has 4 years to profit off of that drug until a bunch of generics spring up. i think it's pretty clear why they would charge a greater amount than what the "real" cost of the drug is.
what dr. rogers suggests is starting that 7 year countdown after FDA approval. now the developing company has 7 full years to profit off of the drug, which would hopefully lower costs for the american citizen.
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On February 28 2013 11:05 Kevin_Sorbo wrote:Show nested quote +On February 28 2013 10:18 JonnyBNoHo wrote:
"5. Doctors Determine Medical Necessity"
There's a conflict of interest if I ever saw one! wow? So you guys (americans) get ripped because you dont have a national healthcare system and the crook is the doctor?? lolll it never crossed your mind that the insurance company denying you treatments might not have your well being as their first priority as opposed to the doctor who is treating you? If the doctor doesnt have the right/ the legitimacy to tell you what you need as far as the treatment goes who does?
Just a little comment:
I have experience working in both the US and Danish healthcare system. I follow the debate in both countries closely. In Denmark doctors are also seen as greedy, lazy bastards gaming the system - and that is in a social healthcare system. Politicians are really good at blaming the doctors instead of looking at the root of the problem. And when it starts hurting the patients, doctors cave in before the politicians EVERY SINGLE TIME.
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CA10835 Posts
On February 28 2013 11:16 JonnyBNoHo wrote:Show nested quote +On February 28 2013 11:00 LosingID8 wrote:
doctors make decisions within the framework of what is allowed (aka what they are able to get reimbursed) by insurance companies. Here's my understanding of the matter (emphasis mine): Show nested quote +The corporate practice of medicine doctrine provides that firms—whether hospitals or HMOs—cannot direct how physicians practice medicine because the firms do not have medical licenses, only the physicians do. Although some states allow hospitals to hire physicians as employees, that change in formal status does not help much if the employer cannot tell the employee what to do. Even if the law did not prohibit such interference, tort law generally penalizes firm decisions to interfere with the medical judgments of individual physicians, making it unprofitable to try, as Professor Blumstein observes. Further, hospital bylaws usually require leaving the medical staff in charge of medical decisions, and those bylaws are in turn required by hospital accreditation standards and often by licensing laws. By dictating autonomy for the various providers involved in jointly producing health outcomes, these rules largely dictate separate payments to each autonomous provider.
Private insurer efforts to directly manage care have likewise been curbed by the ban on corporate practices of medicine and the threat of tort liability. In addition, states have adopted laws requiring insurers to pay for any care (within covered categories) that a physician deemed medically necessary, banning insurers from selectively contracting with particular providers, and restricting the financial incentives that insurers can offer providers. LinkThe idea that individual doctors hold decision making power, to an extreme of sub-optimal results, also dovetails with a lot of Atul Gawande's writings (Ex. Big Med). you're absolutely right. and if it's an emergency situation the doctor will obviously do what is medically necessary for the patient to have the best outcome.
the problem comes in less acute situations, where the doctor might feel like a certain treatment regimen is more optimal or a diagnostic test is necessary but they won't do it because it requires a lot of arguing with the insurance company. for example, i was shadowing a doctor who was seeing a patient. the patient had last been seen 10 months ago and they took an xray at that time. the doctor felt like he needed a new xray to see if the patient's condition had changed, but the pt's insurance only covered 1 of that type of xray per 12 months. in this case, the dr felt that it was imperative to take that xray, but it required 30 minutes of yelling by both the medical assistant and the dr over the phone for the insurance company to give in and agree to reimburse for the xray. that type of scenario is way too common and is a huge hassle for the dr's office that you can't expect them to do that every time. so yes, the dr had the final say but this system of haggling is not optimal for patient care.
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I read through the whole article and I barely understood half the issues. It would take a lot of time to actually critically evaluate what's being said.
That being said I can't help but add my uninformed opinion to the debate. It seems to me that there are some common sense fixes that most people agree on. One would be tort reform, the other giving Medicare the option to negotiate drug prices.
The reason why these (and presumably other, less obvious) improvements fail, because the beneficiaries successfully lobby against them. It would take a lot of time, effort and focused attention from the public to force through meaningful tort reform, for example.
In a sense this whole issue showcases the best and the worst of American democracy. There's a suprising number of well informed and conscientious experts who have thought deeply about these issues and came up with some interesting recommendations. I'm not really that well informed about the politics of other EU countries but public debates of this high quality are basically unheard of here in Hungary.
At the same time special interests have a legally protected right to influence the political process in a way that would be described as corruption in the rest of the world. That's not to say it doesn't happen elsewhere just that it's usually illegal.
Sorry to turn this into a post about the political process. But it does feel strange to debate the details of policy when there's wide agreement on some of the main ideas, at least among those who are informed and not conected to special interests. The most important question seems to be why that agreement doesn't translate to political action and how can that be changed.
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EPT
